Mothers, midwives and post-natal ‘blood’ loss

‘Blood’ loss after childbirth is a normal occurrence for women, due to the separation of the placenta. Excessive blood loss within the first 24 hours is known as primary post-partum haemorrhaging, while excessive blood loss after this period is known as secondary post-partum haemorrhage. Research undertaken by former Bournemouth University staff explores the prevention and early detection of the latter, which can result in chronic ill health and even the need for emergency medical care.

The ‘blood’ loss, known as lochia, gradually changes colour and reduces in volume over several weeks. Observations of the lochia and the gradual reduction in size of the uterus in the first few weeks after childbirth have long been a standard part of midwifery care. These observations are an essential part of monitoring for warning signs of secondary post-partum haemorrhaging.

Dr Sally Marchant and Emeritus Professor Jo Alexander were the lead researchers behind the project, which was partly inspired by Dr Marchant’s earlier career as a practicing midwife.

“I was a Ward Sister for around ten years, specialising in postnatal care,” explains Dr Marchant, “During that time, I noticed that there were some inconsistencies in practice. Midwives were taking very different approaches to the same task, as a lack of evidence meant it was unclear which method was best.”

A review of guidance for midwives in textbooks showed that while certain postnatal practices were advocated as being correct care, there was very little evidence to underpin them. Having established the gaps in knowledge, the next stage of the research was for Dr Marchant to carry out a longitudinal survey of postnatal women to see how their lochia changed over time and what advice they were being given.

“The second stage of the research was quite revealing, as it showed us that there was a huge lack of knowledge among new mothers about why they were being asked to monitor their ‘blood’ loss”, explains Dr Marchant, “Women were aware of what to look for, but not why it was important or why a change might be significant and could be something to be concerned about.”

“For midwives, it seemed to be perceived as just another test which needed to be conducted as part of their routine checks. We also found that the way notes were written up was quite inconsistent. The terms and language midwives used to describe the postnatal uterus varied hugely, so there was sometimes miscommunication about the normality of a woman’s health.”

As a result of their research, the team were able to make a number of evidence-based recommendations which still underpin the advice in midwifery textbooks today. These recommendations also inform World Health Organization (WHO) guidance on this aspect of postnatal health.

The final stage of the research was a case control study in which Dr Marchant compared retrospective data of 530 women who had not experienced secondary postpartum bleeding against 265 women who had. The aim was to establish predictive factors, which might help to identify at-risk women.

“Among other things, Dr Marchant found that if women had a previous history of the condition then they were at higher risk of it happening again,” says Professor Alexander, “We also found that smoking during pregnancy was a risk factor, which wasn’t an obvious connection.”

“In addition, we looked at the extent to which midwives’ observations were predictive of the likelihood of secondary post-partum haemorrhaging. We found that they were significantly predictive, which was reassuring!”

The project took place as part of the work of a wider group of researchers who were exploring a number of different avenues related to the health of women, babies and their families. This included considerable work in the area of post-natal care and breastfeeding which, among other successes, resulted in a module about breastfeeding for the website HealthTalk. This site brings together video clips of women recounting their experiences, with best quality evidence in order to help others to gain a better understanding of any health challenges they may be facing and to feel less isolated.

For more information about BU’s research in the area of maternal health, visit the website of the Centre for Midwifery, Maternal and Perinatal Health: www.bournemouth.ac.uk/cmmph

This article featured in the 2018 Bournemouth Research Chronicle which can be found in full here.  Individual articles can be read here.