All births come with unknowns, but if you have a bleeding disorder, the worry level may be higher than usual. The best advice is to find the right care team and then try to focus on the impending arrival of your child, says Shaveta Malik, MD, co-director of the Specialized Hematology Experts (S.H.E.) Clinic at the Hemophilia Center of Western New York, in Buffalo. If you have a team of professionals in place, including a hematologist, your obstetrician or maternal-fetal medicine physician (a doctor who specializes in high-risk pregnancy) and a neonatologist, and if you’re set to deliver at a larger hospital with on-site blood bank and lab facilities, you’re already in the right hands. But you must also advocate for yourself. Here’s what you should know.
Have your factor levels checked
Coagulation factor levels naturally increase during pregnancy if you have factor VIII or von Willebrand disease, but they may dip as you approach birth, says Danielle Nance, MD, a hematologist at Banner MD Anderson Cancer Center in Gilbert, Arizona. “Most women with a bleeding disorder are going to need treatment with clotting factor or something else in order to prevent bleeding at the time of delivery,” she says. If you’re a carrier and don’t have bleeding symptoms—and your factor levels measured in your third trimester are at 70% or higher—you should be able to deliver without any increased bleeding risk, Nance says.
Ask about pain relief options
If you hope for an epidural, there’s a good chance you can have it—with a caveat: Your factor levels in your third trimester should be above 50% (50 IU/dL), Malik says. “If levels fall below 50%, there’s a possibility of prolonged bleeding at the site of the epidural,” which can lead to a hematoma forming. But even if you can’t get an epidural, there are plenty of alternatives that you can safely use, such as oral or IV analgesics. Just be sure to discuss your concerns and your options with your doctor beforehand.
Natural pain relief during labor
You can also consider nonmedication options for pain management, such as birthing classes or Lamaze to learn breathing exercises, a birthing ball to provide comfort during labor, and massage and aromatherapy. “These options are more feasible if a patient has a supportive family member or doula at the bedside with her during labor,” Malik says.
Cesarean section or vaginal birth?
The mode of delivery will depend on whether you know your baby’s status. “Not every woman with a bleeding disorder automatically needs a C-section,” Malik says. Your healthcare team will make a recommendation based on your bleeding disorder, whether your baby is anticipated to have a disorder, and a careful weighing of the risks and benefits, she says. If the baby has a known or suspected severe bleeding disorder, vaginal birth presents a high risk for a severe brain bleed called intracranial hemorrhage. In that case, a C-section would be planned.
Vaginal births should also be free from forceps or vacuum extraction methods to avoid the risk of a brain bleed. And if you have a C-section, depending on your factor levels, you may be given a medication called desmopressin (DDAVP) or factor concentrates to safeguard you from prolonged bleeding from surgery, Malik says.
Watch for excessive postpartum bleeding
Although most women bleed for two to six weeks post-delivery, watch for anomalies, Nance says. After three or four days, if you are passing large clots, if you need to change sanitary pads more than every two hours or if you are in pain, call your doctor right away. Receiving clotting factor just before and for a week or two after birth is usually recommended for women with bleeding disorders for this reason—and it is often given to women who are carriers as well. That was the case for Sally Drescher, a mom of three in Wickenburg, Arizona, who wasn’t even aware of her carrier status until she lost a son shortly after giving birth. Her next pregnancy—twins conceived via in vitro fertilization—was carefully monitored. “I had factor replacement when I got to the hospital to deliver (via planned C-section) and for 10 days postpartum. It was amazing how much better I felt, thanks to the medications, compared to my previous pregnancies when I didn’t know I was a carrier.” Her infant daughters, Margot and Frances, are safe and healthy, and so is she.