Managing Postpartum Hemorrhage

Considerations for Managing Postpartum Hemorrhage in the Community Setting

midwife helping woman give birth graphicNACPM is committed to informing and supporting evidence-based practices among CPMs and to promoting safe and healthy birth for all people having babies in the United States. Skillful management of postpartum hemorrhage is a cornerstone of safe birthing care. Postpartum hemorrhage remains a leading cause of maternal morbidity and mortality in the United States. Families choosing to deliver their babies at home and in birth centers need guidance through shared decision making addressing their risk, their midwife’s plan for managing hemorrhage, and the resources for emergency care available in their birthing communities.

While competent pharmacologic management is the standard of care during hemorrhage, planning for patients’ safe progression through third stage ideally begins during prenatal visits with careful history-taking, risk assessment, and education for families on what they can do to ensure a healthy, uncomplicated physiologic labor, birth, and recovery.

Some certified professional midwives practice in environments where the pharmacologic formulary is limited. By necessity, CPMs must develop their skills of initial and ongoing risk assessment, partnering with and educating pregnant patients in order to decrease risk, ongoing evaluation of labor disposition, and the timely activation of consultation and transfer. These skills may be deemphasized in hospital practice where medications, procedures, and surgery are readily available.

Community midwives have an opportunity to model assessment and education-based strategies for decreasing hemorrhage risk to their colleagues in hospital practice, while advocating for good access to uterotonic and antifibrinolytic medications in all states.



Support for Managing Postpartum Hemorrhage in the Community Setting - 18th Offering in NACPM’s Clinical Practice Webinar Series Thursday, September 26 3:00-4:30 ET 

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webinar computer pictureWe begin this webinar with a presentation by Margie Mueller Boyer, MS, RNC, C-EFM, CNS-BC.  Postpartum hemorrhage (PPH) remains a leading cause of morbidity and mortality for childbearing people in the U.S., even though researchers have identified PPH to be preventable in many cases.  Margie will explore key strategies to decrease the rate of PPH through early recognition of excessive blood loss.  Based on research, visual estimation of blood loss is considered an imprecise method based on research and quantification of blood loss (QBL) is considered best practice.  Margie will outline the steps for quantifying blood loss, an important and highly practical support to midwives practicing in community settings.


IMG-6942Margie received her BSN & Masters from The Ohio State University where she worked for a decade. She has worked as a Perinatal Clinical Nurse Specialist, a hospital administrative director, and patient safety manager.  Margie serves on the Florida Perinatal Quality Collaborative Obstetrical Hemorrhage Initiative as a Nurse Expert and is an AWHONN Obstetric Patient Safety Instructor.  After working for twenty-seven years at Advent Health Tampa, formerly Florida Hospital Tampa, Margie is now taking a year to travel and work as a consultant.


Autumn-VergoAutumn Versace Vergo, CNM, MSN, APRN, our second presenter, will offer practical information for midwives who attend deliveries and provide shared decision-making about hemorrhage risk and management in community settings.  Included will be a case presentation, a review of risk assessment, a review of pharmacologic management of PPH, and a comparison between hospital-based and CPM-relevant formularies and protocols.

Autumn is a certified nurse-midwife and Chief of Obstetrics at Cheshire Medical Center  Center/ Dartmouth-Hitchcock, a collaborative Women’s Health practice in Keene, NH. She is originally an apprentice-trained, state-licensed midwife and provided home and birth center services for many years. She has worked extensively on regional perinatal quality improvement, focusing on best practice in collaborative care and interprofessional communication. She has served as a subject matter expert on community midwifery to NH Medicaid and the New Hampshire Department of Health and Human Services, and is a member of the faculty at Birthwise Midwifery School, a MEAC-accredited program in Bridgton, Maine.

Register now and join us on September 26 th for this exciting webinar!

 Excellent Resource for Managing Postpartum Hemorrhage in the Community Setting

Screen Shot 2019-09-10 at 12.36.08 PM copyIn addition to NACPM’s September 26th webinar on managing postpartum hemorrhage, we refer you to the Clinical Practice Guideline on Postpartum Hemorrhage from the Ontario Midwives Association. This excellent and comprehensive resource includes basics about PPH, risk factors, prevention, treatment including pharmacologic and herbal agents, recovery, perspectives and needs of clients, considerations for debriefing experiences with clients and families, and more. We invite you to review this guide and let us know your thoughts on this important clinical topic area:


Safe Distance to the Hospital: Impacting the Availability of Midwives

At what distance from the hospital is home and birth center birth safe? This question is especially important to examine due to the critical role that CPMs, as community-based research 1providers, must play in mitigating the birth care provider shortage in both rural and urban areas. Recent research demonstrates that placing arbitrary limits on distance to the hospital is not evidence-based, and in fact there are social and medical risks associated with placing limits on community-midwife services in care shortage areas.

A 2017 report from ACOG, The Obstetrician-Gynecologist Workforce in the United States, Facts, Figures and Implications, tell us that 49% of the 3,143 U.S. counties lack a single obstetrical provider, affecting more than 10 million people who live in predominantly rural counties. The shortage of birth care providers, however, is not limited to rural areas. In Washington, D.C. for example, where mortality for birthing people is among the highest in the nation, the closures of birth care units and hospitals over the past years have left the birthing residents of the poorest and predominantly Black sections of the city with no labor and delivery services at all. People in these neighborhoods often must travel for over an hour on public transportation for care, sometimes resulting in loss of employment. In March of last year, the Atlantic quoted Aza Nedhari, CPM and founder of D.C.’s perinatal support organization, Mamatoto Village: “Every black woman who makes it and has a full term baby – it’s just like ‘You made it!” CPMs provide critical, life-saving services in our rural and urban birth care deserts.

A March 2019 article in the Journal of Midwifery and Women’s Health  – Distance from Home Birth to Emergency Obstetric Services and Neonatal Outcomes: A Cohort Studyconcludes:  “…From a policy perspective, our findings suggest that it is inappropriate to place arbitrary limits on proximity to hospital to determine eligibility for home birth…There are both medical and social risks associated with restricting access to maternity services in remote settings and with imposing a requirement for people to travel to access intrapartum care (italics added).  Arbitrary limits on the acceptable distance for home birth and birth centers from hospitals with cesarean capacity are not evidence based and limit the ability of community midwives to provide skilled maternity services to rural residents.”  These findings would apply to urban areas as well, such as in Washington, DC, where there is no access in whole parts of the city to hospital intrapartum services.  

A related article published in the journal Birth in June 2018Rural community birth: Maternal and neonatal outcomes for planned community births among rural women in the United States, 2004-2009 -using a Midwives Alliance of North America (MANA) dataset of 18,723 people, concluded “…after adjusting for risk factors and confounders, there were no significant differences for a composite of maternal or neonatal outcomes between rural and nonrural pregnancies…Among this sample of low-risk women who planned midwife-led community births, no increased risk was detected by rural vs nonrural status.”

Midwives provide critical, life-saving services in our rural and urban birth care deserts and evidence backs the safety of community midwife practice in these care shortage areas.

From the MANA News, Issue #102, September 4, 2019: How Reliable is the APGAR Score?

mana_logoA new article, authored by MANA Division of Research members, Marit Bovbjerg, Melissa Cheyney and Jennifer Brown, and published in the American Journal of Epidemiology, examined data on Apgar scores using both the MANA Stats dataset and a large, hospital birth dataset from California. This article focuses on implications for research rather than on clinical implications for care. It reports on the limited usefulness of the Apgar score in research and shows that it is not an effective proxy for eventual infant well-being in research settings.



Thursday, 10.17.19 1:30-3:00 ET
2019 State and Federal Legislative Updates! 
  • Kentucky with Mary Kathryn DeLodder, MA
  • Hawaii with Sky Connelly, CPM
  • Washington, D.C. with Aza Nedhari, CPM, MS
  • H.R. 3849, the Midwives for MOMS Act with Mary Lawlor
Thursday, 11.21.19 3:00-5:00 ET  
Annual Member Meeting
with NACPM Board, Staff and Chapter Leaders
Thursday, 12.12.19 3:00-4:30 ET 
On Mentorship: Lessons Learned from the Research Aligned Mentorship Program 
with Keisha Goode, PHD and Ashlee Lien, PHD