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.

 

old-style midwifery

I have tried to capture the essence of the 'extraordinary'

The old-style ‘independent’ midwife, who has learnt autonomy and independence in practice and in decision-making from experience as the responsible primary maternity care provider for an individual woman, knows the value of working quietly and without fuss, in harmony with natural physiological processes, and enabling ordinary women to access their extraordinary strength and health in giving birth and caring for their babies.

[From APMA Blog]



Last week I was writing about the changes that I see taking place around me in Australian midwifery, as government and professional regulators make their efforts to improve the status quo - a task that all modern societies entrust to expert decision-making processes.

Other midwifery matters on my mind at present are the review of a university study module on postnatal midwifery care, for which I am tutor and marker, and a liability report I was asked to write in relation to a case in which a baby has cerebral palsy. These themes have influenced my thinking, as I engage with women in my care, at many points on the pregnancy-childbirth continuum.

Younger midwives may object to my comparing of 'old-style' midwifery with 'new'.  But the truth as I understand it is that midwifery today should be essentially the same at the primary care level as midwifery (by whatever name) in all societies and all times.  The new midwife who understands and is committed to 'old-style' midwifery, with linkages to the best and most effective medical services when needed, is practising midwifery well.

Since 'being' a pregnant-childbearing woman is not an illness, and never has been, the midwife with woman in the childbearing-nurturing time of that woman's life sees beyond the current fashions and time-related activities of a society.  That's what I mean by the 'old-style' midwife.

The debate around social and primary healthcare models, which aim to base all health care on the individual recipient of the care (in maternity care, the woman), compared with medical models of care that focus on illnesses or conditions, and the right treatment is readily applied to primary maternity care.  Sociologist Kerreen Reiger has contributed to this debate in The Conversation , in a commentary on 'Evidence-based medicine v alternative therapies: moving beyond virulence'. I am aware that some of my colleagues in midwifery look to alternative therapies, such as homeopathy, naturopathy, and traditional Chinese medicine in an attempt to provide a more holistic and woman-focused treatment option. This, in my mind, is not 'old-style' midwifery.

It might be 'old-style' treatment of illness, in the same way that people of previous generations concocted medicines out of plants that had medicinal properties. That 'old-style' treatment of illness has developed into the world of pharmaceuticals - a whole new terrain for discussion of ethics and power relationships in healthcare.

The basis I have for trusting 'old-style' midwifery is that the physiological and physical and psychological norms of health in the childbearing woman are consistent across time and culture. As long as it is reasonable to continue without interruption in that finely-tuned natural state, there is no better or safer way. The decisions around what is reasonable and what is unreasonable are quite different in a modern society from what our grandmothers experienced. Similarly women in Melbourne today are able to access a very different level of medical management for illness or complications than are women in tribal societies in developing parts of the world today.

'Old-style' midwifery, focused firmly on the woman in the midwife's care, together with the best available scientific, evidence based interventions when illness or complication are detected, is the recipe for best practice in primary maternity care. 

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.