Understanding Hemorrhage in Pregnancy

In this conversation, Dr. Robert Maupin, Division Chief, Louisiana State University School of Medicine, and Dr. Kimberly Turner discuss critical aspects of maternal health, focusing on hemorrhage during pregnancy and the postpartum period. Dr. Maupin explains the definitions of bleeding and hemorrhage, the significance of placental issues, and the importance of effective communication between patients and healthcare providers. The discussion also highlights the need for training healthcare professionals to recognize and respond to emergencies, as well as the importance of patient education regarding symptoms and risks associated with pregnancy and postpartum care.

Catch full episodes of the Moms, Minds, and Medicine (M3): Inside Maternal Health Research Podcast here on YouTube: https://youtube.com/playlist?list=PLv4qXQ6sECQPdkBvXPng5RXOvh3rUrbLY&si=MerdAjUvSdJQLVQr 📺

—

Subscribe to our channel here: https://www.youtube.com/channel/UCbCKCKG5N4ZWZMF0oGzIeyA

—

Follow our social media accounts to keep up with the Maternal Health Research Collaborative:

Instagram: https://www.instagram.com/maternalhealthrc/

Facebook: https://www.facebook.com/maternalhealthRC

Transcript

Introduction to Moms, Minds, & Medicine: Inside Maternal Health Research

SPEAKER_02 0:00

Dr. Kimberly Turner. Welcome to medicine inside maternal health research. This podcast is your trusted competent on the pregnancy journey, where you break down the latest insights, answer the real questions, and empower you to make informed decisions every step of the way.

Welcome Dr. Robert Maupin

SPEAKER_02 0:28

Hello to our viewing audience. Welcome to Mom's Minds and Medicine inside maternal health research. We are so excited to have our guest from Louisiana State University, Dr. Robert Maupin. Can you tell the viewership a little bit about yourself?

SPEAKER_00 0:48

Oh, um, well, I am a lifelong clinical provider in women's health. Um, I presently serve at LSU Health School of Medicine as the Associate Dean for Community Engagement, but on the clinical side, uh, I am a professor of obstetrics and gynecology and I'm the division director for our maternal fetal medicine section. Uh I've been with LSU Health for 30 years. I'm originally a native of the Washington, D.C. area. Grew up on the East Coast, although from a family standpoint had Louisiana roots. But following completion of medical school on the East Coast, uh came to LSU for training, and after going through advanced training in maternal fetal medicine early in my career, I came back to LSU on faculty and had had a journey in academic medicine with various roles and various areas of emphasis for about 30 years.

SPEAKER_02 1:45

Yes, 30 years is a long time. I think that's roughly when you and I worked together at the University of Maryland. So thank you so much for spending a few minutes with us to educate our viewership on bleeding and particularly hemorrhage in pregnancy. So I'd like you to tell them what exactly constitutes a hemorrhage in pregnancy. And we're going to talk primarily about the end stage of pregnancy called the third trimester. For anyone who doesn't know, we break pregnancy

Understanding Hemorrhage in Pregnancy

SPEAKER_02 2:15

into thirds basically: first, second, and third trimester. And when bleeding is in the third trimester, sometimes we have to deliver the baby. So can you just explain a little bit what's significant bleeding, what's insignificant, what is a hemorrhage?

SPEAKER_00 2:29

Well, just one thing that's sort of amplifying add-on to your um to your classifications or categories. One of the things that's been super important in recent years, led by important work from individuals who are leaders in the field, is that we really have a fourth trimester as well. Um, and that's the window that begins, you know, traditionally in the postpartum window. Um, and that is a space that's also very important for us to touch on when we talk about bleeding and specifically hemorrhage. Because in fact, that's that window shortly after birth can be the window when there is the greatest potential risk for adverse bleeding that leads to complications. So there's a difference between bleeding and hemorrhage. Um bleeding can occur in to various degrees throughout pregnancy. Um, it is very common for mothers to experience very mild or light bleeding, even following conception. So after the implantation of pregnancy in the first trimester, there's commonly a little bit of first trimester post-implantation bleeding. When moms see that, they're alarmed, but usually, if it's very self-limited, medically it doesn't lead to any complications. Bleeding in early pregnancy, our major concerns are going to be in those instances where it may be associated with the risk of miscarriage. But as we move through pregnancy, as we move further through second and third trimester in the perfect world, um bleeding should in the big picture become an uncommon entity. I think our estimates are that when we look at the span of pregnancy, especially late pregnancy, uh probably about five percent of pregnancies are complicated by bleeding. Um estimates you know suggest it's up to 10%, but I'd say 5% is probably probably the range. Overall, about 3% of instances in terms of pregnancy, we might say significant bleeding. And so when we use the language hemorrhage, we're talking about medically significant bleeding that leads to the possibility of the mom's condition and/or the field conditions being medically unstable. One thing to note is when we actually look at obstetric hemorrhage and especially hemorrhage around the time of delivery, we've actually advanced our definition. A lot of times we were using different language and different means of estimating what constitutes hemorrhage as opposed to normal bleeding. But but the definition that's accepted currently and that's that's really proposed that's really advanced by our college is that there is uh the loss of up to a liter of blood or more, and it's associated with some changes in mom's physiology, uh, meaning blood pressure drops, or um she becomes hyper, uh she becomes tachycardic, meaning a fast pulse. Um so if there are some changes in the mom's clinical status in association with bleeding that reaches about a liter, we can use a thousand cc's, but people you know can commonly associate what a liter is when you think about a liter drink, um, a liter soda that you get at the at the at the grocery store, that amount of bleeding constitutes what we describe around the time of birth as hemorrhage. Just a few other notes of importance. There are different factors that we see that go into areas of significant bleeding that occur in late pregnancy before the birth, so i.e. the third trimester, as you mentioned. Um, and then there's another window of bleeding that becomes medically important, and that is right around the time of delivery. Um, when we're managing the mom through the birth process and the immediate aftermath of birth, that's a window where some mothers may be susceptible to significant bleeding.

SPEAKER_02 6:17

Yes. This is one of the reasons that I really wanted to touch on and talk about in in depth the problem of hemorrhage, because when you're pregnant, you don't expect to see blood.

SPEAKER_01 6:29

Right.

SPEAKER_02 6:29

And we're hearing quite a lot in the press about women dying in pregnancy. And one of the number one causes is from bleeding, either late in pregnancy or postpartum. So thank you so much for that definition.

Recognizing and Responding to Bleeding

SPEAKER_02 6:45

So if I was a patient, and in the past I was a patient, um, and I see blood and I'm 37 weeks, what do I do?

SPEAKER_00 6:57

The first thing is to be completely aware of what you're seeing, right? It's important when you're communicating with your providers that you can describe, you know, if I'm seeing blood, obviously I'm alarmed. We're always going to ask, you know, give me some estimation of how much bleeding you're experiencing. Is it just a little bit of spotting when you use the restroom, or are you actually seeing, you know, more overt bleeding? Um, and when we're talking about obstetric bleeding, we're talking about vaginal bleeding. Um, so are we seeing something that's that's more than just spotting when you're using the restroom? We're gonna want to know do you have any associated symptoms in the third trimester? Because we know that in the third trimester there are probably two big factors that translate into a risk of when we when we're seeing bleeding, um, that this is gonna be medically risky. Those two factors include one condition that we call that we describe as placental abruption, and in simple terms, it means that the placenta separates from the wall of the uterus either partially or completely, which you know can be a medical emergency, or in other instances we can have a patient where the placenta location is too low in the womb and either covers the cervix or is right adjacent to the cervix. And the medical term we use for that is placenta previa. So those are the two factors that most commonly are associated with late pregnancy bleeding, i.e. third trimester bleeding, that turns into something that's medically alarming. So describing for your provider, um, and that means your obstetrician, your nurse-midwife, uh, nurse practitioner who might who might be responsible for your prenatal care, how much bleeding are you seeing? What does it look like? Um, and do you have any associated symptoms? Are you contracting? Is there watery discharge associated, which could it could suggest that your membranes have ruptured or that your water bag is leaking? Or is it painless? Because if there is significant bleeding that's painless, sometimes that moves us in the direction of, you know, might this mother have a placenta previa? If contractions or pain are associated, then the thing we we want to make sure that we evaluate is there's some something that suggests that this might be a placental abruption where the placenta is separating, because that's going to be something that is a fairly significant medical emergency. So being able to be aware of what you're of what you're experiencing with your body with a symptom of bleeding is important. But then being able to communicate with your providers exactly what you're experiencing. So it leads them to evaluate, uh at least it assists them with their evaluation. In the long run, if if this is occurring in late pregnancy, almost invariably we're going to ask you to come to the hospital or come to the office so that we can evaluate things. It should never be something that if you're seeing bleeding that's enough that it's getting your attention and it's alarming, you should never just blow it off. For instance, if it's a weekend, say, well, I'll just wait and talk to my doctor, you know, on Monday or Tuesday or my provider, or or I'll just wait till my next appointment. Um, sometimes we see moms that unfortunately you know make that, make the decision to kind of have a delayed conversation. And that delayed conversation, in many instances, may not necessarily you know translate into a complication, but in some instances it will. So the sooner we're aware of what you're experiencing, the sooner we're able to undertake some objective evaluation, um, the better the opportunity for us to get to the root of what's going on so we can determine is this something that's benign, um, not an emergency, or is this something that actually requires our attention or treatment?

The Role of the Placenta

SPEAKER_02 10:42

Right, right. So, just as a reminder, you know, the placenta, it's such an important organ, and I became so fascinated with obstetrics because of what the uterus can do. It can grow a placenta, which is a huge blood vessel that nourishes the baby. The uterus can expand to accommodate up to like eight babies, and the next day, if everything is normal, kind of be back to its normal state. So we talked about abnormal placenta. Placenta previa. That's the low-lying placenta. Luckily, in today's, and correct me if I'm wrong, most today's medical world, most of us would know if we had a placenta previa because of the advent of ultrasound. We were scanning patients many times in pregnancy, and that's pretty easy to see after 20-ish weeks. Um even before. Placental abruption, I think, is a little harder because you wouldn't know that you had that. And when I was in clinical medicine, if you have placenta previa and you see any blood, we want to see you. Placental abruption is a little harder, um, at least to know that it's going on from the clinician's standpoint before we see the patient. So, can you tell the viewers what are the risk factors for a placental abruption?

Risk Factors for Placental Abruption

SPEAKER_00 12:01

So there are a range of things that could contribute to that as a risk. Um, probably the thing that's most central is hypertension. There are a range of different hypertensive conditions that moms may experience during pregnancy, from having underlying essential hypertension to having uh gestational hypertension or pre-eclampsia, which is a more involved version or form of gestational or pregnancy hypertension. Hypertension is probably the biggest risk factor, uh, especially that can translate into an acute presentation of placental separation. Other background risk factors, there are a range of different things that we might see for, for instance, smoking or tobacco use. We know that that can affect the quality of the interface between the placenta and the womb and the quality of the blood vessel integrity. So smoking is a risk factor. In the subset of mothers where they may be using additional substances, um, for instance, like cocaine, um, which fortunately we're seeing less of in many of our settings these days, but we know because of the abrupt changes in blood vessel integrity that may be associated with using that substance, um, there may be a risk for an abruption. But we also know that other instances, you mentioned a mother who has up to eight babies, which is going to be pretty rare, but it is relatively common for us to see see moms with twins. So multiple gestation sometimes affects the placement of the placina and the integrity of the placina. And there may be a little higher occurrence of an abruption with multiple gestations. Some instances a prior cesarean delivery could be associated with uh with a risk of abruption. So those factors as backgrounds go into the information that's important when we're receiving the communication from a mother that they're seeing bleeding in the third trimester. Often, if you actually have an abruption, um, there's gonna be pain and you'll have contractions to some extent. Not always, and so sometimes the diagnosis isn't always readily uh apparent, but those things are often often going to be present. Dialing back to you to one of your first observations, and that is you know, about knowing if we have a placenta preview or not. Um it is it is a fact. You know, ultrasound is very liberally liberally used in obstetric care. And in fact, that's what I spend quite a bit of time doing. I've you know spent pretty much most of my day yesterday involved with obstetric uh imaging for my for expectant patients. Um however, we know that sometimes there's a difference in the quality of ultrasound, and there may be a difference in in terms of the interval or window in terms of when someone's exposed may have the opportunity to have an ultrasound exam. And so it's important that we always keep that on our differential. Um, but it's also important, and I think this is something that's hopefully is a take-home, that um these changes in the quality of the placenta, whether it's an abnormal location like a previa, or whether or not it's a risk for abnormal separation like an abruption, these things are often one of the underlying factors that can contribute to these is a prior cesarean delivery.

SPEAKER_01 15:14

Yes.

SPEAKER_00 15:14

And we have tried to work very diligently, not always successfully, but very diligently over recent decades to lower the occurrence of cesarean births in our expectant populations for our birthing patients. And that's important because we know that a cesarean delivery is associated with a risk of abnormal placentation with a subsequent pregnancy. Whether or not it's a placenta previum, whether or not it may be a risk of an abruption, whether or not there is a risk of abnormal attachment of the placenta to the womb, where at the time of birth it actually doesn't separate the way it's intended to, which it can also be associated with risk of significant bleeding or hemorrhage. Um those three conditions are all contributed to by a history of a prior caesarean birth. And we know the large the greater the number of prior caesarean deliveries, the greater the risk that there may be a placental abnormality with a future pregnancy. Um that's information that's critically important. I know that all the all of the moms that I evaluate in early pregnancy who have a prior history of a cesarean birth, one of the things we spend extra time evaluating is the location and integrity of the placenta. So that we have the opportunity to diagnose and catch early instances where there's an abnormal as where there may be a suspected abnormality in placentation.

SPEAKER_02 16:47

Right. That placenta boy, it's so important. And uh one of the things I used to like to tell patients when I was a clinician is you can control a lot of things, but you can't control your placenta. And even the healthiest mother can have an abnormal placenta because another risk factor for abruption, too, is a trauma, right? Um, a car accident, a fall. When I was in training, there was a mother who got kicked in the abdomen from a horse imprint was on her belly. So, of course, that's a significant risk factor, especially if the placenta is at the front of the uterus for it to separate. So when you're training, and I do believe that part of your role is as a teacher at LSU, when you're training your staff, your medical students, what do we tell them, the nurse students, the nurses on the floor? Because the attending physician is not always the first person that gets to the root. So, what do we tell them to do when these patients arrive? We haven't really talked about what these things do to the fetus, which we'll get to. Um, but what do we tell our trainees briefly?

Training Healthcare Providers

SPEAKER_00 17:56

Briefly, I mean, it what's important is is to is to be attuned to a very comprehensive assessment of a mother who presents to your unit with bleeding. You know, whether you're part of the nursing team, whether you are one of the one of the obstetric residents, um, if you're a student trainee that's working with the team, be attuned to a comprehensive assessment in terms of getting the history. History, information is still the most powerful tool we have, right? So we get information so we understand what we think, what what things may be maybe present. We also want to understand the mom's vital signs, right? We often move past that to more exotic things, but in simple terms, um, getting a fetal heart rate, checking the mother's blood pressure and pulse at the moment that they hit the unit goes a long ways into speaking to what her stability is. And that gives us the opportunity to understand is this more of an emergency or is this something we have more of an opportunity to spend a little more time in our evaluation? And that's important because we may or may not always have an ultrasound that's immediately at our fingertips. You know, in many of our advanced centers that that's the case, but in many, many hospital settings, you know, you it may take a little time to get an ultrasound evaluation in the moment. Um, and so you have to use best practice clinical judgment using those other tools. What are the vital signs telling you in terms of fetal heart rate, evaluating the bleeding? When the mom comes in, if she has a has symptoms of bleeding, you immediately want to get IV access, right? So that you can, if necessary, give IV fluids, you know, prepare for blood transfusion if the bleeding is severe. So those basic steps are the first steps, and then you go through the sequence once you have more information. What else what other things are we gonna use for the evaluation? Fetal monitoring and ideally ultrasound, so we can directly image the womb, the fetus, and the placenta.

SPEAKER_02 19:47

Yes, I love that you called the fetal heart rate a vital sign.

unknown 19:50

Yes.

SPEAKER_02 19:51

Because that's one of the first things that happens if you're in a hospital setting, um, along with taking the blood pressure impulse. And so the baby is also really important. Can you explain again like what these things do to the baby?

Impact of Bleeding on the Fetus

SPEAKER_00 20:06

Well, as you mentioned before, um the placenta is a lifeline for the fetus, right? That it anchors everything for our expectant infant. So if there is a condition that causes significant bleeding, especially if we take example of an abruption. In the instance of an abruption, we actually will have a separation of the placina, which means that there's a disruption in the integrity of what the plus of one of the key roles of the placenta, and that is the exchange of oxygen from the mother to the to the fetus. And so if that separation is significant enough, and if it's if it goes on for a a period of time, then we're actually decreasing. There are two things that occur. One, we're de decreasing the oxygenation of the baby. The other thing is we can have bleeding from the placenta itself, which means there's a depletion in the baby's blood volume if the amount of bleeding is severe and if it goes on for long enough. All of that means that the baby becomes hypoxic, meaning low oxygen levels, which then can translate into injury to different organ systems, the brain, the heart, etc. So if this is an acute presentation, and if this if the bleeding rises to the level of hemorrhage, then that becomes a significant risk for the well-being of the infant.

SPEAKER_02 21:26

Right, right. So now let's move a little bit into this fourth trimester. And well, let's circle back for a moment. We talked about taking the history. And one thing that we're hearing again and again in the United States is that the providers aren't listening. We're reporting these symptoms and they're not listening. So, with your trainees and even with your own clinical practice, how do you attack that problem?

The Fourth Trimester and Postpartum Care

SPEAKER_00 21:55

One way that you can actually think think think about it practically and attacking it is is Using a principle of pausing, all right? Slow yourself down, put yourself even in your own sort of you know, your body position, the way that you're interacting with the environment, put that into sort of a pause mode. So if you kind of downregulate your own stress level, downregulate, you know, how much you're sort of in a as a provider in sort of a hyperactive mode, you will actually be more attuned to hearing what your what your patient is communicating. Um so pausing to actually meet that patient where they are and navigate best practice tools for communication creates that rapport that hopefully will dismantle the sort of that hierarchy or that sort of power and balance between a patient and a provider. I like to sit down when I talk to patients from at their level. And I like them to explain exactly what they're experiencing and show me. Like if they're saying I'm having bleeding and I'm also having pain, ask them to kind of point where are you hurting and tell me what that's what it feels like, what you're experiencing. When we kind of slow ourselves down, bring ourselves to the same end of the same space that the patient's in, we're gonna have a greater success in being attuned to what patients how patients are communicating. That's really an important step because too often we're in this hurry and you know, fight and flight kind of state in a busy unit and time crunch, and I've got I'm juggling all these things. That allows you to miss things and also not to communicate effectively with your patients.

SPEAKER_02 23:32

Yes, yes, slowing down on our end is challenging because kind of in rapid fire sometimes on an obstetrical unit, but I totally agree. Like you do have to be able to one-on-one at some point and really hear what the patient's saying if you're gonna figure out exactly what's going on. And as you know, if I'm bleeding and I'm pregnant, I'm in a panic. It's also harder for me to communicate. So may also be we also are using patient advocates, family, doulas, other providers to help with the communication aspect. Um, so back to the fourth trimester, unless you have something to say about that.

SPEAKER_00 24:14

I was just gonna say, you know, I often, you know, will, you know, if they have a partner with them, I'll say, you know, can you, you know, is this, you know, what do you what did you observe, right? Because you see, like you mentioned, patient may be in that panic mode. They may they they may forget things that they that are important to communicate. But their their family member, their partner, can help share, okay, yeah, this is what I observed, this is what they were really experiencing.

SPEAKER_02 24:40

Right. So in the fourth trimester now, this new phenomenon, the postpartum period, there can be bleeding in the immediate stage or within the first 24 hours or even up to 12 weeks. What are we telling patients about when to report significant bleeding? What are some of the causes of that immediate and delayed bleeding?

Early Maternal Warning Signs

SPEAKER_00 25:04

So, um, in terms of what we communicate with patients, um, it kind of follows the principle of I think a tool we've developed in more recent years, and that is the principle of early maternal warning signs. And that principle is, you know, simple, patient-centered language that we can give to patients or help help them with in terms of their literacy, of when you see these things, this is a potential alert where you need to communicate that to your provider, or you need you may need to seek care. Sort of like you know, the the approach we take when we when we're counseling folk in general in the community about signs and symptoms of a stroke. We say, if you see this, if you're experiencing this, as a layperson, as a family member, if you're observing this with your family member, this it could be this, and so that's why you need to look at seeking care. Um so we'd use the principle of early maternal warning signs with both concerns about hemorrhage or bleeding or or hypertension. There's certain things that we say, these are triggers, right? Once somebody has gone home, if they're having bleeding that's heavier than a light menstrual cycle, uh menstrual period, uh, and especially if it's associated with significant pain or if it's associated with fever, um, that needs to be evaluated, right? That shouldn't you shouldn't wait and watch. You need to communicate that back to your provider. Um so those are some of the things you know we should consistently communicate in discharge planning following the birth.

SPEAKER_01 26:33

Yes.

SPEAKER_00 26:33

When we think about this window, you know, post-delivery. What's important is when we you you referenced concerns about the overall landscape of maternal mortality, we know that more than 50% of maternal deaths that are pregnancy associated occur following birth, in that you know, either post early postpartum or quote unquote for fourth trimester period for a range of reasons, including including hemorrhage. The factors at the at the sort of the near-birth window that are most common are instances either where there's something that's damaged the uterus or reproductive tract, um, where there's a laceration or an injury, or most commonly the womb itself is just not contracting down effectively following the delivery for various reasons. Some of it is if you have somebody who's been through a very prolonged induction, if you have patients who have twins or triplets where the uterus is over distended, if you have someone who for whom this is their seventh pregnancy, their seventh delivery, so they're what we call grand multiparous, the the efficiency with which the uterus contracts after birth and after the delivery of the placenta may not be what is needed to control bleeding. One of the things that you know is that maybe people may or may that people may or may not fundamentally understand is when you deliver the baby, when the placenta is delivered, the process of controlling bleeding naturally is that the uterus, which is a muscle, contracts down. You mentioned before that you can may have seven or eight babies there, and a few days later the uterus is back to its normal size. Well, that's because the uterus itself contracts down as a muscle, the majority of the tissue being muscular, into a state that begins to move back to its normal, normal anatomy. And in doing so, it clamps off those blood vessels that were at the bed of the placenta to prevent excess bleeding. So there's a little bit of bleeding that occurs with every delivery. Um, but when it gets to the level of like that liter of blood, one of the biggest factors at the time of near the time of delivery is that the uterus just isn't efficient, squeezing down to the degree that it should or that it needs to to control natural bleeding. And that's where our management then kicks in. Our diagnosis is important first and foremost, but then our management steps, which are very intentional and are very timely, are important to control that so we don't end up with an emergency.

SPEAKER_02 29:14

Right. And one thing that's um evolved during my career is now we have kind of almost like kits, so we call them bundles, so that the nurses are aware the medications that can sometimes help that uterus come back down, are readily available, and that everyone is thinking in the same way. They're weighing and measuring the amount of um products that we're using to sop up, for lack of a better term, the bleeding, so everyone's aware of what's going on. Situational awareness, listening to patients, educating the community, which is what we're trying to do with the Moms Minds and Medicine podcast. This is such a vast topic, and there's so many more nuances, but we hope that maybe we our viewership got a little bit of education, and maybe Dr. Maupin will come back and we will do a little bit more deeper dive into this very important topic of late pregnancy bleeding and fourth trimester postpartum bleeding. Welcome back to our podcast, Moms, Minds, and Medicine, where we're joined by maternal fetal medicine physician, Dr. Robert Maltman from Louisiana State University. And we were talking about the differences in outcomes in different parts of the world. What is the United States doing to help women to not have any severe morbidity, mortality, complications from bleeding?

Improving Maternal Health Outcomes

SPEAKER_00 30:50

Well, that that's a hugely important question because you know we know maternal mortality is has been something that's very much on the forefront these days. We've actually seen that hemorrhage-associated deaths in terms of maternal mortality have decl declined significantly over the past decade through measures that our systems have put into place. Probably the simplest way to think about it is developing protocols, training, and readiness pathways for our birth and health systems. The fundamental things that go into that are every time a mother, for all mothers, not just ones we think are high risk, but for every mother that comes to the unit, doing a risk assessment of what factors might lead her to have the risk of a hemorrhage. The second thing is readiness, making sure that your facility has the tools and the medications available so that if we start to see excess bleeding, we can uh we can respond in terms of treatment very promptly. We want to have drills, right? We know that airline pilots, um even the ones who are veterans, um in the air, they go through simulation training to prepare for emergencies, things that don't commonly happen. Um, but when they do, they're able to navigate those things successfully because they've drilled and trained. Doing that has the same benefit when we're talking about this type of emergency. And and then having better means of assessing when we actually have excess bleeding. So we've implemented a range of different tools. Some of these are captured in what we call patient safety bundles or toolkits that are now standard protocols that are available to birthing units and platforms. Implementing those widely, getting the buy-in of providers, health systems to incorporate these into the ongoing practice environment has actually allowed us to be successful in dropping severe morbidity and especially mortality associated with hemorrhage and pregnancy. In my state, in recent years, we've actually seen a 35% reduction in adverse events associated with hemorrhage because of the the implementation of those types of measures. That's and so when we actually look at the data for maternal mortality related to pregnancy associated uh causes or factors, actually hemorrhage in Louisiana is not at the top of the list anymore. There are three or four.

SPEAKER_02 33:27

Congratulations.

SPEAKER_00 33:29

Yeah, it's you know, it's it's been through the efforts of of our public health system and our hospital systems and providers, but there are now other factors that very much will occupy our attention. But hemorrhage has moved down the list in Louisiana, especially because of measures like this.

SPEAKER_02 33:46

I love it. I'm not sure what those statistics are throughout the country, but I'll have to look into that. Um, see if Louisiana is one of the first or one of the only. So if I'm worried about having an abnormal placenta, is there anything that I can do to prevent some of these things? Placenta previa, placental abruption, early labor.

Preventing Abnormal Placenta Issues

SPEAKER_00 34:08

Well, it probably, I mean, it's some sometimes this is not always under your control, right? But one of the things you can navigate as you go through the landscape with your provider is to talk with them about what are the approaches that in their practice and at their hospital center that promote the greater likelihood of a vaginal delivery. If you've had one C-section before, talk very carefully with your provider about the opportunity to undertake a vaginal birth after cesarean delivery for your next pregnancy, not just automatically having another C-section. If it's medically safe. Those types of things then alter that as a risk factor for future pregnancies where if a cesarean section or especially multiple C-sections are part of that patient's experience or that mother's experience, that then sets the stage for a risk for a placenta previa abruption or crita, which is where the placenta's abnormally attached. So that's probably the single biggest thing. I mean, there's a huge initiative through our American College and through Joint Commission in terms of patient quality and safety to drop our C-section rates to those to only when necessary, really clearly medically to try to optimize the chance for uh for vaginal birth. So that that's probably the most important thing. And then in terms of just knowing the system that you're receiving care, um it's it's reasonable to say, look, there are many other reasons why I may have bleeding. You know, what types of things allow your hospital to be prepared if I have an emergency. We often don't think like that, right? We think of you know the pregnancy or birthing experience through sort of this perfect lens, and you know, it should be this beautiful experience, but we know complications can occur whether it's from bleeding or hypertension. It is important as an expectant family to know if you have an emergency, is your is your health center prepared to handle different emergencies? And and it does it have the level of of resources to do so. That should be part of your decision making in terms of where you're receiving care.

SPEAKER_02 36:16

I agree, I agree. Especially people are starting to want to give birth outside of systems, and that's a whole that's a topic for a whole other podcast. Um finally, if viewers want to learn more about this topic, I love that you talked about our college, the American College of OBGYN. We call it ACOG, um amongst ourselves. They have a lot of patient literature that's um very easy to navigate.

Resources for Expectant Mothers

SPEAKER_02 36:46

Aside from that, on our podcast, do you have any information about some topics like this on your website? What should our viewers do if they need more?

SPEAKER_00 36:54

Well, I I think one of the things that we always talk about for pregnancy care overall, especially for new mothers, the book What to Expect When You're Expecting has a wealth of information. Um, and they will talk about issues like this. It's fairly fairly comprehensive. So it's worth investing in, whether you get the actual book or you download it to your phone or your tablet. If you Google online, you have access to the there's an organization called AIM. It's called the Alliance for Innovation Um in Maternity Care. And they have, I think, outward patient-facing documents or or or tools or information that individuals can tap into that describes, you know, what are the things that should be considered in terms of having a safe birth, um, include including instances where there's where there are bleeding complications. Those are resources that are best practice sources of information as opposed to Dr. Google or TikTok. And and and many of our larger centers will actually have some additional information on their websites. One of the things, if you've experienced um a cesarean birth before, and you know, if there is a risk for abnormal placental structure, um many of our centers will have information describing if we have what we call a placental accreta team, meaning a team of physicians and providers and a whole network of resources that's geared and designed to manage that type of complication, which can you know confer a risk of hemorrhage or bleeding. Um, so being aware of what those resources that are being publicized or advertised by the center that you're receiving care is another great resource.

SPEAKER_02 38:32

Sure. All right. Well, Dr. Maupin, thank you again for your time and your hospitality and answering all of my questions and the viewers' questions. And again, until we meet again.

SPEAKER_00 38:44

Until we meet again. It's a pleasure.

SPEAKER_02 38:46

Bye bye.