Showing posts with label third stage. Show all posts
Showing posts with label third stage. Show all posts

Tuesday, February 1, 2011

Video of an OBGYN speaking on timing of cord clamping

I wanted to share the link to the video Dr. Nicholas Fogelson posted on his blog of him speaking at a Grand Rounds on the topic of Delayed Cord Clamping. It is a 50 min talk shown in four parts, check it out if you can make the time.

Delayed Cord Clamping Grand Rounds--Academic OB/GYN

From Dr. Fogelson's conclusion:
Delayed cord clamping clearly increases fetal hemoglobin, blood volume, and iron stores. The evidence supports a clinical benefit of delayed clamping. There’s really no strong evidence against delaying the cord clamping. When we talk about interventions in medicine, really, the burden of evidence is on the intervention. And I think people say. “Delayed cord clamping, you can't prove that that’s an intervention that helps.” And I’m like, oh, no, no, no, no. Delayed cord clamping is what we evolved to do. We evolved to get the blood that’s in the placenta. I don’t have to prove that that’s right. You need to prove to me that phlebotomizing the baby of forty percent of its blood volume is right."
I personally would see it from a perspective of God's design, and not evolution, but I think his point about the burden of evidence is spot-on. I think it would make sense to look the same way at a lot of other common routine maternity care practices.

Tuesday, November 9, 2010

Results Are In: Austrailan Study Supports Physiological Third Stage!

Back in June, I wrote about a theory paper by Australian researchers that I read that discussed the limits of current research literature that does not compare medically managed bith with truly "psychophysiological" birth, meaning unmedicated birth without routine interventions, in a comfortable setting with supportive care. This means that you can't compare the third stages of an actively managed hospital birth with a hospital birth where oxytonics and cord traction are not used, but other hospital factors are included--such as early cord clamping/separation of mother and baby, distractions, stressful atmosphere, IV fluids, unnatural positioning, etc, and claim that "expectant management doesn't work." The article proposed research that could be done comparing what they called "midwifery guardianship" with "active management."

I just learned today (thanks to Birth Sense) that the Australian researches who wrote the theory paper have completed a study on third stage management. The abstract is available here, and the results are very interesting! The study found that for low risk women, active management in a hospital was actually associated with a significantly higher rate of postpartum hemorrhage (11.5%) than the rate they found for midwife-led "holistic physiological care" in a freestanding birth center (1.7%). Considering that previous studies had found the risk or hemorrhage using other definitions of "expectant management" to be higher, these findings are important for determining what factors are necessary for a safe, natural third stage.

Monday, October 18, 2010

Hands-off Neonatal Care

My previous posts, A Natural Third Stage? and Physiological Third Stage, without the "as long as" have discussed how some common procedures right after birth can be disruptive and sometimes even harmful, both for the mother and the baby.

Suctioning of newborns is very common in U.S. hospitals. MidwifeThinking has an excellent post on meconium that also details the risks of routine suctioning. I actually did not know that routine suctioning was not done in other developed countries, so I found it enlightening to hear the perspective of a UK-trained midwife practicing in Australia on this.

I have discussed the theory that immediate skin-to-skin after birth may reduce the risk of postpartum hemorrhage. It also influences the initiation of breastfeeding. This video (which I saw for the first time when Bonnie shared it on her blog, Birth-Joy) demonstrates the results of a study that found that not only was a baby's ability to self-initiate breastfeeding affected by pain medication used in labor, but also by whether or not the mother and baby were separated following the birth.

Given the benefits of skin-to-skin contact, I feel that hospitals really should work to make initial skin-to-skin between mother and baby possible. Here is an excerpt from what I hope will be a great tool for improving hospitals in this reguard. (Thanks to Rixa, who posted this after seeing a presentation on it at the Lamaze/ICEA MegaConference)

Tuesday, August 31, 2010

Physiological 3rd Stage, without the "as long as..."

I shared a link to my post A Natural Third Stage with Buscando la Luz after reading two posts on her blog, Birth Faith, called Preventing postpartum hemorrhage naturally and Preventing Postpartum Hemorrhage: a follow-up. She shared it on her facebook page and my live traffic feed has been going crazy with hits to that post. One commenter was a former L&D nurse who said her experiences backed up the theories I wrote about.

If it is true that keeping mother and baby together reduces the risk of hemorrhage, then that is a good reason not to cut the cord immediately. According to Dr. Nicholas Fogelson of AcademicOBGYN,research does not support the current standard practice of immediate clamping. (I also love this post also because of his example of routine episiotomy as a practice that is very obviously passe. I know from a first hand conversation that there are some dinosaur OBs out there who don't stay up to date on research who still use them liberally--I should post about that conversation sometime)

Someone on the Childbirth International e-mail group recently shared a link to a beautiful series of birth photos by Patti Ramos called Emergence. One of the photos shows an attached cord that is simply beautiful. I never knew they were that color.

Later timing of cord clamping may better for both mother and baby. However, after two hospital births where clamping occured earlier than I preferred both times, I have come to believe that physiological cord clamping is still quite rare in hospitals. I think this is partly because they have been conditioned to believe that routine immediate clamping is normal and may subconsiously look for a reason to cut the cord, partly because they have narrow parameters for what constitutes a "healthy" newborn and are quick to provide support, and partly because they aren't set up to provide transitional support to neonates without moving them away from their mothers. Often "delayed" cord clamping is only available at special request and "as long as the baby is doing okay."

In a post at her blog Midwife Thinking, The placenta--essential resuscitation equipment, one homebirth midwife discusses her reasoning for keeping cords intact no matter what and explains how she goes about doing that. She also talks about obstetric pracitces that contribute to the need for babies to be given support. In a response, Navelgazing Midwife shared pictures of the wooden board she brings to births so that she has a hard surface she could use without cutting the cord in case she ever needs to do chest compressions on a baby.

This just goes to show that in some things, both your choice of provider and the equipment aviailable in your chosen birth location can influence what happens in your birth.

Thursday, June 24, 2010

A Natural Third Stage?

The idea of active management of the third stage has never sat right with me. Even before I developed my interest in natural childbirth. When I was pregnant with my daughter, I was taking one of the hospital classes I talk about that are not so great. The nurse who was teaching the class told us that after our babies were born, we would be getting pitocin in our IVs to help the placenta come out and help the uterus clamp down to put pressure on the placenta site to prevent too much bleeding. I asked if you can decline it and she acted like that would be a stupid thing to do, because why would you want to risk bleeding too much and before we had it a lot of women died from hemorrhage.

It just didn't seem right to me. I didn't like the idea of having a medication to prevent a complication that only might happen. This was part of my reasoning behind changing providers and hospitals. My CNMs told me that with an unmedicated birth, third stage pitocin is often unnecessary, so my birth plan said I didn't want it unless I started to hemorrhage. I ended up being induced with pitocin for that birth anyway, so it didn't matter.

When I moved to a new area while 3 months pregnant with my son, I called the hospital where I was planning on birthing for a recommendation for a provider who would be supportive of natural birth (they recommended Dr. I., who was awesome) and the nurse and I talked about the policies. She said that if I really didn't want an IV, they could do the postpartum pitocin as an IM injection instead and told me that in her 10 years as a nurse, she had never seen a woman not get pitocin after giving birth. When I met with Dr. I., I talked to her about this, and she brought up that breastfeeding really should work just as well as pitocin. She said she would support trying breastfeeding first.

So, then, I had an unmedicated birth, but they had to take my baby to the warmer to give him oxygen. Dr. I. waited until the placenta was out to see how much I bled, but it was too much, so I got both pitocin and methergine--I think it is possible that doing it later is why I needed both.

I wondered if perhaps I'm just a "bleeder" and will need pitocin for all of my births. I don't have a problem with it if it is actually necessary. Then Gloira Lemay shared with me an Australian article called Optimising psychophysiology in third stage of labour: theory applied to practice. I read the full article (link is to the abstract). I believe these authors are on to something, and I would love to see more research on this topic. You can read an interview with one of the article's authors at the Science and Sensibility blog.

The basic idea is that studies of "active management" and "expectant management" haven't really studied truly physiological third stages. The authors theorize that in order to produce the oxytocin surge necessary to help her uterus contract sufficiently to avoid hemorrhage, the mother needs to focus on her baby, holding him skin to skin, in a calm environment with little distraction. This is certainly different than how my 3rd stage was with my son, and I think it is likely pretty rare in a hospital setting.

In natural childbirth education, and especially with hypnosis, we try to help women produce the right natural chemicals in their bodies to promote smooth (and even comfortable) birthing in the first and second stages (though the second seems to be more difficult for some of us). There is scientific evidence that the mind and body are connected and our thoughts and feelings have direct effects in our bodies (the research of Dr. Candace Pert on neuropeptides is one example). We strive for a relaxed, comfortable state of mind to promote oxytocin and endorphins in the first two stages--it makes sense that the same sort of mental state would be necessary for a natural third stage. Third stage is still part of birth, and it's important for both women and their caregivers to recognize this.

The belief of the L&D nurses I have spoken with seems to be that an unmedicated third stage with a small amount of bleeding would be an exception. It seems to me that under the right conditions, a gentle, hands-off approach could make postpartum hemorrhage the exception rather than the rule. According to Gloria Lemay, it works.

In order to accomplish a natural third stage, separation of mother and baby must be avoided whenever possible. This is easy if you don't cut the cord right away. Check out Navelgazing Midwife's recent post on the gross practice of using shoestrings to clamp the cord in unplanned out-out-of-hospital births. And for more on keeping mother and baby together, check out the recently posted Healthy Birth Blog Carnival #6: MotherBaby Edition

be sure to check out my new follow up to this post: Physiological Third Stage, without the "as long as"