by Alan Lindemann, M.D.
USA Today has written a series of articles on the high rate of maternal deaths in the United States. In conjunction with this series, USA Today has produced a two-page check list Advocate for Yourself: Lifesaving Tips for a Safer Birth. The notion of advocating for yourself is an important one, including the information on how blood pressures should be taken during labor and delivery.
Yes, most births in the US occur without incident. But you want to be prepared for an emergency. Whatever happened to the doctor or the midwife being the advocate? And why does anyone think this article is needed? For one thing, every “country with resources” has a declining rate of maternal deaths—except the U.S., Afghanistan, and the Sudan . Why?
Centers for Medicare and Medicaid Services (CMS) has with their payment structure for Medicaid replaced the patient as the primary player in childbirth. Patients are taking the back sat to corporate medical facilities search for higher payments, or from keeping the costs of the patient low enough to be paid well from Medicaid. For example, corporate medicine has developed the “doc on deck” approach to childbirth, guaranteeing that laboring mothers see a different, probably unknown, obstetrician every 8 hours of their delivery. That is, laboring mothers are unlikely to see the obstetrician they worked with for the preceding months before they went to the hospital to deliver. Despite all these factors introduced to keep the cost of deliveries down, the price tag for labor and delivery is increasing.
The advocacy sheet lists three main symptoms to watch carefully:
- ensure they’re measuring blood loss,
- pay attention to blood pressure readings, and
- know the signs of pre-eclampsia.
Ensure Blood Loss is Measured
Excessive blood loss is one of the main causes of preventable death and damage. Not all hospitals have a policy of the nurses measuring blood loss. Estimates can be too high, but more often too low. Measuring blood loss is a simple process, but in my experience, one many nurses would rather not do. The weight of the dry pad is known. When changing pads, weight the pad and subtract the dry weight from the weight of the wet pad.
At my first job in 1981, I asked the nurses whether they weighed all the wet pads. They said they did not, but they would start. As I moved to other delivery sites, I found there was no uniform policy on measuring blood loss. In one hospital, the nurses could weigh pads but only if they thought the bleeding was excessive. At other hospitals, no nurses would or could weigh a wet pad correctly, even to save their own lives.
Some bleeding is not easily detectible. If the doctors or nurses cannot do appropriate fundal checks, including massage, several units of blood can pour into a flaccid uterus. Then there is the episiotomy which might be bleeding, or even a vaginal tear. Two years before I arrived at my first hospital in 1981, a mother had died from a bleeding episiotomy. This type of bleeding can be very hard to detect. Several units of blood can bleed into a mediolateral episiotomy, even moving up to and around the kidneys. These kinds of bleeding will NOT show up on a wet pad.
The moral of the story: some kinds of post-partum bleeding cannot be easily found. Training and effective post-partum management are required. Wet pads should be weighted for every birth, but there also needs to be accurate assessment of the post partum uterus and episiotomy.
Your caregivers should learn about your personal risk factors and prepare for thrombophilias [https://www.ncbi.nlm.nih.gov/pubmed/23963422] and hereditary clot disorders such as hemophilia, Factor V Leiden, and methylenetetrahydrofolate reductase (MTHFR).
If your blood type is rare, your birthing center should have that blood type available. They should be able to start a large bore IV and know how to give a large amount of blood rapidly.
Pay Attention to Blood Pressure Readings
This is much easier said than done. The meaning and understanding of blood pressure values is both intricate and complicated. The authors of this advocacy sheet indicate that a blood pressure reading of 160/110 is dangerous and certainly requires immediate treatment. However, for some women, lower blood pressures than this can be dangerous. To understand the real meaning of pregnancy related hypertension, the caregivers need to know the pre-pregnancy blood pressure as well as the blood pressure course during pregnancy, which can and does vary according to trimester.
In pregnancy, blood pressure usually drops in the first trimester, stays low in the second trimester, and then gradually increases in the third trimester. Blood pressure in labor and delivery is relative to what it was before and during pregnancy. I had a patient pregnant with her first baby who had a blood pressure of 158/104 on her initial visit. I prescribed aldomet and during her pregnancy she ran blood pressures of 120-130/80-89. She delivered a 9 lb baby vaginally at term. Was I worried, yes. Did she suffer any harm, no.
In another case, I had a 15-year old pregnant with her first baby with an initial visit blood pressure of 90/50. Of the 6000 births I managed, there were no strokes, no eclampsia, and no deaths from blood loss or any other causes. She was the one which I was most worried about because her blood pressure went up to 129/90. Her liver, kidney, and complete blood count (CBC) all showed evidence of pre-eclampsia. I did her c-section. She did well during the surgery and post partum.
Medications today are much the same as used 30 and 40 years ago. Blood pressure is lowered to prevent strokes, not to prevent or treat pre-eclampsia or eclampsia. Magnesium sulfate is still used to treat pre-eclampsia and eclampsia. Labetalol and hydrazine are both used IV for the treatment of high blood pressure. They worked 40 years ago and they still do today. They remain beneficial and safe.
Know the Warning Signs for Pre-eclampsia
If we use only the hard and fast rule that a patient is safe until her blood pressure reaches 160/110, many pregnant women will have a seizure. It is true that high blood pressure in pregnancy (140/90) or more may signal developing pre-eclampsia. Know your pre-pregnancy, first trimester, and second trimester blood pressures. Yes, it’s true that elevated blood pressure is usually the first sign of pre-eclampsia.
There are some other signs of pre-eclampsia.
- Swelling of the hands and face. Swelling of the face and hands can warn of pre-eclampsia, but on the other hand, it is not always a sign of anything.
- A headache that won’t go away, even with medication. It can be a migraine, brain tumor, hypertension, pre-eclampsia, or stroke.
- Change in vision. This could be many things, including pre-eclampsia or a sign of migraine.
- Difficulty breathing. This also could be anything from normal pregnancy air-hunger to congestive heart failure. While this condition could be benign, delaying attention to it can be very dangerous—and too late.
- Sudden nausea or vomiting after pregnancy mid-point. While vomiting and nausea could be morning sickness, after the mid-point in pregnancy, it could also be associated with pancreatitis (either primary or secondary), cholecystitis (gall bladder infection), cholelithiasis (gall stones), hypoglycemia, or bad food choices.
- Pain in the right upper belly. Yes, this could be “Hemolysis, Elevated Liver enzyme levels, and Low Platelet levels” (HELLP), pancreatitis, liver capsule rupturing, cholelithiasis, orcholecystites, constipation, or diverticulitis.
How to Take Your Blood Pressure
This article on advocating for yourself insists that nurses take your blood pressure correctly. For anyone who has spent more than three months in a hospital working with doctors and nurses, the process described here is bad advice. Telling nurses how to do their job will offend them. You will be seen as a troublemaker and more likely than not, insisting on having your blood pressure taken in a chair will backfire and your care will suffer.
How likely are you to have your blood pressure checked according to these instructions while you are in Labor and Delivery. Not very. In my 50 years in health care, I have NOT seen blood pressure taken this way in a hospital. Frankly, taking your blood pressure correctly is not the greatest problem.
Placing the patient in bed in the left lateral decubitis position (midway between back and left side) will produce a blood pressure probably lower than it really is. Additionally, and I’ve never seen it otherwise, the nurses will take your blood pressure several times and record the one that is lowest. I have sent more than 1000 patients to the Labor and Delivery with what I knew was high blood pressure because I found it in my office. The patients and nurses would report to me that there was no elevated blood pressure.
On occasion I have even heard of nurses who turned off the blood pressure monitor because they already knew the blood pressure was high.
In short, blood pressure hardly ever rises precipitously, based upon what I’ve seen in over 6000 pregnancies. It almost always rises slowly and predictably. A “sudden rise” is more likely due to lack of attention to detail.
There Are Only Two Real Obstetrical Emergencies
The two deadly emergencies in labor and delivery are the saddle pulmonary embolis and the cerebral congenital aneurysm.
Saddle Pulmonary Embolis
A saddle embolis is fatal most of the time (99.9%). Even if the clot is removed, there is uncontrollable disseminated intravascular coagulations (DIC) and hemorrhage. The usual best outcome would be post-partum so the baby doesn’t die. The surgeon has 5 to 10 minutes to get the baby out in a post-mortum c-section.
Cerebral Congenital Aneurysm
The cerebral aneurysm rupture usually occurs during pushing. This could present as the worst headache ever. Pay attention to recurrent headaches. Just because headaches are frequent or long-term does not mean they are benign. They should never be ignored. A computerized tomography scan (CT scan) or magnetic resonant imagery (MRI) is needed. Ideally, the aneurism would be taken care of before delivery and need to be fatal, but the diagnosis would be either by the CT or MRI of the head. With this complication, there is more time to get the baby out because maternal death is not always simultaneous with delivery and indeed, may well not occur at all.
Avoid Some of the Problems by Interviewing Your Caregivers
My advice is to have input into your prenatal, delivery, and post-partum care. Interview candidates until the ones you feel most comfortable with are found. The time to “make deals” is before you need the care and before you have paid them. This goal can be part of your birth plan. Let those who will be caring for you at last have a chance to get accustomed to your needs and wants.
You might also consider a midwife or doula to advocate for you if you can find one you like or who is welcome in the hospital. It’s certainly possible for the baby’s father to advocate for you, but it can be difficult to advocate for a family member. Dad may just want to be a dad in this process.
I have always welcomed the baby’s father into my office for prenatal care, into the labor and delivery rooms, and even in the operating room during c-sections. I’ve never had a reason to regret it. They have been pleasant, supportive, and not one of them has fainted. Their presence in the anti and intrapartum course promotes a healthy post-partum. For example, the father of the quadruplets I delivered says with pride that he figured he changed 7000 diapers a month. How we as caregivers support our patients in the prenatal and delivery process promotes effective family bonding and decreases the risk of post-partum depression and psychosis.
With careful planning, we should be able to promote healthy bonding which can last a lifetime.