research

Picture this scene:
Part 1 - Plan A:
A woman having her first baby has laboured spontaneously through the day and the next night.  She has gone to the hospital, and spent a few hours in the water, staying upright and mobile.  At 08:00 hours her cervix has dilated to 4-5cm; her cervix is soft and baby's head is 'high'; and her contractions are less frequent than they were a few hours ago.  She is told that she needs her labour to be augmented: move to 'Plan B'.
[This is a major decision point for a labouring woman.  She can either continue working with her body's natural processes (hormonal, physical, and emotional), or give permission for medical processes to be commenced - all with the goal of a healthy woman giving birth to a healthy baby.]

Part 2 - decision to move to Plan B:
The woman agrees to augmentation of her labour, and after considering pain management options available, requests epidural anaesthesia. 
The hospital staff organise the intervention without delay: and IV line is sited, a pump with a second bag of IV fluids plus oxytocic is prepared, and the anaesthetics doctor introduces herself, asks questions about the woman's health, and explains what she is about to do.  The epidural is commenced, and after a couple of contractions the woman feels less pain and lies down quietly in the bed.  The electronic fetal monitor provides continuous information about the baby's condition, as well as charting the presence of uterine contractions.  After the doctor has checked the level of the anaesthetic block with ice, she goes out of the room.

Part 3 - invitation to participate in research
[and the reason for this post]
Soon after, a person comes into the room and introduces herself as a research midwife. She asks the woman if she would agree to being enlisted in a research trial.  She explains that the purpose of the trial is to reduce unnecessary caesareans.
She explains that, in this trial women who have already elected to have an epidural would be randomly allocated, if the question of whether or not to have a caesarean birth, to a particular test of the baby's blood (lactate), which would be accessed vaginally via a scratch on the baby's scalp.
[I won't tell you what the woman chose.  How would you respond?]

Comments on this research from a scientific, professional point of view:

1. Research is an integral part of professional health care today.  I accept that.  
2. The design of a particular trial - in this case to enlist women in labour after they have had an epidural, means that those who have spontaneous uncomplicated labours and births, or those who have elective surgical births, do not even think about the issues such as a decision to go to caesarean, or to continue in labour.
3. This research seeks to look at those for whom the intervention (intrapartum fetal blood sampling for lactate measurement as an assessment of fetal wellbeing, in the presence of non-reassuring fetal heart rate trace) could be critical in making a decision about the way a baby will be born.
4. The randomisation of all research subjects (labouring women who agree to being enlisted in the trial) into treatment or control groups seeks to prevent bias in decision-making. 
5. Research on human subjects can only be approved if the researchers are able to demonstrate the value of the information to the relevant discipline(s), and strategies that prevent harm (to the mother and/or baby, in this case). 
    
   Comments on this research from a woman's point of view:
6. If I agree to what you are asking, and my baby becomes distressed, do I have any say in what is done?  No - the decision is made according to the randomisation.
7. I feel exhausted after a couple of nights without sleep, and now I am being asked to make a decision about something which I have never thought about before.  How can I know what's going to be best for me and my baby?  That's why the research is being done.  Noone knows what is the best way to proceed.  
8. If I say no, I don't want to be in the research, and a decision needs to be made about whether or not to do a caesarean, how will that happen?   ...

I often argue that there is really only one real choice in childbirth: to do it yourself (Plan A), or to ask someone else to do it for you (Plan B). 

There are no guarantees in birth.  It's a journey, and decisions must be made as events unfold.

Midwives are bound, by definition, to promote normal birth.  A woman whose labour proceeds without complication is in the optimal position to give birth spontaneously, and with good outcomes for herself and her baby.   There will never be a safer or more appropriate way for these women to give birth, than to do it themselves.

Any intervention brings potential benefits and risks.  Augmentation of labour with oxytocic may, in many cases, bring about a more coordinated labour than what was being experienced before the augmentation, and a happy, healthy mother with a happy healthy baby in her arms a few hours later.  However, augmentation of labour can also lead to hyper-stimulation of the uterus, a distressed hypoxic baby, an emergency surgical birth, haemorrhage, ...

When a woman needs/chooses to move from Plan A to Plan B, the presence of a known and skilled midwife who can reassure her, and at times offer guidance, is essential.  Midwifery is not limited to promoting normal birth.  It's about being 'with woman' - a midwife with a woman, in a professional arrangement that enables sharing of information and support that is uniquely tailored to that woman and her baby.  The journey that leads to the birth is not predictable, but each woman's decision making is her own, without pressure or coercion.  This is, in my opinion, the pathway to safe birth through accessing appropriate interventions when indicated.

bleeding after birth

Today I am reflecting on experiences I have had with post partum haemorrhage, linking those clinical scenarios to my body of knowledge, reading reliable references that relate to appropriate interventions and drugs to treat bleeding, and applying learning to my practice.


The real test of primary maternity care is FIRST the safety and wellbeing of the mother, and SECOND the baby (even though the baby's birth usually comes first).

The aweful possibility of sudden dramatic bleeding after the birth, and what that can mean in terms of loss of life, is the spectre that hovers in the mind of many public health decision makers.  The burden of such loss, particularly in resource-poor parts of the world, has led to many initiatives that seek to make changes that will protect life and reduce harm.  An example is the Joint Statements on Prevention of Postpartum Hemorrhage, released in 2011 by the international peak bodies for midwifery (ICM) and obstetrics (FIGO).  The key recommendation, active management of third stage of labour, is explained in the joint statement released in 2003.

Active management of the third stage of labour should be offered to women since it reduces the incidence of post-partum haemorrhage due to uterine atony.

Recently released 3 Centres Guidelines, confirm the practice:

Active management of the third stage of labour is recommended practice worldwide, with an anticipated completion period of 30 minutes.

Midwives (and I am one) have learnt, over the past few decades, to value our knowledge of working in harmony with natural physiological processes. The third stage of labour is one of the key challenges that a midwife faces when attending a birth.  I do not fear the third stage.  If that were the case I would not be suitable to continue in the work that I do.


The discussion that I have around third stage with my clients in preparing for birth always includes consideration of our plan for the management (or non-management) of the third stage.  The clinical decisions that I will make in the minutes and hours immediately after the birth include my assessment of the need, or not, for drugs at that time. 

Midwives around the world work this way.  This is alluded to in a statement on physiological management of third stage  released by ICM in 2008 and reviewed in 2011.

The midwife's skill and competency resides in protecting the woman and her baby in healthy natural birth (PLAN A), and in recognising situations and conditions that may require medical interventions such as active management of third stage (PLAN B).

At a very practical level, I understand that the physiological separation and expulsion of the placenta without excess bleeding is a process so finely tuned that it can easily be interrupted.  Today's birthing community in my world has introduced all sorts of extraneous and potentially disruptive elements - clocks, bright lights, telephones, cameras, text messaging, men, children, other invited onlookers, ... 

Women giving birth are not a uniform, pristine group whose bodies all function at optimal levels.  Women may have internal uterine abnormalities from fibroids or procedures or terminations of pregnancy.  Women may have poor abdominal muscle strength, allowing their wombs to sag excessively, and putting unusual pressure on other supportive structures.  Women may be overweight, or poorly nourished.  Women may be emotionally drained or have specific painful deep memories that are triggered by labour and birth.  ... and so on!

So, you may ask, what's the problem?  What causes uterine atony in an otherwise uncomplicated situation?  Why does a woman bleed after a normal, unmedicated birth of a healthy baby (or babies)?

I won't attempt to give a text book answer here.  I would encourage students who are reading this post to review your text books, while reflecting on your own experience of haemorrhage, and seeking to learn from each situation.  You will need to decide, in practice, whether you follow the current recommendation of universal active management, which is not without risk, or if you are able to work competently with a woman who is intentional about natural, unmedicated birth.

I have looked through my birth register.  In the past few years several of the women who I have attended have had post partum haemorrhage of in excess of 500 mls.   I remember these women, and the setting of birth.  I remember the (thankfully rare) instances in which we called the ambulance and transferred to hospital.

The challenge that I return to, having reflected critically on my own practice and my experiences of bleeding after birth, is to continue to practise and learn my role in protecting the natural process.

"Western practices neither facilitate the production of a mother’s own oxytocin nor direct attention to reducing catecholamine levels in the minutes after birth, both of which can be expected to physiologically improve the new mother’s contractions and therefore reduce her blood loss."

  Dr Sarah J Buckley 2009 (page 179)

This topic will be continued here.

 

Pain

Beautiful Eve

Am I rushing in where angels fear to tread?

A recent post at the Science and Sensibility blog about Epidural Anaesthesia, written by well known Canadian family physician, Michael Klein MD, will be of interest to anyone who is interested in pain and childbearing. Dr Klein's paper is well referenced, and a reliable review of current medical knowledge about the topic.

The comments by readers reveal to me some of the myths and misunderstandings about pain and childbirth that I encounter from time to time. Comments quickly become defensive, assertive, and even aggressive in defending one camp or the other.