PPH risk - need some hand holding (and firm talking to) please

[peggyblackett]

I have had two minor PPHs with my previous pregnancies (500-600mls). They were managed successfully by having a managed third stage, and whilst I felt a bit weak afterwards I bounced back very quickly. Apart from the PPH my labours have been very straightforward, with no interventions required.

I saw an obs last week (not for the PPH risk, but for something completely unrelated), and she has advised that I have a canula put in during labour just in case I need oxytocin, fluid, blood etc. after delivery. The problem is I am MASSIVELY IV phobic and this is likely to have me climbing the walls with anxiety. She also suggested misoprostol as an alternative to the oxytocin, but obviously that is not as effective as IV oxytocin.

I have discussed this with a couple of family friends who are HCPs and they have advised having the canula put in, as trying to find a vein in a semi-emergency is no fun. Plus as this is my dc3 it is likely that my uterus is going to struggle with tonicity and therefore the chances of PPH are increased this time. I know they are right, and I am being ridiculous, but the thought of the canula is causing my anxiety levels to go through the roof and I still have 2 weeks to go :(.

I'm not sure what to put in my birth plan - I'd be interested to hear from anyone else with experience of PPH and how you handled it in future pregnancies.

Right no exact experience as my pph was in my third pregnancy - but that's why I'm posting. It wasn't huge about 800mls and I was fine afterwards BUT there was a nasty moment or two when I realised I was bleeding in a way I hadn't before. Dh remembers it more clearly than me - I was a bit high on the baby I think and his memories aren't good either.
So - it's your third baby, you've bled a bit before, chances are you're going to bleed this time. What are the chances you'll suffer a massive bleed - probably not that great a chance but definately increased over somebody who hasn't bled much before I expect.
I think it would be wise to take the cannula tbh. It is hard to get one in in a crisis and it's an intervention you can have and if you need it great and if you don't also great - no pph!

The problem is though that you don't want the needle - so how can we work round that? First of all can they use emla cream to numb the needle? Do you think you could bear it if you looked well away and maybe tried some visualisation whilst they do it? Sort of like this is another step that brings me closer to my baby, breathe through it sort of thing. Also insist that your midwife gets the person on the ward that she would want doing it to her to do it. If that's her great - if not you want the best they have

I had a pph with both my deliveries - I had a canula in place second time around as first time round it was a huge problem getting the line in once I was in shock and that depleted as well.

It became horrific whereas, although I dislike the whole process, during labour and with gas and air and distractions it wasn't nearly as bad as I built it up to be in my head.

You really wouldn't want to go through the mess I did when it was too late. I ended up with tubes everywhere and both arms splinted etc whereas with the canula it was one needle and it was done.

If it is done during labour your natural pain killers are high and you don't really notice.

I would strongly advise that you take medical advice.

Can you train yourself with self hypnosis techniques to overcome the anxiety in the run up to delivery?

Thanks both. I know you are both right (and thank you for being so understanding about my phobia, as I know its irrational and stupid - your kind responses have made me blub).

I was wondering about saying I need your best canula inserting MW on the case NL! Whenever I need a blood test I get very picky about the phlebotomist that does it, I have actually asked for a more senior phlebotomist to take the blood in the past as I didn't trust the junior PB to do it. Control freaky I know.

I have two packs of EMLA in my bag ready to go. I suspect that you are right that mid contraction and high on G and A I won't care so much.

Thank you both for sharing your experiences, it has made me take stock and realise I have to deal with this, as to not deal with it is worse.

I could try the natal hypnotherapy CD for c-section, as I suspect that covers interventions like being prepped for surgery.

If you have the time and money you could try seeing a local hypnotherapist for support with this.

The other option would be seeing psychologist for Cognitive Behavioural Therapy but I imagine that might take a while.

I feel for you as I hate them with a passion but in the circumstances it is the lesser evil and it won't be the same as sitting in a midwife's office for one.

I think you're being very sensible OP. I am not keen on unnecessary intervention but this is one thing I think is well worth it. I agree the thing to do is work out how you can manage this. Absolutely say you want their best in there - HCPs should know their limits and the importance of getting it first time.

I had a pph after my first delivery which meant I was under consultant care for my second. The consultant put together a plan which included, blood being drawn on admission to labour ward for cross match, two cannulas to be inserted, managed third stage and 24 hours on a drip to keep womb contracted (can't remember the drug).
In the end midwife did the blood draw, I got one cannula (and she took one look at my veins and went and found the ward expert who did it first time - I am phobic too!). I had managed third stage and blood loss small so no drip.
Good luck - hope all goes well with your delivery!

carrots I've had CBT and hypnotherapy - they got me to the point of being able to have blood taken, but only if I have been SLATHERED in Emla first. God, I really am an embarassment.

I will see if I can find a local hypnotherapist, I'm 38+2, but a couple of sessions would help.

Fortunately DH is a superstar about all of this, so feel much better knowing he will be there.

Littone my Obs sounds remarkably chilled by comparison. She did say to discuss it all with the MWs on the day, so perhaps there will be a compromise position e.g. canula goes in during 2nd stage (noone touches me during transition, noone :o).

How about asking if the anaethetist will cannulate you? They're really good. Better than an SHO or most midwives (I'm a m/w so I can say that)

But better to have the cannula in and not need it/or it be there if needed than to need a cannula in a hurry and lose time while having one put in.

It's not embarassing to want the emla - it's perfectly logical. You're having a small procedure which can cause some pain and the emla avoids that. It's just a tool that's all. There's nothing to be gained by being 'hard'.

You are not an embarrassment Peggy. Everyone has phobias. Yours makes a bit more sense than a lot of them (eg baked beans). They are not something we choose and it sounds like you have done a lot to try to deal with yours already. Hold your head high.

Viva - that is an awesome idea. The thought of some SHO buggering about trying to find a vein is....not calming :o.

Off to pick up 3rd pack of Emla - something I cannot have enough of going into hozzy.

Definetly embarassing - I ask for EMLA cream. I had a gynae op last year and they had to use EMLA cream and I was still hysterical. They had to sedate me before they could put the full size cannula in. Now when all the Drs in the room are people that you work with and socialise with thats embarassing! I'm still struggling to look various ones in the face.

Definetly NOT embarrasing I meant to say. Sorry!

I'm glad I'm not alone Viva :o. Most of my family are (and their friends) HCPs and consider me utterly ridiculous!

Most people who have had previous blood loss of 500 - 600 mls would not need to have a cannula. Most healthy women can easily cope with that sort of blood loss without the need for any treatment. Some might feel a bit wobbly afterwards but many will be absolutely fine. I suggest you speak to someone who can review your old notes, did the obs actually see your old notes or is she just someone who thinks everyone should have a cannula 'just in case'? Where I work unless you had major problems with that amount of blood loss you would probably deliver in the midwife unit up the corridor from the labour ward as long as your iron level in pregnancy was normal and there were no other complications.

I had a blood loss of 500 at my first home birth as I recovered well and had needed no treatment to stop the bleeding after the birth so I went on to have my next one at home with about a loss of 300. I don't want to belittle the risk of a haemorrhage, obviously some women really do need to have a cannula and intense management but iirc the world health organisation has changed the definition of a pph to 1000 mls. Some obs have seen so little normal that they can't cope with anything that is vaguely unusual.

Sorry I'm wrong, don't know where I got that from about changing the definition of pph, must be the night shifts addling my brain!

WHO say this "Postpartum hemorrhage (PPH) is defined as the loss of 500ml or more of blood from the genital tract after delivery of the baby that usually occurs in the first 2 to 4 hours after delivery but can occur later. McCormick et al. states that, "A more accurate definition of postpartum hemorrhage is any blood loss that causes a physiological change (e.g., low blood pressure) that threatens the woman?s life.""

In my experience more people use the second part of the above paragraph these days as it is a more individualistic and holistic approach.

.......but then why would you listen to anything I say after I was talking a load of nonsense earlier

Maxbear - the midwives at the birth of ds were totally cool about my previous PPH with dd1. No talk of canula (probably because I already had a crazed look in my eye :o). My obs didn't read my notes, I suspect she is just looking to take a minimal risk approach. The irony is that I was under a different Obs earlier on in my pg who was completely unconcerned about my PPH history, saying that it was a minimal loss.

I'm seeing my MW on Tues, I will phone her on Mon and see if she can get hold of my notes so that we can review them (good idea, thanks).

The sad thing for me is that in the past I have laboured well (thanks hypnobirthing and Ina May), and phobia aside I'd really rather not have any intervention. Obviously I need to offset that with keeping dd2 and me safe.

I was surprised to see this was being advised for you with PPHs of "only" 500-600ml as 500ml is defined as "average" or "normal". I think 1000ml is for a CS. I would advise doing a bit of research & going back to them to ask why they are taking such an approach esp given good labours in the past, unless you have a blood clotting disorder or anaemia or something that makes any blood loss significant.

I had 3l PPH last time, this time I have to deliver at a teaching hospital ages away rather than my local, have an iron tranfusion the week before birth & syntocinon for 4hrs post delivery. Strangely they do seem to focus on the canula! I have no issues but every different MW/obs I see tells me first thing that I will have to have a canula put in as soon as I get in to hospital! It's probably cos it's a common phobia so no need to feel embarassed by it.

idlevice - you having to go all that way to a teaching hospital is certainly putting my position into perspective. Thanks for the feedback, I will discuss it further with the MWs as I don't have a history of difficult labours, and my Hb count at the 28 week blood test was 11.5, which I think is perfectly normal. I'd rather have another blood test to check Hb levels prior to labour, and get myself psyched up for it, than have the IV during labour when any rationality I do have has disappeared out of the window. Wishing you well with this delivery.

I was (and at some levels) terribly needle phobic so I went for hypnotherapy. Basically I tell myself that in 20 seconds it will all be done and that this situation/baby/op is worth 20 seconds of discomfort. Then I count down slowly from 20 as they start. Using the Emla makes it feel like no more than a pinch and I've also found that putting it in my arm is mikes less painful than the back of my hand.
Fwiw I had a cs and severe 3l pph (haem said he thought it was more as Hb dropped to 3 during the mad bit.) and was already canulated, but they had to get a second wide bore access line in on the other side. They whacked me full of diamorphine though, so I hardly noticed it. V best of luck!

500ml isn't normal, its classed as a PPH. It might only be a small PPH but its not a normal blood loss.

In the NICE guidelines a PPH of 500-1000ml is described as "standard", maybe that has a different meaning in the clinical sense rather than something regular or routine in nature?

OP, the NICE guidelines do cover PPH so worth checking for more background info if you haven't already.

Yes, a standard pph is a standard pph rather than a catastrophic one. However it's still a pph rather than a normal post partum blood loss. So it doesn't mean that 500ml is a standard blood loss.