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.

midwife-centred language

We midwives have theories about woman-centred care.  The woman and her baby are the focus, and their individual needs guide the planning and providing of maternity care.  The provision of basic primary maternity care through the months of the pregnancy, birth, and neonatal period from a known midwife facilitates, in theory at least, the development of a unique partnership between the woman and her midwife, and supporting woman-centred care.

Many times, in reality, 'woman-centred care' is a hollow and meaningless phrase.   Aspects of the care are dictated by the service providing maternity care, limited by staff numbers and funding arrangements, and fragmented into 'items' that can be entered as numbers into databases.

My attention was piqued the other day when a midwife in a hospital used the word 'passive' in relation to the third stage.  The mother who was about to give birth spontaneously, without medication, had indicated that she did not want synthetic oxytocin to be injected into her after the birth.  The midwife, correctly, informed the woman that the hospital's policy required her to perform active management of the third stage.  The woman replied "No, thankyou."  The midwife then referred to what proceeded as 'passive management'.

• ... passive [management], as opposed to active management

Before you nod your head and say, "OK, passive means not administering the oxytocic, not applying cord traction, not checking the fundus for evidence of separation of the placenta (and whatever else, such as cord clamping, is considered part of active management)", let me explain what is wrong with the concept of 'passive' third stage.

• midwife-centred language

Active management, or passive [non-]management are terms that refer to the midwife's actions.  The woman is virtually invisible.  This is not woman-centred care.

• ignorance

I witness appalling ignorance within the mainstream midwifery and obstetric community with regard to the uninterrupted physiological processes that lead to safe and optimal completion of the third stage of labour.  The 'broad brush' approach, treat everyone, regardless of the need, as required by the hospital's policy, leads to the deskilling of midwives who ought to be competent in protecting and supporting the physiological processes in childbirth.  This is also not woman-centred care.

• denial of a woman's ability to make an informed decision

A woman who is progressing spontaneously in birth, and who indicates that she prefers a spontaneous and unmedicated third stage, can easily be denied the opportunity to proceed when the midwife uses the 'hospital policy' card. 


What is a physiological third stage?
Put simply, a physiological third stage is the spontaneous and unmedicated completion of the birthing process, after the birth of the baby (second stage), resulting in the expulsion of the placenta and membranes.

The Women's Hospital guidelines* defines physiological management of third stage as:

Physiological management: The birth of the placenta and membranes are expelled by maternal effort only and without using uterotonic agents or controlled cord traction.

[note the midwife-centred language: turning the focus from the woman, whose body is achieving a significant and healthy function, to the midwife.]

This is a totally inadequate definition, and is evidence of my previous assertion that midwives and obstetricians have become de-skilled in supporting physiological processes in birth.

I have described aspects of physiological third stages in recent posts, for example:

... The cord was not clamped.  We supported the mother as she stepped out of the birth pool, holding her treasure to her chest, dried them off, and sat them quietly in the prepared chair.  As contractions returned, the mother stood, then squatted over a plastic bowl, all the time holding her naked baby against her naked body, and the placenta was expelled spontaneously.  Blood loss was minimal.  [from The After-Glow]

 and

... A healthy baby made his grand entrance, and no drugs were used.  The woman birthed her placenta spontaneously about 30 minutes after the birth, with minimal blood loss. [from Hospital policy in the spotlight]

What is the midwife's role in physiological third stage?

Having accepted that a woman who gives birth spontaneously and unmedicated, and who is intentional about continuing in the natural physilogical mode unless there is "a valid reason to interfere with the natural process" (WHO 1996. Care in Normal Birth: a practical guide),  the midwife's role is (obviously) to support and protect that natural process.

In the two birth accounts that I have referred to above, the midwife's role included assisting the mother into a supported position, such as sitting upright on a chair, with warm, dry wraps around herself and her baby.  The midwife manages the environment, rather than the labour, encouraging the mother to focus exclusively on her baby who rests quietly in her arms before seeking the breast.  The midwife ensures any activity around the mother is kept to a minimum.  If photos are being taken, this is done in an unobtrusive way.  The midwife notices signs of separation of the placenta, and instructs the baby's father on how to support the mother as she stands or squats over a bowl to expel the placenta, if she needs to.

There is nothing at all passive about the midwife's role in supporting and protecting the natural physiological processes in birth. 

I need to sign off now, as a mother is in labour and I expect to be called soon to attend.

The message of this post is that when we, the midwives, focus on the woman, we are able to work with her.  Our language reveals the focus of our care: either the woman, or ourselves.


*Active Management: go to the Women's Hospital guidelines and click on 'Labour-Third Stage Management'

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.