Anaemia in Pregnancy

Implications of low haemoglobin levels

My midwives have been worrying me because my Hb was 9.8 and then fell further to 9.3. They say it is:
a) more dangerous if you lose blood and
b) more likely that you will PPH

The independent midwife who I asked at an aquanatal discussion class mentioned the MCV (mean corpuscular volume) as being important and when I looked up my notes this morning I see that this has never been below 94.

My own midwives (a community-based NHS team) say they cannot recommend home birth, but they will support me in it if I choose it.

They are trying to bargain with me that I can stay at home as long as I have an active 3rd stage, with syntometrine. I am going to be firm that they can keep the injection ready for emergencies but that I want to try for a physiological 3rd stage. I was talking about it last night with my birth partner, and we agreed that I want the cord left intact until the placenta is born.

J, mother-to-be


Did your midwives not recommend you take an iron supplement when your initial hemoglobin was 9.8?

With 13 weeks to go and a hemo of 9.3, unless there is a hemoglobinopathy problem which has been missed, it should be easy to get the Hgb/Hct to 10/30. At 10g/dl which is the magic cut-off point, they should stop worrying!!

Floridix takes a week to raise a hemo about one point (sometimes it may take up to 3 weeks) as does a product called “Spatone iron+” .This last product I saw available for free when I visited my local midwives/Health visitors community office. Both these products are gentle on the stomach and do not cause constipation as a rule whereras the prescribed treatment, ferrous sulphate tablets often are not tolerated well by pregnant women,(and their livers!) nor absorbed as well. caffeine and tobacco inhibit iron absorption and vitamin c aids it.

Women who have hemoglobin levels on the low side , in my experience tend to bleed less at birth. (they cannot afford to bleed and the body knows this). Nutritional anemias will not predispose you to postpartum hemorrhage, but they can worsen its impact if it does happen, and this is what they will be worried about.

A woman who has a low hemo owing to adequate blood volume expansion as seen by hemodilution (falling hemoglobin) from start to end of pregnancy is at less risk for adverse reactions to bleeding than a woman who has a high hemo concentration owing to reduced blood expansion.

A UK study by Steer et al in 1994 found hemoglobin levels at 9.5 or below were not associated with retarded fetal growth or preterm labor but rather a failure of the hemoglobin to fall from early pregnancy levels, indicating a healthy blood volume expansion was associated with these problems.

It takes a few moments to draw up syntometrine but if it is already drawn up and at hand it is more likely to be used. I would hope that the midwives would assess the labour to see if there are other factors which might actually predispose you to a larger than wanted blood loss, such as large baby, increased blood pressure, fast or slow labor or extended pushing stage. These would be reasons to anticipate a hemorrhage. A low hemoglobin is a reason to avoid blood loss but it will not cause it.

Find out if any of them have any experience with physiological third stage..that means hands off the fundus and the cord and watchful waiting while baby suckles..NOT JUST NO SYNTOMETRINE!

Tania, midwife


(for more on physiological vs active management, see  The Third Stage of Labour)


The Midwives who are worried-concerned about the fall in Hb. need to do their homework. What is the mean cell volume? What is the packed cell volume? They appear to be perpetuating the obstetric myth about “low” Hb. and increased risk of PPH, and I suggest you advise to them a period of study either on the web or in a good medical library.

Having said that, iron deficiency anaemia is rare but can occur, and a pregnant woman who is showing symptoms on anaemia needs to check her diet and make sure she is eating the iron rich foods that she finds acceptable and palatable. I won’t bore you with a list, as most people can find them out from their own sources.

As for “doing a deal” with a pregnant woman about home birth and 3rd stage managment – words fail me (nearly!). If you intend to have a spontaneous 3rd stage make this clear in words of one syllable.

If they are concerned about THEIR skills in this area, again remind them of the existance of info in libraries, and on the net, and inform them that they have time before you give birth to update themselves. Sally Inch’s book and many others come to mind but they can do their own research.

Mary Cronk, midwife


Firstly, ‘anaemia’ in pregnancy is physiological, i.e. normal. The apparent anaemia is caused by an increase in circulating blood plasma, which means that there are less red blood cells per ml of plasma than in ‘unpregnant’ blood. That is, the blood is more diluted. As Hb specifically measures the amount of red blood cells in relation to the circulating volume, it shows that there is less, which until recently has been taken to mean that the woman is anaemic. A more accurate measure of whether a woman is anaemic or not is the MCV (Mean Corpuscular Volume).

In my own practice, if a woman has an Hb of < 8 g/dl, I look at the MCV, if this is less than 80 then I consider haemoglobinopathies (such as thalassaemia) if these are not present, then I get the doctor to prescribe Ferrous Sulphate 200mg tds. So, really Hb below 10 g/dl in an otherwise healthy woman should not preclude home birth.

Dianne, midwife


I would appreciate it if anyone can direct me to some solid references or research on the significance of low Hb in labour. Specifically, some parties suggest that a woman with low Hb is in a high-risk group because she would not tolerate even a minor bleed in the third stage of labour, and might go into shock.

However, the second edition of ‘A Guide to Effective Care in Pregnancy & Childbirth’ by Enkin, Keirse, Renfrew and Neilson stated:

“A possible advantage claimed for a high level of haemoglobin in pregnancy is that the woman would be in a stronger position to withstand haemorrhage. There is no evidence to support this claim. indeed, as a low haemoglobin in healthy pregnant women generally implies a large circulating blood volume, it is at least possible that women with a low haemoglobin might better withstand a give loss of blood. “

The new (June 2000) 3rd edition of the book omits this paragraph, but does not make any claim to the contrary.

Response from Obgyn-Net Women’s Forum:

As with most things, it depends on how bad it is. Pregnant women have the marvelous ability to increase their blood volume by about 50% during pregnancy, but there are really 2 components that we are talking about, the volume of the blood, and the amount or percentage of that blood that is red cells. Only the red cells can carry Oxygen, so they are critical. When the topic is anemia, you are really discussing the number of functional red cells that someone has for this essential task.

Volume is important too, but in pregnancy, volume increases more than the red cell mass increase, resulting in a dilution effect, and a relative anemia. This is perfectly normal and expected, but if the the red cell mass is further reduced by lack of appropriate nutrition, or by blood loss, the anemia can reach critical levels.

Then there is the other side of the equation, the blood loss. Even a severely anemic woman who has an unevenful, low blood loss delivery can hold her own with some IV fluids to maintain volume, whereas a woman with normal red cell mass is still at risk for bleeding out due to some obstetrical disaster. You are really talking about relative risks. An anemic woman simply has less reserve, fewer red cells that she can lose before she is unable to move enough O2 around to supply her body’s needs.

William D. McIntosh, MD, FACOG


I looked after a woman yesterday, and while checking through her notes came across several blood results forms .. I noticed that two of them were taken on the same day, half an hour apart according to times on them, but definitely on the same day. One result was 12.3g/dl and the other was 14.3g/dl!!! What does this say about the accuracy of these tests?

Donna


Low Hb and Birth Weight

Here are two abstracts from Steer which suggest that an Hb of under 10.5 is actually a good sign, rather than dangerous. In the 1995 paper he said that failure of the Hb count to fall below 10.5 was associated with an increased risk of low birthweight and preterm delivery. In the 2000 paper he said that optimum Hb in terms of avoiding low birthweight and preterm delivery appears to be between 9.5 and 10.5:

“This is widely regarded as indicating anemia in the pregnant woman but, if associated with a mean corpuscular volume > 84 fL, should be considered optimal.”

Is this controversial, or has it just not filtered through to the majority of units?

Angela

Maternal hemoglobin concentration and birth weight.

AUTHORS: Steer PJ
CITATION IDS: PMID: 10799403 UI: 20262136

ABSTRACT: Pregnancy requires additional maternal absorption of iron. Maternal iron status cannot be assessed simply from hemoglobin concentration because pregnancy produces increases in plasma volume and the hemoglobin concentration decreases accordingly. This decrease is greatest in women with large babies or multiple gestations. However, mean corpuscular volume does not change substantially during pregnancy and a hemoglobin concentration <95 g/L in association with a mean corpuscular volume <84 fL probably indicates iron deficiency. Severe anemia (hemoglobin <80 g/L) is associated with the birth of small babies (from both preterm labor and growth restriction), but so is failure of the plasma volume to expand. Hemoglobin concentrations >120 g/L at the end of the second trimester are associated with a </=3-fold increased risk of preeclampsia and intrauterine growth restriction.

The minimum incidence of low birth weight (<2.5 kg) and of preterm labor (<37 completed weeks) occurs in association with a hemoglobin concentration of 95-105 g/L. This is widely regarded as indicating anemia in the pregnant woman but, if associated with a mean corpuscular volume >84 fL, should be considered optimal.

Medline abstract

Relation between maternal haemoglobin concentration and birth weight in different ethnic groups

AUTHORS: Steer P; Alam MA; Wadsworth J; Welch A
AUTHOR AFFILIATION: Academic Department of Obstetrics and Gynaecology,
Charing Cross and Westminster Medical School, Chelsea and Westminster
Hospital, London.
SOURCE: BMJ 1995 Feb 25;310(6978):489-91
CITATION IDS: PMID: 7888886 UI: 95195482
COMMENT: Comment in: BMJ 1995 Jun 17;310(6994):1601
Comment in: BMJ 1995 Jun 17;310(6994):1601; discussion 1602
Comment in: BMJ 1995 Jun 17;310(6994):1601-2

ABSTRACT: OBJECTIVE–To assess the relation of the lowest haemoglobin concentration in pregnancy with birth weight and the rates of low birth weight and preterm delivery in different ethnic groups. DESIGN–Retrospective analysis of 153,602 pregnancies with ethnic group and birth weight recorded on a regional pregnancy database during 1988-91. The haemoglobin measurement used was the lowest recorded during pregnancy.

SETTING–North West Thames region. SUBJECTS–115,262 white women, 22,206 Indo-Pakistanis, 4570 Afro-Caribbeans, 2642 mediterraneans, 3905 black Africans, 2351 orientals, and 2666 others.

MAIN OUTCOME MEASURES–Birth weight and rates of low birth weight (< 2500 g) and preterm delivery (< 37 completed weeks). RESULTS–Maximum mean birth weight in white women was achieved with a lowest haemoglobin concentration in pregnancy of 85-95 g/l; the lowest incidence of low birth weight and preterm labour occurred with a lowest haemoglobin of 95-105 g/l. A similar pattern occurred in all ethnic groups.

CONCLUSIONS–The magnitude of the fall in haemoglobin concentration in pregnancy is related to birth weight; failure of the haemoglobin concentration to fall below 105 g/l indicates an increased risk of low birth weight and preterm delivery. This phenomenon is seen in all ethnic groups. Some ethnic groups have higher rates of low birth weight and preterm delivery than white women, and they also have higher rates of low haemoglobin concentrations. This increased rate of “anaemia,” however, does not account for their higher rates of low birth weight, which occurs at all haemoglobin concentrations.

Low Hb and Home Birth

A woman has been told that her blood count is currently 8.6 and she’s been told that she’s not ‘allowed’ a home birth unless it is at least 10. Can anyone tell me more about why low Hb might be a problem?


Do remember that it’s not up to anyone to ‘let’ you have a home birth. It is your legal right, whether your health authority likes it or not. Obviously it’s best to avoid aggro and stay on good terms withyour healthcare providers, but both you and they should remember that it’s your decision whether to have a home birth or not. Ask your midwives to explain to you exactly what they are worried about.

As far as I know, low Hb does not make you more likely to haemorrhage. However, if you *did* haemorrhage then it could make your recovery more difficult. I don’t know that this is particularly relevant anyway, because if you had a bad PPH then you would transfer to hospital regardless of your haemoglobin level. Some people believe that it is therefore irrelevant to ‘risk out’ a woman from home birth because of her Hblevel, and apparently sometimes it’s due to an incorrect understanding from the midwives on the case of the implications of low Hb levels.

The only other problem with low Hb levels that I’ve heard suggested is that,as you have less haemoglobin in your blood than ‘normal’ (whatever that is),your blood has lower oxygen-carrying capacity, and so there is a small riskthat you or the baby would not be getting as much oxygen as you need. However, as I recall, this concern hasn’t been borne out in clinical trials.

For advice on your rights and for sources of more info, you could call Beverley Beech of AIMS. She is an expert in helping women get the maternity care they want, and will almost certainly be able to help you find out the significance of your iron levels. Her phone number is on the AIMS website at www.aims.org.uk under ‘contact details’.

Generally, to improve your iron count you could try the following things, which are less likely to give you digestive problems than cheapo iron supplements. Natural source iron supplements are apparently better absorbed and don’t cause nausea or constipation compared with synthetic source:- Floradix yeast/iron supplement, from health food shops.- Dried apricots- lots of red meat! And read a good nutrition book, but I dare say you’re doing that already.

Angela
Home Birth Reference Site


Taking milk or tea (I think it’s the tannin that’s the problem) when she takes iron supplements or iron rich food will inhibit the uptake of any iron she ingests. Taking vitamin C at the same time seems to aid absorbtion.

The client should at least have her serum ferritin levels checked which will indicate the background levels of iron in her system, which is a more accurate assessmnent of her iron levels. The normal range of ferritin levels is 15-300 ug/l. This is carried out using a blood sample and her midwives may suggest other screening blood tests such as packed cell volume (the number of red cells as a fraction of the blood volume, can be reduced in anaemia): measuring the size of red cells etc.

Iron deficiency anaemia can lead to irregular heart rhythms, exhaustion and breathlessness and it is important that it is identified and treated if neccessary.

Jill


She has a slightly greater risk of haemorrhage. But with a low Hb, even a normal blood loss could be detrimental to her health. So she does need to get it up as close to 10 as possible. How many weeks pregnant is she? How much time left will determine what measures she will need to take. If she has time, double iron could bring it up in a few weeks. If she has an absorption problem with a chemical iron, then she could switch to something like Floradix, an iron tonic made from food sources. If she hasn’t got more than a few weeks she will need to resort to more drastic measures. There is the good old iron injection (does anyone still use this?) Or if she is stoic she could get yellow dock root from a herbalist. It can be made into a bitter tea sweetened with honey. If really desperate she will need to chew it to get the iron out of it and then spit out the pulp. An Hb was increased from 7.7 to almost 10 in less than 2 weeks using this last method by a very determined woman who, like your friend, wanted a home birth but was refused on the basis of her Hb.

One last point to consider. If her Hb drop was around 33-36 weeks and a severe drop, one must consider that she is carrying twins and hasn’t been diagnosed. The fetus takes up a good bit of iron at this time as a reserve and most women can handle it. But if it is 2 babies, well you get the picture. The reason I mention it is that the woman I previously described chewing the noxious yellow dock had that little problem. After the first baby was born at home with the community midwife she told the midwife that there was another baby. She was already seen as cranky so the midwife assumed she meant the placenta. What a surprise! I got the whole story by phone, never met the woman, but was the one advising her about the yellow dock. After the birth she called me to let me know about her babies and in relating the information to a wiser midwife (Kate Jackson) learned about the Hb drop and undiagnosed twins.

Melody


Referring to a woman with an Hb count of 8.6: She has a slightly greater risk of haemorrhage.

I have heard this before and I know it worries a lot of midwives, but others have said that the actual risk of haemorrhage doesn’t increase, only the difficulty in recovering from it if it happens – and some sources dispute even this. For example, in the section from ‘A Guide to Effective Care in Pregnancy & Childbirth’ by Enkin, Keirse, Renfrew and Neilson copied below,

A possible advantage claimed for a high level of haemoglobin in pregnancy is that the woman would be in a stronger position to withstand haemorrhage. There is no evidence to support this claim. indeed, as a low haemoglobin in healthy pregnant women generally implies a large circulating blood volume, it is at least possible that women with a low haemoglobin might better withstand a give loss of blood. 

I’ve trawled through Medline and found nothing on correlations between low Hb antenatally and risk of PPH. Not surprisingly, there are papers showing that a low postpartum Hb level is associated with having hada PPH! Do you have any refs for this, or any more suggestions?

Angela


A Guide to Effective Care in Pregnancy & Childbirth” by Enkin, Keirse, Renfrew and Neilson :

The normal haematological adaptations to pregnancy are frequently misinterpreted as evidence of iron deficiency that needs correcting. Iron supplements have been given with two objectives in view: to try to return the haematological values towards the normal non-pregnant state, a strange objective when millions of years of evolution have determined otherwise, and to improve the clinical outcome of the pregnancy and the future health of the mother. The first objective can certainly be accomplished; the key question is whether or not achieving the “normalized” blood picture benefits the woman and her baby. Routine iron supplementation raises and maintains serum ferritin above 10 microgram/litre and results in a substantially lower proportion of women with a haemoglobin level below 10 or 10.5 grams per cent (below 6-6.5 mmol/litre) in late pregnancy. Routine folate supplementation as a haematinic after the first few weeks of pregnancy substantially reduces the prevalence of low serum and red cell folate levels, and of megaloblastic haematopoiesis.

As yet, neither iron nor folate supplementation after the first trimester have shown any detected effect on the following substantive measures of maternal or fetal outcome: proteinuric hypertension, antepartum haemorrhage, postpartum haemorrhage, maternal infection, preterm birth, low birthweight, stillbirth, or neonatal morbidity. Women do not feel any subjective benefit from having their haemoglobin concentration raised.

A possible advantage claimed for a high level of haemoglobin in pregnancy is that the woman would be in a stronger position to withstand haemorrhage. There is no evidence to support this claim. indeed, as a low haemoglobin in healthy pregnant women generally implies a large circulating blood volume, it is at least possible that women with a low haemoglobin might better withstand a give loss of blood.

There are few data derived from communities in which nutritional anaemia from either iron or folate deficiency is prevalent. Trials are needed in these populations to establish the most appropriate strategies for combatting the deficiencies.

Whether routine iron supplementation causes any harm in well-nourished communities is still unclear, but it is clearly wasteful. The evidence suggests that, except for genuine anaemia, the best reproductive performance is associated with levels of haemoglobin that are traditionally regarded as pathologically low. There is cause for concern in the findings of two well-conducted trials that iron supplementation resulted in an increase in the prevalence of preterm birth and low birthweight. Perhaps there is an adverse effect on fetal growth due to the increased viscosity of maternal blood that follows the iron-induced marcrocytosis and increased haemoglobin concentration, which may impeded uteroplacental blood flow.

An individuals’ haemoglobin concentration depends much more on the complex relation between red-cell mas and plasma volume than on deficiencies of iron or folates. The advent of electronic blood counters has given an opportunity for more appropriate criteria to be applied to the diagnosis of anaemia. Mean cell volume may be the most useful; it is not closely related to haemoglobin concentration and declines quite rapidly in the presence of iron deficiency. A low haemoglobin without other evidence of iron deficiency requires no treatment.

If there is evidence of genuine iron deficiency, iron treatment is needed, and the usual approach is to give iron salts by mouth. There is no convincing evidence that the addition of copper, manganese, molybdenum, or ascorbic acid improves the efficiency with which the iron is used.

The cause of megaloblastic anaemia in pregnancy is almost always folate deficiency, and treatment with folic acid supplementation is rapidly effective.


Responses from doctors and students on sci.med.obgyn newsgroup:

Is there any evidence that low Hb can increase the chances of PPH, or is this a myth?

This myth has been around a while…I’ve never seen any evidence…

It also depends on definition…if your definition of PPH is need for transfusion, then maybe it’s true since if you start with a lower Hgb, you can suffer less blood loss before you need a transfusion. If your definition is strictly how much you bleed, then starting Hgb is irrelevant…

Adam Newman, MD


I have heard it suggested that a woman with low Hb levels in late pregnancy is at increased risk of PPH.

I am studying obstetrics at the moment (exams in 3 days). I know of no evidence to this effect. The mechanisms of PPH are uterine atony, lacerations, and retained products. None of these should be affected by anaemia, though I guess a general aplasia of marrow could lead to thrombocytopenia as well as anaemia.

The reason why haemoglobin levels are low is because the plasma volume increases, while erythrocyte production doesn’t increase so much. Hb levels are measured as a concentration, not as an absolute amount. Thus there is a normal ‘anaemia’ associated with pregnancy, which causes no problems. Of course one can also get folate/iron deficiency or malnutrition which causes a genuine anaemia.

Richard Cavell


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Home birth with low Hb, and Does haemorrhage risk increase with fourth baby?

Having booked with my maternity unit midwives some time ago for my third homebirth (although my first in this particular area of Scotland), in the last four weeks I’ve had an iron count of 9.4, told that if it doesnt go up ‘Doctor won’t support a home birth’. I’ve also been told that ‘I have to have syntometrine because I’m anaemic and that because it’s baby number four my uterus will be flabby, and I’m more likely to bleed’ They have handed me a load of scare stories re. post natal bleeding, in spite of no previous history…in fact I’ve bled very little at all, and today, been told that in spite of taking herbal iron and vit c the iron count has gone down to 9.

According to the midwives, the doctor won’t countenance a home birth, I can’t attend the maternity unit as their cut off for delivery is 9.5 or 10, and I have to go to the local large teaching hospital to have baby. (all the above from the not particuarly supportive midwives, who have spent the last 10 weeks telling me about their staff shortages, ‘there’s another woman at the other side of the glen wanting a home birth, so we might have to see to her rather than you’…….’this local woman who had a home birth and had to be rushed to the infirmary bleeding to death’…….’you’d never be allowed a home birth if it was baby number five….’)

What really infuriates me is I asked for this test at 30 weeks knowing this might happen having had problems with anaemia and iron absorbsion previously, and was refused because ‘doctor doesnt think it’s necessary at 30 weeks’. So he waits until 36 weeks when there’s precious little I can do to up the count.

I’m 40 weeks now (baby due tomorrow but doesn’t feel as if poppet will appear just yet), I was relaxed,happy, tired, but cheery, sitting in the sun drinking chamomile tea, but now I’m completely flustered, and extremely upset. Not only do I prefer my home births to hospital ones, the hospital is 20 miles away, I’m the sole driver, I’ve had one precipitate delivery, and the children and my husband wont be able to visit. (he doesnt drive and there are no busses in the middle of the countryside where we live). Completely impractical!

I’m sorry to rant so disjointedly, I just feel so let down by these people, and given the half truths I’ve been told by the doctor and midwives about the results of not taking syntometrine (in spite of three healthy deliveries without it) , and scare stories so far, I just don’t trust them at all. So am I being reckless in not going to the hospital? (I don’t even feel anaemic….in fact I felt great until they started pushing this. They don’t seem to get upset about my very low blood pressure which is normally about 95 over 60, so why are they upset about this?)


At our independent midwifery practice we look after a lot of women who have been told by their doctors that they don’t “support home birth” for various reasons. We NEVER ask for GP involvement in intrapartum care – GPs these days have very little to do with obstetrics (except from an honorable few who enjoy it and try to build up that side of their business) and therefore usually a GP’s input during a home birth is not useful. Either the birth is going well, in which case a doctor is not needed, or else a complication is developing, in which case transfer to hospital (even over 20 miles) may become appropriate. Midwives are qualified to do everything necessary to help you birth at home, as you know. They are trained in resuscitation of adults and neonates, and carry drugs to stop bleeding (syntometrine and ergometrine usually, but in some areas syntocinon as well – worth asking this question of your midwives) and equipment to set up I/V fluids should that become necessary.

I’ve also been told that ‘I have to have syntometrine because I’m anaemic and that because it’s baby number four my uterus will be flabby, and I’m more likely to bleed’

A woman’s uterus is more likely to be “flabby” if her nutritional status is poor, if she is under severe chronic stress, if she is knackered by the burdens of life – such as looking after three young children, running a house etc. It is a gross generalisation to say that your uterus WILL be flabby because it is your fourth pregnancy. You know your own nutritional status better than anyone – not too late to take it seriously now, if you aren’t already, because it will also help you greatly with postnatal recovery. Floradix is OK, and you can double dose on it, but I would also take sustained release vit C to help your immune system generally, and iron absorption also. If you are freaking out about iron levels, you could decide to take mainstream iron supplements till after the birth. Ferrous citrate is better than ferrous sulphate – doesn’t have the same nasty digestive side effects. Since you have suffered from similar problems with previous pregnancies, reading between the lines, it sounds to me more likely that you are a healthy woman showing a wonderfully healthy increase in blood volume (mostly increase in plasma levels, which means there are fewer red blood cells and more plasma present in the sample. Probably overall you have an increase in red blood cells as well, but not enough to balance the rise in plasma levels, so it looks as if you are getting increasingly anaemic). Woman who do not have a healthy haemodilution towards the end of pregnancy tend to have much more serious problems.

With regard to the burdens of life, it will be important to arrange for excellent support networks around the birth, and to rest and chill out as much as you can. Farm the kids out to friends for an afternoon and go to bed! If you can meet labour strong and rested, it sets you up for the next weeks of postnatal life, as well as an efficient labour.

They have handed me a load of scare stories re. post natal bleeding, in spite of no previous history…in fact I’ve bled very little at all

If you didn’t bleed during previous births, and if what I said above does not apply to you, then I would suggest it is unlikely that it will be a problem this time either. Since the midwives carry the necessary drugs with them, they can pursue a wait and see policy after the birth (on your directions). If it seems that you are bleeding heavily then they can give you the appropriate drug (which does have nasty side-effects for some women, but not for all), which is almost always quickly effective.

I was relaxed,happy, tired, but cheery, sitting in the sun drinking chamomile tea, but now I’m completely flustered, and extremely upset.

Trust your body, do what you can to up your iron and to rest, and chill out!

I don’t even feel anaemic….in fact I felt great until they started pushing this.

Different women can tolerate very different amounts of blood loss. Some women will react very badly to a relatively small loss (say, 400 mls, which does not officially count as a PPH, over 500 mls ) whereas I have seen a farmer’s wife whose Hb post delivery was down to 5 g/dl refuse a blood transfusion and discharge herself from hospital because she had to be back home to look after things. I visited her throughout the first ten days, and I never say anyone make such a good recovery!

I recommend you contact the AIMS website (www.aims.org.uk) if you have time, where I am sure you will find helpful and accurate information about third stage, and good support to help you stand against the moral blackmail of short staffing and lack of confidence in your situation.

I am sure things will go well for you!

Melanie, Independent Midwife


First of all I need to say that I’m not a midwife, just an interested mum – I run a website on home birth. However, I can read and think, and to my mind those are the main qualifications for discussing research of any kind!

The significance of low haemoglobin counts for women planning a home birth is something that I’m very interested in, because it’s quite common for mothers to be told that they ‘cannot’ have a home birth unless their Hb level is 10 or 10.5. This is sometimes accompanied by the suggestion that you are more likely to have heavy bleeding after the birth if you have low Hb. That assertion certainly seems to fall into the category of ‘obstetric myths’ as I’ve searched far and wide, and have found no evidence in support of it at all. In fact, I’ve found little evidence of any real problem with Hb levels in the range you are describing, although the midwives on the list will undoubtedly know more.

There are several issues here, so I’ll try to separate them out a bit.

1. Is there any evidence that low Hb makes you more likely to have a post-partum haemorrhage (PPH)?

Not that I’ve been able to find – despite extensive searches. I’ve trawled through Medline and found nothing on correlations between low Hb antenatally and risk of PPH. I’ve asked far and wide, but nobody has produced a reference for this in any textbook or study so far.

Not surprisingly, there are papers showing that a low postpartum Hb level is associated with having had a PPH! But that’s like saying “Your car has a dent in it, so it is likely that you had a crash in the past”, as opposed to “Your car has a dent in it, so you are more likely to HAVE a crash in future”.

See Implications of low haemoglobin levels/anaemia for more discussion of this issue.

2. Is it harder to recover from a PPH if you have low haemoglobin levels?

It is also sometimes said that the actual risk of haemorrhage doesn’t increase, BUT if you do have a PPH, it will be more difficult to recover from it. However, some sources dispute even this. For example, in the section from ‘A Guide to Effective Care in Pregnancy & Childbirth’ by Enkin, Keirse, Renfrew and Neilson :

“A possible advantage claimed for a high level of haemoglobin in pregnancy is that the woman would be in a stronger position to withstand haemorrhage. There is no evidence to support this claim. indeed, as a low haemoglobin in healthy pregnant women generally implies a large circulating blood volume, it is at least possible that women with a low haemoglobin might better withstand a loss of blood. ”

3. Are you at more risk of PPH with your fourth baby?

See Grand multiparity and PPH risk , below.

4. To have Syntometrine or not?

See Active versus Physiological Management

5. Ways to increase your Hb count

I know Junior is due any day, but still – it sounds like you are taking Floradix or something similar? That, vitamin C, and avoiding tea (normal, not herbal) are suggestions that have come up on this list before.

The American Midwife Archives at gentlebirth.org have lots of ideas on supplements and foods to increase Hb counts: (http://www.gentlebirth.org/archives/nutrition.html#Anemia)

6. Having a Home Birth Anyway

You probably know this, but you can insist that you are having a home birth regardless of what your midwives/doctors say. After three home births I doubt there’s much you don’t know about it!

It is not your responsibility to arrange doctor cover for a home birth – your midwives can arrange that if they feel it is necessary.

I suppose if it would keep your midwives happy, you could always say that you will have the baby at home, but agree to syntometrine ‘just in case’ because it is your fourth baby? And if the labour goes well and you decide on the day not to have it after all… well, a woman has a right to change her mind….

Plenty of women do have home births with their fourth and subsequent children – it’s all about looking at your risk factors as an individual, rather than just seeing you as a mother who has four or five children, or who is over 35, or whatever. It is important to accept that there is a higher risk of needing to transfer in certain situations, but as long as you understand the risks, the decision is yours. From what you’ve said, booking a hospital birth with a history of precipitate births sounds very risky indeed – imagine if you gave birth in the car on the way there, and had a PPH on the roadside! – so maybe your caregivers need to think that through a bit more carefully…

As a matter of urgency, I would contact AIMS for advice on rights and strategies – in Scotland, Nadine Edwards would be your first call, otherwise Beverley Beech will no doubt have plenty of ideas. Contact details, from the AIMS website (www.aims.org.uk):

Nadine Edwards telephone 0131 229 6259 nadine.edwards@aims.org.uk

Beverley Lawrence Beech telephone 01753 652781 beverley.beech@aims.org.uk

Partly on the basis of the above stuff on Hb levels, I have had no blood tests at all during this pregnancy (am due in 3 weeks) – I feel fine, I know my immune status, and it seems to me that blood tests are just another thing to worry about. Even if you feel really laid-back, for me having blood samples taken is stressful, and once I’ve had the sample taken, somewhere in my mind there will be a nagging worry about the results until they turn up. Then I would be focussing on the Hb reading to tell me how ‘healthy’ I was, as opposed to taking notice of how my body seemed to me – if this makes sense. My midwives have been absolutely fine about this – in fact, they have repeatedly pointed out that it is entirely my decision, they’re completely happy as long as I feel well, and that if I were anaemic enough for it to be a problem, I would be feeling tired and looking unwell.

Angela Horn
Homebirth Reference Site (www.homebirth.org.uk)


Updates from mother wanting a home birth with low Hb for fourth baby:

Thank you so much for all the information and references regarding anaemia and pph. I got to my ante natal on Tuesday fully armed :0) but in the event, the only reference that was made was that the midwife had written on my notes that the obstatrician had recommended transfer to the local teaching hospital, but my husband and I were staying with our decision to have a homebirth. I noticed a note on my file too that I was ‘ unhappy with the service given by xyz midwives’ which wasn’t entirely true. It was the continual shroud waving re syntometrine etc and the doctor’s obvious reluctance to support a home birth!

And a few days later:

Just to say that my son was born at home yesterday. Waters broke gently in bed at ten to seven in the morning, climbed into the bath about ten when the contractions became more regular, phoned midwives at the same time, they arrived at half ten, and baby arrived at eight mins past eleven. No pph no syntmetrine, just a normal, gentle birth….uterus has obviously been working out!


Should you take iron supplements?

At 11weeks I am having a serious conflict about what to do about iron supplementation, I have read in most places that no matter how much iron you get in your diet, as a pregnant woman you will be incapable of maintaining “normal” iron levels without supplementation.

Hello……isn’t our body trying to tell us something, like maybe we are not supposed to have high levels of iron?

Sheila Kitzinger in “THE COMPLETE BOOK OF PREGNANCY AND CHILDBIRTH” explains that if you did not start out anemic, then iron supplementation is not necessary for the normal drop in hemoglobin from mid-pregnancy. This reduced hemoglobin is a sign that plasma volume is rising and that the placenta is providing good nutrition for the baby.” In a different chapter she explains” A pregnant woman has about 40% more blood flowing in her body. It used to be thought that a woman’s hemoglobin levels must be kept high during pregnancy by iron supplementation. But most women whose hemoglobin concentration does fall are more likely to go full term and have babies of good birth weight. If hemoglobin concentrations fail to fall there is a marked increase of the incidence of low birth eight and preterm labor.” She quotes two medical studies to back this up. The babies are probably LBW and preterm because the placenta wasn’t nourishing the baby properly so therefore hemoglobin levels did not drop.


This is based on information from a variety of sources, but primarily from Gabbe’s Obstetrics (which also has some very nice charts utlining this physiology and gives good numbers as well!)

Blood volume starts to expand at 10 weeks, expansion plateaus at 30 – 34 weeks. Average increase is 50%, normal range considered to be 20% to 100% increase. Bigger babies, multiple gestations will have increases on the higher side.

Seen in lab work as dropping hemoglobin/hematocrit (physiological anemia of pregnancy), Rising Hg/Hct may be early signs of problems, but diagnosis confounded by iron supplementation.

Red blood cell count (RBC) increases throughout pregnancy: 18% increase if not supplemented, 50% increase if supplemented.

Platelets: Count progressively decreases in normal pregnancy by about 15,000/mm3, still stays well within the normal range for non-pregnant women. Average count goes from 275,000 to 260,000. Counts below 150,000 are indicative of potential trouble.

Coagulation Fibrinogen levels increase, other clotting factors stay about the same as in the non-pregnant state. Marked increase in fibrinogen levels a sign of trouble Hemolysis. RBCs are turned over faster during pregnancy, the accelerated breakdown being matched by an accelerated production. This can stress the liver (excreting bilirubin and other byproducts of hemolysis). Breakdown not matched by production signals a problem.


The thing that helped me when my iron got low was something called “Floradix + Herbs”–it’s a natural-liquid iron that is absorbed into your body without a lot of the usual side effects from an iron supplement. My iron count was 9.5 and within a week was 10.5 and got up to 12 before the baby was born.

Dawn


There are many suggestions for diet and supplements on the Midwife Archives page on prenatal nutrition (http://www.gentlebirth.org/archives/nutrition.html#Anemia).


Nutrition and PPH

Taking milk or tea (I think it’s the tannin that’s the problem) when a mother takes iron supplements or iron rich food will inhibit the uptake of any iron she ingests. Taking vitamin C at the same time seems to aid absorbtion.

(A mother with a low Hb) should at least have her serum ferritin levels checked, which will indicate the background levels of iron in her system. This is a more accurate assessmnent of her iron levels. The normal range of ferritin levels is 15-300 ug/l. This is carried out using a blood sample and her midwives may suggest other screening blood tests such as packed cell volume (the number of red cells as a fraction of the blood volume, can be reduced in anaemia): measuring the size of red cells etc.

Iron deficiency anaemia can lead to irregular heart rhythms, exhaustion and breathlessness and it is important that it is identified and treated if neccessary.

Jill


From Midwifery Today E-News:

Hemorrhage in Asia by Robin Lim

During my six years of catching babies in Indonesia, I never saw a fatality from hemorrhage in Indonesia (we were able to control them), but I saw far too many women bleed excessively after birthing. Speaking with elder healers who used to catch babies in Bali, I discovered what they believed was the cause of so much postpartum hemorrhage: In the early 1960s US government aid organizations introduced “Green Revolution” hybrid rice to Asia. This rice matures in three months rather than six, so it was supposed to end hunger. But because it is also a weak variety, it is susceptible to fungus and pests and must be heavily sprayed with herbicides, anti-fungals and pesticides.

Overnight the people went from eating organic red rice as their staple food to ingesting a hybrid, sprayed rice that was polished down to white. Even the rats won’t eat this rice. This is handy—it makes it easy to store.

According to Mangku Liyer, a healer priest in Pengo Sekan, Bali, “Within the first season of the new rice I saw women dying, so many dying, bleeding too much after childbirth. Before, when a woman would bleed too much, I could stop the bleeding with herbs and young coconut water. After we began to eat the new rice, I could no longer help the women. I only could help bury them.”

In June 1998 we arrived at Baguio, Philippines, the home of my mother. I immediately began to catch babies for the marginalized mountain people.
I was astonished to find that these Filipino women, unlike the Indonesian women I had helped, were not hemorrhaging after giving birth. Their secret seemed to be in their food. They were eating organically grown red rice and sweet potatoes. Unfortunately women living a more modern lifestyle (in either the Philippines or Indonesia) in the city and eating commercially grown white rice and fast foods, had higher blood pressure and more postpartum blood loss.

So let me take this opportunity to say what we all already know: sound nutrition equals healthy mother, healthy baby and better birth outcomes. Please, if you’re pregnant or helping pregnant women, choose organic foods. It makes a tremendous difference.

Note: The family health clinic I raised funds to build in Bali is now open and being run by two wonderful Balinese midwives. Thanks to everyone who helped in so many ways. Some gave their time, books, used baby clothing, equipment, birth supplies, money, etc. Your generosity has gone a long way.

I will be returning to the Philippines in November to open a free-standing birth center in cooperation with Good Shepherd Convents and the Dept. of Health in Baguio. We hope to encourage traditional birth attendants and help them get the supplies, supplementary training and networking they need and want. Many women have been trained in college as midwives but there are no jobs for them. Right now 30% of the reported births in Baguio are unattended homebirths. As fatalities are not reported, Mary Fernandez of the Baguio Dept. of Health can only imagine how many births actually still take place at home. Our shared dream is that if low cost or free homebirth services could be made available, birth outcomes could be much improved.


Links to other sources of information:

Midwifery Today article on PPH
(www.midwiferytoday.com/Library/articles/hemorrhage.html )

Midwifery Today E-news edition on PPH
http://midwiferytoday.com/E-News/enews1n35.htm

Suggestions for increasing Hb levels through diet and nutrition
www.gentlebirth.org/archives/nutrition.html#Anemia

Thrombocytopenia of Pregnancy – Low Platelet Levels


AH updated 31 January 2001

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