Tuesday, September 15, 2009

thoughts on the afterbirth

The birth of the placenta or 'afterbirth' is known as the Third Stage or S3.

Midwives who promote normal birth are usually confident to proceed under physiological conditions through the third stage, working in harmony with the mother's natural birthing processes. The elements of physiological S3 include trust between the woman and her known midwife who is professionally responsible for conducting the birth, attention to a safe, non-stimulating birthing environment, cord not clamped prior to cessation of all pulsation, uninterrupted skin to skin contact between baby and mother - all following the spontaneous unmedicated birthing of a healthy baby by a healthy mother. The baby's instinctive movements in seeking the breast enhance the natural production of oxytocin, and the baby's pressure on the mother's abdomen encourages contraction of the mother's womb, ensuring the functioning of living ligatures within the uterine muscle wall at the placental site.

Midwives attending homebirths use oxytocics when clinically indicated.

[The attached tables show the rate of pph for homebirth mothers in Victoria each year 2002-2007. These tables do not indicate severity or degree of morbidity.]

Hospitals in Australia strongly promote active management of S3. This involves injection of a synthetic oxytocic, with or without an ergot alkaloid, soon after the birth of the baby, causing strong contraction of the uterine muscle. When there are signs of placental separation (cessation of pulsation and lengthening of the cord, and sometimes blood loss), the midwife or doctor exerts controlled traction on the cord while guarding suprapubically with the other hand, until the placenta and membranes have been delivered.

Postpartum haemorrhage (pph) is a serious and life threatening condition, which is one of the main causes of preventable maternal death globally. The International Confederation of Midwives statement on pph includes instructions for active management of S3.

[Click on the picture to enlarge - Summary of a paper by Carolyn Hastie and Kathleen Fahy, 'Optimising psychophysiology in third stage of labour: Theory applied to practice'. Women and Birth (2009) 22, 89-96. Australian College of Midwives.]

Efforts by midwives to describe a physiological approach to S3 underline the need for research into the effectiveness of such midwifery care. A recent paper by Hastie and Fahy (2009) [first page scanned above] reviews literature, defines key terms, and presents a theoretical framework of Midwifery Guardianship applied to the third stage. This paper adds to the writings of Michel Odent and others in the past couple of decades, exploring and explaining the neurophysiology of unmedicated, normal birth.

There is no 'one size fits all' in maternity. Each woman and each baby are individual, and decision making is an active process that continues throughout the episode of care. The midwife's toolkit includes the skill and knowledge to promote normal birth, and to work in harmony with the natural processes, when that is likely to lead to the best possible outcomes. The midwife is also able to intervene in a timely and appropriate manner, using current strategies that are supported by contemporary evidence, and critically reflecting on practice in an effort to continually learn and improve maternity care for mothers and babies.


itchy said...

I had active management for first kid and not for second.

Now that I know about the risks I would never made the choice for active management (in absence of clinical indicators). No risks were disclosed in the hospital (Royal Womens Melbourne) and I chose it for what now looks like the silliest of reasons - to get pregnancy over and done with as absolutely soon as possible.

That said, my personal experience was that I preferred the active third stage. It was much faster. Luckily nothing seems to have gone wrong.

Joy Johnston said...

In response to this blog a question has come to me by email: "I am interested in your views on how you navigate the situation where a laboring woman seeks one path which runs counter to your best professional opinion?"

The short answer is, I accept and respect a woman's decision.

The big differentiation I make is not about choice, but it is around working in harmony with normal neuro-physiological processes. There are many decision points in any pregnancy-birthing continuum where the woman may be confronted with the need to make a decision about either continuing in the normal-natural-physiological mode (Plan A), or accepting a medical intervention (Plan B) if it is available.

My 'guardianship' of normal birth is that I have the opportunity to give a woman information about the likely consequence of her decision, either to continue in 'Plan A' or to move to 'Plan B'. A midwife's professional duty is to promote normal birth (Plan A) when ever that is reasonable, and to seek other options when complications arise. The midwife has an understanding of the fragility of the natural process, that once interfered with, it may be difficult to restore normality. A woman who does not understand the importance of the natural process in birth may 'choose' an induction of labour without realising the likely implications of her choice.

My professional commitment is separate from the woman's right to make her own choices and change her plan according to her own wishes.

Joy Johnston said...

The following comment has been sent to me by email, and I am copying it here without identifying the writer, who is medical director of a public hospital maternity unit in Melbourne.

"I believe that the available evidence shows that the Active Management of the third stage of labour has been shown to reduce the risk of post partum haemorrhage. I don't believe there is evidence to show that this does not apply to any particular sub-group of women, or women managed in any other way. I think that the evidence is such that the active management of the third stage should be available (and encouraged) for all women no matter where they choose to deliver until such time as there is evidence to the contrary. I think that to suggest that women having home birth will not benefit from the active management of the third stage is not evidence based and may put some women at risk."

This statement sums up the current 'evidence based' obstetric positon, which is also supported by the International Confederation of Midwives.

More research is needed in that small sub-set of the maternity population who engage in 'psychophysiological' third stage.

Please note that in order to have psychophysiological S3, the preceding events also need to be psychophysiological.

The sort of research trials that are required to produce the 'gold standard' Level 1 evidence, in which research subjects are randomised into treatment or control groups to minimise bias are not possible. Women who intentionally engage their minds and bodies in making informed decisions about their births, who choose to avoid interveniton unless there is a valid reason for it, and who work in partnership with a known and trusted midwife who is their primary responsible professional carer can not be randomised into treatment or control groups.