Friday, October 17, 2008

Preventing and treating post partum haemorrhage

Since attending a study day last week, I have been reflecting on the way midwives and obstetricians 'manage' the third stage of labour, and the effect this has on the amount of blood loss a woman experiences.

Karen Moffatt, a senior midwife at the Women's, illustrated the unreliable nature of the estimates of blood loss recorded after birth. The test is to ask midwives, doctors, and students, to record their estimates after looking at fake blood that is poured and spread over sheets and pads, in a way that is meant to approximate what we see as we clean up after a birth. The results of these tests are usually that we are more correct on smaller amounts, such as 100-300 ml, and seriously less correct on the larger amounts, such as 1000ml. My guesses were, too. I underestimated the larger amount.

Blood loss in excess of 500 ml is recorded as a post partum haemorrhage. But if we are mis-recording the amounts, it's difficult to make any conclusions from what we record.

I would like to ask any blog readers who are interested in this topic to tell me what you think of it.

At the study day the presenters were unequivocal - they require midwives in the hospital to practise active management of third stage because it's supported by the evidence. The International Confederation of Midwives and FIGO, the international peak body for obstetricians, have written a joint statement, requiring all skilled birth attendants to carry out active management of third stage of labour.

Independent midwives attending homebirth in Australia carry the oxytocic drugs (Trade names Syntocinon and Syntometrine), and would usually use them as treatment rather than prophyllaxis. This means taking a 'wait and see' attitude, or as Michel Odent says, "don't manage the third stage".

I do not want to argue against the evidence, which applies to most women in hospital settings. But I do want to argue that women who are giving birth to the baby safely under optimal physiological conditions are more likely to ALSO safely complete the process by expelling their placentas without excessive blood loss and potential morbidity.

What are the optimal physiological conditions I speak of? This will be slightly different for each woman, because it will be her own space. The same undisturbed space in which she entered the deepest and most demanding stage of her labour. The personal, quiet space. There can be many 'non-medical' disturbances and disruptions, some of which are inadvertently brought on by the mother herself or her midwife. Photography, family congratulations, phones, showing the baby to the children - these are often enough to take the mother out of her birthing space, and interrupt the intense hormonal and physical process of receiving and bonding with a newborn baby.

Since establishing my private practice about 15 years ago, I have needed to learn from women how to work in harmony with the wonderful natural processes in birth. I did not know about physiologically normal third stage. I knew how to administer oxytocic, how to apply controlled cord traction, and how to record blood loss.

In my early years as a homebirth midwife I experienced one serious post partum haemorrhage, and transferred that mother to hospital for a manual removal of the placenta. It was a horrible experience for the mother, the father, the second midwife, and for me.

The promotion of normal birth includes protecting women from excessive blood loss. That's obvious. I am concerned, and have therefore written this blog, because the way to achieve the protection from excessive blood loss for well women seems to be so very different from the way it's done in mainstream maternity services. I look forward to hearing from anyone who has wisdom on this matter.


1 comment:

Julie said...

In my practice I think I use active management more than I strictly need to. I always lament when I feel the pressure to clamp and cut if there have been concerns during labour but the baby is born in good condition.

I recently heard interesting statistics about blood loss and active management where a hospital was audited and it was found that there was a higher incidence of PPH with active management than physiological management. Unfortunately I can't remember where I heard this...I think it was the NZ College of Midwives Conference in Auckland this year. I realise this isn't backed up by the majority of the research. I do wonder if we are doing more harm than good interfering as we do but as you say, there are lots of factors and the mere fact of the excitement around the birth and everyone in the room trying to get their hands on the baby distracts and interferes in the natural process.

I come back to every birth being unique and I treat the third stage in the same way, reacting and interfering only when I feel I really need to.