What should lochia look like?
26 Jan 2012 Leave a Comment
In a recent post, I discussed a training simulation that I and a fellow midwifery student did to increase our skill at assessing postpartum hemorrhage. Obviously all women are assessed for PPH before leaving the hospital or as part of the midwife’s postpartum visits, but secondary hemorrhage can develop unnoticed in the weeks following birth. If you are reading this, your chance of developing hemorrhage after your baby is 24 hours old is something around 1%, meaning that, in the developed world, approximately 1 in 100 women will experience non-normal lochia due to inefficient uterine contractions, unrepaired trauma, or other causes. Because this can occur well after many moms are home from the hospital and still 6 weeks away from seeing their OB/GYN, (and while they are probably too absorbed in the wonderful experience of caring for their new baby to think about much else) knowing what is/is not normal can help moms seek help when needed, and avoid unnecessary trips to the dr’s office.
I’ve put together the following information arranged by days postpartum. Notice that there is some overlap in the ranges suggested, because every mom is unique. This is only a representation of what might be typical – use it as a guide, but if you have any questions or concerns about your own health, it’s best to call your midwife or OB just to be sure.
Birth – 10 days
Normal: in appearance and volume, similar to a heavy period. Bright red in color, contains clots of blood and tissue, no more than 8 saturated pads in 24 hours. (it is normal to have larger gushes of flow when standing up, walking, or breastfeeding.)
Abnormal: foul smell, clots larger than a golf ball, consistently soaking a large pad in under an hour, feeling dizzy or lightheaded (not to be confused with having low blood sugar – make sure you are eating good-quality food and drinking lots of water to prevent this.) fever/chills.
8 -14 days postpartum
Normal: flow begins to lessen. The color changes to brown, pink, or a fainter red.
Abnormal: flow that continues to be heavy and dark red with large clots, foul odor, fever and chills.
2 – 6 weeks postpartum
Normal: color is white, yellow, or faintly brown. Bleeding may stop and restart during this time, a phenomenon known as “6-week bleed”. This is usually a very light flow. Anything heavier than you normally would have on the last day of your period may in fact be the return of your menses – this is most common in moms who are not breastfeeding or in those who strictly schedule their infant’s feeding times, but can happen to anyone. Check with your dr or midwife if unsure.
Abnormal: foul odor.
It should go without saying, but this blog is not meant to replace advice from your medical practitioner. If you are worried about your health or are experiencing a medical emergency, don’t just sit there on the Internet, go call a real doctor.
I’m still teaching… sort of.
24 Jan 2012 Leave a Comment
I’ve been asked recently whether I’m still teaching. Yes, and no. My mother had a stroke last October and I’m helping to care for her as she recovers. For the time being, I am not accepting any doula clients, and I’m not teaching regular classes. I am, however, constantly studying to keep up with the latest evidence and teaching private classes. If you’re interested in Lamaze and the six Healthy Birth Practices, I’d love to talk with you about teaching a class in your home for you and your birth support team, designed around your interests and needs. The cost is $200 and includes a 2-hour class and all the “goodies” and treats I normally give out in my regular class. You must live within the Huntsville or Madison, AL city limits or be within 20 minutes or so of the Monrovia-Harvest area. To set up your private healthy birth prep course, call me at 256-453-2711. Cheers!
Class date change!
25 Aug 2011 Leave a Comment
in Uncategorized Tags: Alabama Birth Coalition, midwifery, midwives, Walk for Midwives
I’m changing the Piedmont Saturday session from September 17 to October 1. Why? Because on September 17 I’ll be walking to show my support for midwifery in Alabama. Why not join us there? Click on over to Alabama Birth Coalition to get tickets for the Walk for Midwives in your city!
Alabama Birth Coalition
postpartum bleeding: how much is too much?
04 Aug 2011 1 Comment
in Uncategorized Tags: hemorrhage, lochia, postpartum
I was recently discussing with a fellow midwifery student how difficult it is to estimate postpartum blood loss. During pregnancy, blood volume expands by as much as 50% to allow for circulation of blood to the expanded uterus and placenta, and to provide a buffer for blood loss during the birth. Some of this blood is lost during the birth, and the rest is expelled (along with tissue from the contracting uterus) in the form of lochia.
Although some blood loss is normal, postpartum hemorrhage is life-threatening and, in one midwife’s words, when a mama begins to hemorrhage, “We don’t play around.”
So how do you know the difference between normal blood loss and hemorrhage? The traditional definition of hemorrhage is >500 mL between the birth of the baby and the delivery of the placenta, or >500 mL after the birth of the placenta but within the 24 hours after the baby’s birth. (Davis, Heart and Hands, 4th ed.) (Note: I am assuming normal, physiological vaginal birth. With a cesarean birth, the term “normal” is anything up to 1000 mL.) You can rely on rules of thumb such as “saturating a pad in less than an hour”, but in many situations that can be hard to estimate. We need to keep an eye on our mamas as best we can, and the only way to master a skill is to practice. So we got some chux pads and a bathtub, and made up some fake blood, and started playing “bloody hemorrhagic mess”. Here are the results of our little experiment:
warning: images of fake blood following. If you are sensitive to the sight of blood and simulated medical waste, or if these images might be triggering to you, please skip the rest of this post.
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1 cup, or approximately 250 mL, on our chux
after adding a second cup - also, doesn't this resemble the United States?
this is the amount most texts define as hemorrhage. We noticed that at this point, it definitely puddled on the surface, and took way longer to soak in. Also, the chux was heavy. We each held it up for a few minutes to get an idea of how heavy that much blood would be.
after adding a third cup, for a total of 750 mL on the pad
after it had soaked in for a few minutes
We agreed that 3 cups, or 750 mL, is probably the maximum that a chux can soak up. It was pooling on the top, spreading to the edges, and in fact, ran off two edges within minutes. This is definitely past the point where I would already be halfway through emergency procedures to get the hemorrhage under control.
So, we now have a good idea of what is and is not normal for blood flow immediately postpartum at a vaginal birth.
Then we wanted to be able to estimate blood flow on a maxi pad, to help us help mamas figure out normal lochia flow.
1/8 cup, or maybe 30 mL, on a maxi pad
1/4 cup, or maybe 60-70 mL on a maxi
We both agreed that this is past the point we personally would allow our own pad to be soaked. 1/4 cup, or 1/8 of the threshold for hemorrhage, more than saturated the center of the pad and ran over the sides. In fact, I myself would have changed at the 1/8 cup mark or before – at least on every trip to the bathroom if not when the pad started feeling wet. So assuming most mamas are the same, I would guesstimate that a loose definition of too much would be oversaturating a pad in under an hour, which holds with what I was taught.
the back of the saturated pad
with just over 1/2 cup
the remains of the 250 mL we had planned to pour on the maxi
From here, we wanted to explore blood flow in the bathtub, as with a waterbirth.
immediately after adding 1 cup to our bathtub full of water
Notice that the water is still basically transparent.
after adding almost another cup
One thing I noticed is that my fake blood solution was much less… bloody in water. My personal experience with waterbirth is that blood tends to keep its gooey, coagulating state in water, tingeing it much more darkly than this simulation. So I would say our experiment was less valid here.. but, oh well. Pressing on:
with 4 cups, or twice the threshold for hemorrhage
Again, with real blood, I believe the water would have been much more opaque. Even so, it became hard to see the drain or a hand placed in the water.
From here, we wanted to test what we had learned. Each of us left the room and returned to an unknown volume that we had to estimate. Success! We both estimated with a 100% success rate and good confidence in our estimates.
Side-by-side comparison of 3 cups (750 mL) vs 1 1/2 cups (375 mL)
See how the 3-cup amount (on the left) is spilling over the sides? And the 1 1/2 cup is soaking in, with less puddling? In a real setting, there would be amniotic fluid mixed in and making the volume appear greater, but generally you use the heavily-colored stain in the center and ignore the watery stuff along the sides.
All in all, our experiment was a tremendous success and I feel much more confident in the skill of assessing postpartum bleeding.
Relevant reading for new parents – ultrasound
26 Jul 2011 Leave a Comment
Ultrasound is a common screening test used to look for the possibility of a problem. No high-quality, long-term data exist to indicate the absolute safety or danger of prenatal ultrasound. We simply don’t know what impact, if any, ultrasound use has on the developing baby or its future offspring. We definitely don’t have good-quality data showing, for example, the effects of ultrasound when done at various stages of pregnancy or for varying lengths of time or when the wand is held at varying positions near the uterus. This is the reason why there are no hard-and-fast protocols regarding ultrasound in pregnancy.
Any testing carries the risk of false positives and negatives (showing a problem that doesn’t exist, or not showing a problem that does exist.) Even accurate results can have an emotional, financial, and medical impact on expectant parents.
Before having tests such as ultrasound done, ask yourself:
- What does this test indicate about the health of myself, my baby, and the pregnancy overall?
- How accurate are the results likely to be?
- What is the best result I am likely to get? What will I do if this is the result?
- What is the worst possible result? What will I do if this is the result?
- What will I do if, when the baby is born, the test result was inaccurate?
The answers to these questions can help you decide whether to have the test done and how to use the results.
One good mnemonic for any test or medical procedure is to “Use your BRAIN”.
B – Benefit (What is the benefit of the procedure?)
R – Risks (What are the risks of having the procedure done?)
A – Alternatives (Are there alternatives to this procedure – other procedures that have a similar result, or simply doing nothing?)
I – Intuition (What does your intuition say you should do?)
N – Nothing (What happens if you simply do nothing, or if you wait for a while and reconsider the decision?)
The American College of Obstetrics and Gynecology position on non-medical ultrasound
How often should a working mom pump?
11 Mar 2011 Leave a Comment
“Full breasts make milk slower.”
An excellent article on sustaining milk supply for working moms or those otherwise separated from their babies.
Want a healthy birth? Get up and get moving!
09 Mar 2011 Leave a Comment
in Uncategorized Tags: healthy birth practices
One mom’s account of her “free range labor” at Giving Birth With Confidence:
Doula services resuming in November 2011
03 Dec 2010 Leave a Comment
I am taking a year off from labor support to mother my new baby, but if you need a doula in the Huntsville-Madison, AL area before then, please contact me for the names of some awesome area doulas who are currently practicing.
This summer only – save $100 on private classes!
05 Aug 2010 Leave a Comment
in Uncategorized Tags: private classes
I’m expecting my third child in early October. And to celebrate, I’m giving you $100 off a private series of birth classes! It’s the same class as my group Lamaze class, built around the six Lamaze healthy birth practices, but given at your convenience and tailored to the topics that matter most to you.
Private classes are great if you’re busy or on bed rest. I’m also happy to include your older children or other members of your birth team, so invite your mom, sister, and best friend along too! To make it super-convenient, we can do classes in the setting of your choice – either in my Madison class location or in your home.
To take advantage of this offer, give me a call at (256) 453-2711 and we’ll set up a time!
Strategies for a safe, comfortable hospital birth
04 Aug 2010 Leave a Comment
In 2002, the Listening to Mothers survey found that fewer than 1% of women surveyed experienced all six healthy birth practices, and that none of these took place in a hospital. None. An alarming number of women were subjected to routine interventions which do nothing to increase the safety of birth, but which create the need for further intervention: 93% had continuous fetal monitoring, 86% had an IV, 74% gave birth on their backs – all practices that offer no routine benefit and that can do more harm than good.
You have done your research and you are determined to have the most physiologically normal birth possible. If you are planning to birth with a midwife at home or in a birth center, this is easy to achieve. Birthing with an OB in a hospital? It can still be done! First step: ask lots of questions and choose your caregiver with your birth goals in mind. Next step: be sure that you have clearly communicated your priorities with your doctor, and that he/she is supportive of your desire for normal birth. Also, take a tour of the hospital you will be birthing at, and ask lots of questions. Are there nurses on staff who enjoy helping women desiring normal birth? In what ways does this hospital encourage women to birth normally? If you don’t get the right answers to your questions, you need to look further for your birth facility.
- Remember that you can always change care providers, no matter how late in your pregnancy. As a mother, you have instincts. Use them. If at any point something begins to feel wrong – find another caregiver with whom you feel more comfortable.
- Be your own advocate. If there’s a procedure you don’t understand or agree with, speak up. Ask for a second opinion. Ask for studies that show that the offered intervention works. Ask what would happen if you waited. Say, “I refuse {whatever} at this time, but if we change our minds, we’ll let you know.” Ask for some time alone to discuss the intervention with your partner before agreeing. Remember that YOU are the customer, and your preferences and wishes rule the day, not “hospital policy”.
- Vaginal exams late in pregnancy are the norm with obstetrical care. Before agreeing to this routine intervention, ask your care provider what information they are looking for and how this information will be used. In general, there is no point whatsoever to weekly cervical checks. They can’t predict when you will go into labor, they can cause you to feel crampy or even make you spot-bleed, and being told you are X number of centimeters dilated can make you crazy because you start thinking you’ll go into labor any minute now, and then when you don’t it’s terrifying. Mentally this can set you up for agreeing to a convenience induction – you’re tired, you’re tired of being pregnant, and you were told you’d be in labor last Monday but you still are pregnant a week later. So you agree to an induction, which can start a chain-reaction of painful and unnecessary interventions. Avoid this like the plague! You can just tell your nurse, “I don’t really feel like having a check today.” and it’s usually no big deal.
- When completing your hospital paperwork, look for the “informed consent” form. Although you have the legal right to withdraw consent to any procedure at any point, in practice it is much easier to refuse up front. For example, if you know you do not want vacuum or forceps extraction, refuse an episiotomy. State this on your paperwork. “I do not consent to episiotomy.”
- Withholding food and drink during labor is a common intervention that is routinely done in hospitals. Unfortunately it has been shown to do far more harm than good. At one of your checkups, ask your caregiver to write on a prescription pad, “Food, drink, and movement as desired” and sign it. Voila! A prescription for healthy birth.
- You’ve woken up during the night with contractions. Is it the real thing? Who knows? Ignore it and go back to sleep, or back to whatever you were doing. The longer you ignore it, the better you will feel mentally and physically. Once you’re sure you’re in labor, go bake a cake or knit or read a book – anything to distract yourself. You’ll be having to focus on your comfort measures soon enough, and then it will really be “the real thing”.
- Request a hep lock instead of an IV. And request for intermittent monitoring rather than continuous EFM. Research has proven that intermittent monitoring is safe for the majority of births, while continuous monitoring increases your risk of having a needless cesarean.
- Wait before you go in to the hospital. The longer you labor at home, the less chance you have of being talked into interventions you don’t want (or having them done without your knowledge or consent. Sadly, this happens often.) You really should wait at least until you have had bloody show for a while. For best results, time your arrival to whenever you start feeling the urge to push. Hopefully while laboring at home you have had good labor support in the form of a friend or loved one and/or a doula who can stand by you, reassure you that what you are experiencing is normal, and help you with comfort measures.
- Take a good childbirth class. Lamaze classes are evidence-based and designed to increase your confidence in your body’s ability to birth your baby. Once you feel confident in your choices, it’s easier to insist that you get what you want in your birth.
- Call your Lamaze teacher for support. I’m available to my students any time you need to ask a question, get a confidence boost, or be reassured that you’re doing well. So call me!
