The Human Microbiome: considerations for pregnancy, birth and early mothering

This post was co-authored by Jessie Johnson-Cash and based on her presentation at the USC Midwifery Education Day.

The human microbiome is rather fashionable in the world of science at the moment. The NIH Human Microbiome Project has been set up to explore correlations between the microbiome and human health and disease. To date the human microbiome as been associated with, amongst other things obesity, cancer, mental health disorders, asthma, and autism. In this post I am not going to provide a comprehensive literature review – this has already been done, and the key reviews underpinning this discussion are: Matamoros et al. (2012) ‘development of intestinal microbiota in infants and its impact on health’and Collado et al. (2012) ‘microbial ecology and host-microbiota interactions during early life stages’. Instead I am going to focus on what this means for pregnancy, birth, mothering and midwifery.

What is the human microbiome?

Based on a chart by Matamoro et al. 2013. Adapted and extended by Jessie Johnson-Cash.

Based on a chart by Matamoro et al. 2013. Adapted and extended by Jessie Johnson-Cash.

Considerations for mothers and midwives

The following are not research based recommendations – the research is yet to be done. They are more considerations/questions arising from the developing knowledge around the human microbiome. There are quite a few health practitioners writing about gut health currently – one of my favourites is Chris Kresser because he includes references if you want to read the source of his information.

Pre-conception and Pregnancy

The commonly accepted belief that the the baby inside the uterus is sterile (whilst membranes are intact) is now being challenged. It seems that maternal gut microbiota may be able to translocate to the baby/placenta via the blood stream (Jiménez et al. 2008; Metamoros et al. 2013; Prince et al. 2014; Rautava et al. 2013Zimmer 2013). Women’s gut microbiota change during pregnancy and this impacts on metabolism (Koren et al. 2012Prince et al. 2014). So ideally women need to head into pregnancy with a healthy microbiome and then maintain it. Unfortunately our modern lifestyle is not very microbiome friendly, and many of us have dysbiosis (an imbalance in gut bacteria). Dysbiosis and too much of the ‘wrong’ bacteria has been linked to premature rupture of membranes and premature birth (Fortner et al. 2014; Mysorekar & Cao 2014; Prince et al. 2014).

Suggestions:

Birth

There is a difference between the microbiome of a baby born vaginally compared to a baby born by c-section (Azad, et al. 2013; Penders et al. 2013Prince et al. 2014). During a vaginal birth the baby is colonised by maternal vaginal and faecal bacteria. The initial bacterial colonies resemble the maternal vaginal microbiota – predominately Lactobacillus, Prevotella and Sneathia. A baby born by c-section is colonised by the bacteria in the hospital environment and maternal skin – predominately Staphylocci and C difficile. They also have significantly lower levels of Bifidobacterium and lower bacterial diversity than vaginally born babies. These differences in the microbiome ‘seeding’ may be the reason for the long-term increased risk of particular diseases for babies born by c-section.

The environment in which the baby is born also influences their initial colonisation. A study by Penders et al. (2013) found that term infants born vaginally at home and then breastfed exclusively had the most ‘beneficial’ gut microbiota. It is likely that these babies only came into contact with the microbiota of their family during the key period for ‘seeding’ the microbiome. No one has researched waterbirth and the microbiome yet. Might it dilute the bacteria? The chance of colonisation and infection with group B streptococcus (GBS) is reduced with waterbirth (Cohain 2010Neugeborene et al. 2007). This may be due to dilution of the GBS or additional colonisation of the baby with beneficial bacteria. Another future research topic is caul birth and the microbiome. Does a baby born in the caul miss out on colonisation via the vagina?

What we do know is that antibiotic exposure alters the microbiome in adults (see above). When a woman is given antibiotics in labour her baby also gets a dose. In 2006 a medical expert review (Ledger 2006) raised concerns about prophylactic antibiotics in labour. A study in 2011 found that antibiotics given in labour increased the incidence of late-onset serious bacterial infections in infants (Ashkenazi-Hoffnung et al. 2011). I think more research needs to be carried out considering the number of women/babies given antibiotics in labour (eg. ‘prolonged’ rupture of membranes).

Suggestions:

  • A vaginal birth in the mother’s own environment is optimal for ‘seeding’ a healthy microbiome for the baby (Penders et al. 2013).
  • Minimise physical contact by care providers on the mother’s vagina, perineum and the baby during birth.
  • Avoid unnecessary antibiotics during labour. If antibiotics are required consider probiotics for mother and baby following birth.
  • If the mother has a c-section… and I know it sounds weird but… she may want to consider swabbing her vagina and ‘wiping’ the baby with this swab. It is even more important to encourage and support breastfeeding for mothers who have had a c-section. Again, consider probiotic support.

Postnatal

After birth, colonisation of the baby by microbiota continues through contact with the environment and breastfeeding. There are significant differences in the microbiota of breastfed babies compared to formula fed babies (Azad, et al. 2013; Guaraldi & Salvatori 2012). Beneficial bacteria are directly transported to the baby’s gut by breastmilk and the oligosaccarides in breastmilk support the growth of these bacteria. The difference in the gut microbiome of a formula fed baby may underpin the health risks associated with formula feeding. In the short term, infant colic may be associated with high levels of proteobacteria in the baby’s gut.

Suggestions:

  • Immediately following birth, and in the first days baby should spend a lot of time naked on his/her mother’s chest.
  • Avoid bathing baby for at least 24 hours after birth, and then only use plain water for at least 4 weeks (Tollin et al. 2005; RCM 2008).
  • If in hospital use your own linen from home for baby.
  • Minimise the handling of baby by non-family members during the first weeks – particularly skin to skin contact.
  • Exclusively breastfeed. If this is not possible consider probiotic support.
  • Avoid giving baby unnecessary antibiotics (Ajslev et al. 2011; Penders et al. 2013). Again, if antibiotics are required probiotics need to be considered.
  • Probiotics may also be beneficial for babies suffering from colic.

Summary

The more we understand about the human microbiome the more it seems fundamental to our health. Pregnancy, birth and breastfeeding seed our microbiome and therefore have a long-term effect on health. More research is needed to explore how best to support healthy seeding and maintenance of the microbiome during this key period. I have discussed a number of considerations and suggestions arising from what we already know. I welcome any comments, discussion and further suggestions from readers.

Further reading and resources

Watch the trailer for MicroBirth and support their project

5 ways gut bacteria affect your health

Gut feelings: the future of psychiatry may be inside your stomach

Gut bacteria might guide the workings of your minds

Posted in baby, birth, midwifery practice, pregnancy, uncategorized | Tagged , , , , , , , , , , | 54 Comments

The Future of Midwifery and Homebirth in Australia?

http://king-animal.blogspot.com.au/2012/07/wolf.html#.UsTquXn5i04A lot of changes have occurred in Australian midwifery over the last few years, and I think many midwives and women are unsure or confused by them. I am going to attempt to make a clear and coherent summary of the changes, and discuss the impact of them now, and in the future for midwifery and homebirth. There are going to be a lot of acronyms in this post which may be new to some and familiar to others. So here is a glossary before I begin:

  • ACM – Australian College of Midwives
  • AHPRA - Australian Health Practitioner Regulation Authority
  • AMA – Australian Medical Association
  • ANMC - Australian Nursing and Midwifery Council
  • ICM – International Confederation of Midwives
  • NMBA - Nursing and Midwifery Board of Australia
  • PII – Professional Indemnity Insurance
  • PPM - Privately Practising Midwife
  • RANZCOG – Royal Australian and New Zealand College of Obstetricians and Gynaecologists

Before AHPRA and PII (pre 2010)

The following is an overview of how PPMs worked based on myself and other midwives I know. I realise there will be some variation across individual midwives…

Before AHPRA PPMs were regulated in the same way as any other midwife – at the time this was by ANMC. They collaborated with GPs, hospitals and other health care practitioners, referring and transferring care when needed. The ACM’s ‘consultation and referral guidelines’ were freely available online which meant women could access them, and they formed the basis of discussions around scope of practice and consultation/referral. If a woman transferred to hospital during labour the PPM could no longer act as a ‘midwife’ – instead handing over the professional role and responsibility to the hospital midwife. This allowed the PPM to focus on the woman’s emotional, physical and advocacy needs rather than on the needs of the institution. Hospital midwives are well placed to work within their environment – they know how to deal with the obstetricians, equipment, medications, policies and paperwork. There was no indemnity insurance available for PPMs (since 2001) – so they worked without it. PPMs were employed directly by women and worked directly for women. The above factors were discussed and stated in a signed mother-midwife contract

Meanwhile consumer groups such as Maternity Coalition and the ACM were pushing for medicare funding for PPMs. I supported this, and still believe that the health care system should fund homebirth, and that all women should have access to PPMs regardless of their financial situation. There was/is also a government commitment to increasing access to continuity of care for all Australian women.

In 2009 AHPRA was formed in order to have one National registration body rather than individual State registration boards. This was to prevent dangerous healthcare practitioners switching states to continue practising. The ANMC was absorbed into this new registration body. The role of AHPRA is to register and regulate all health care professions including midwifery. Each profession has their own Board within AHPRA – and the Nursing and Midwifery Board of Australia (NMBA) is responsible for midwives and nurses. To understand why midwifery is so entangled with nursing in Australia see Fahy’s (2007) article ‘an Australian history of the subordination of midwifery’ . The perception of midwifery as a branch of nursing underpins the ongoing medical control of the profession described below. Anyway – back to the NMBA. The primary role of the Board is to ‘protect the public’ ie. these are the people who deal with misconduct hearings and ensure midwives are undertaking continued professional development. The formation of AHPRA brought with it two key changes to PPM practice - eligibility and indemnity insurance.

Eligible midwives

In 2010 the ‘eligible midwife registration standard’ came into effect. The aim of this was to enable women to access medicare rebates for PPM care. In order to get rebates women need to engage the services of an ‘eligible midwife’. Note that rebates are not available for homebirth – only antenatal care, birth in a hospital/birth centre (where the PPM has visiting rights) and postnatal care. To become eligible, the midwife must apply to AHPRA for notification and demonstrate that she mets the requirements which are:

  • current general registration as a midwife in Australia with no restrictions on practice
  • midwifery experience that constitutes the equivalent of three years’ full-time post initial registration as a midwife
  • current competence to provide pregnancy, labour, birth and postnatal care to women and their infants
  • successful completion of an approved professional practice review program for midwives working across the continuum of midwifery care
  • 20 additional hours per year of continuing professional development relating to the continuum of midwifery care
  • formal undertaking to complete within 18 months of recognition as an eligible midwife, or the successful completion of a course to acquire the skills required to order diagnostic tests and prescribe scheduled medicines

You can download the ‘guidelines and assessment framework for the registration standard for eligible midwives‘ for further details about the requirements. It could be argued that these requirement (excluding prescribing – which is whole other rant/issue) merely reflect the normal scope of midwifery according to the ICM. However, in Australia most midwives are unable to practise to their full scope due to constraints imposed by the structure of the medicalised maternity system.

The ‘eligible’ classification is often misunderstood, with many believing that you must be eligible to be a PPM or attend homebirths. This is untrue, and many of us continue to work as described above, choosing not to be ‘eligible’ for a number of reasons. There is also an assumption that an eligible midwife is ‘better’ and ‘more experienced’, and again this is not necessarily true. For example, a midwife can gain eligibility without any experience in attending homebirths. The point of eligibility was/is for women to access medicare rebates – not to create a separate and higher class of midwife.

Medicare eligibility has resulted in a number of changes. Firstly, it has increased women’s access to continuity of care and given them access to rebates for maternity care via a PPM. Many midwives have set up as PPMs and midwifery group practices are popping up everywhere – again this increases women’s choices. Some midwives are continuing their homebirth practice with the additional benefit of women being able to claim rebates if they wish. Other midwives are setting up new practices. There are so many different ways in which eligible midwives are working… I am not going to attempt to list them all. In my local area maternity service options for women have increased from hospital (public or private) or PPM in 2009; to hospital, midwifery led birth centre (medicare rebates), midwifery group practice (medicare rebates), non eligible PPMs and eligible PPMs. And for those who do not want to engage with standard maternity services there are birth workers, doulas and the option of freebirth.

However, medicare rebates come at a price…

Collaborative arrangements

In order for a woman to claim medicare rebates for care by a PPM, the PPM must have a collaborative arrangement. The nature of this arrangement has evolved since 2010…

Initially, during negotiations with AHPRA about eligibility, the requirement was going to be that the midwife must ‘demonstrate’ collaboration with medical practitioners and health services. This would have been easy – PPMs were doing this anyway (see above), and documentation would have provided evidence. However, the AMA and Rural Doctors Group ensured that the requirement became a signed collaborative arrangement with a medical practitioner. Interesting that doctors got the final say in midwifery practice. I doubt there are any midwives involved in negotiations with AHPRA about how obstetricians practice. Disappointingly midwives and consumers (the ones at the table) agreed to this requirement in order to gain eligibility, maintaining that they would work to change the requirement in the future. Personally, I think they should have refused to allow medicine to control midwifery practice in this way, even if it meant losing eligibility. Instead, the types of collaborative arrangements midwives were required to have were determined as (Dept of Health):

  1. being employed or engaged by a medical practitioner or an entity that provides medical services; OR
  2. receiving patients on written referral from a medical practitioner; OR
  3. a signed written agreement with a specified medical practitioner/s; OR
  4. an arrangement in the midwife’s or nurse practitioner’s written records

There was/is no obligation for doctors to collaborate. And in case there is any confusion about this, the AMA published a handy  guide for doctors ‘collaborative arrangements – what you need to know’ stating clearly that: “If you do not want to be part of a collaborative arrangement, or you are unable to reach agreement on the appropriate terms of a collaborative arrangement, then there is no obligation to be part of one. You do not have to commit to being part of a collaborative arrangement for any particular period.”

The collaborative arrangement was the equivalent of requiring the manager of Woolworths to agree in writing to allow customers to buy vegetables directly from a local farmer.  Not surprisingly, getting a collaborative arrangement, and therefore claiming medicare rebates was fairly impossible. In 2013 in response to the predictable ‘difficulties with establishing collaborative arrangements’ an amendment was made to the requirement expanding the types of collaborative arrangements. Now, in addition to a collaborative arrangement with a doctor who provides obstetric services (as above), a PPM has two further options for collaboration:

  1. That she is credentialed for a hospital, having successfully undergone a formal assessment of his or her qualifications, skills, experience and professional standing. It is expected that appropriately qualified medical practitioner/s would be involved in the assessment; OR
  2. That she has a written agreement with an entity other than a hospital that employs or engages at least one obstetric specified medical practitioner.

Effectively medical practitioners, individually or via the institutions they work in still control access to medicare for PPMs.

Midwives are pretty resourceful, and many have found ways to make this work for them and the women they care for. However, it is very dependent upon the people and organisations providing collaborative arrangements. Because it is so complex, there is a lot of confusion and misunderstanding. For example, some believe that a medicare eligible midwife cannot care for a woman having a VBAC. This is not true. She can – just as any PPM can. She may not be able to secure a collaborative arrangement to do so ie. there will be no medicare rebate for that care. However, in some cases medical practitioners or hospitals will agree to antenatal and postnatal care by a PPM for VBAC women. Women need to discuss options and boundaries with their individual PPMs… regardless of eligibility. This is part of negotiating the mother-midwife relationship.

Currently eligibility and collaboration remain an ‘opt in’ choice for both midwives and women. Personally I have chosen not to ‘opt in’ because I feel that the current collaborative arrangement requirements are not aligned with my philosophy of midwifery and ‘with-woman’ care… and I won’t compromise. There are women who also feel this way, and specifically want a non-eligible midwife. Or, who do not want to jump through the hoops required to access a medicare rebate (eg. booking into hospital). While both options are available – eligible and non-eligible PPMs – women can choose the option that works best for them.

However, this choice may disappear in 2015…

Professional Insurance Insurance – the wolf at the door

AHPRA registration standards require that all health care professionals have ‘professional indemnity insurance’ (PII) for all aspects of their practice. No big deal for midwives working within the system because they are covered vicariously by the organisations they work for. But this left PPMs with a problem. There was no insurance product available for them, and to practice without insurance breached their registration standards. Long story short, following a lot of protests and negotiations a compromise was found. Two insurance companies stepped in with PII and we now have two products, both excluding homebirth. MIGA only provides insurance to eligible midwives and covers antenatal care, labour in hospital/birth centre and postnatal care. Medisure will insure any PPM for antenatal and postnatal care only. 

Because there is no cover available for homebirth an exemption for PII during a homebirth is in place until June 2015. Not surprisingly, neither insurance company is jumping at the chance to offer PII for homebirth. The NMBA recently published a report on PII for midwives which analyses the issues involved with offering an insurance product that covers homebirth with a PPM. The difficulties centre on the size of the market (ie. number of homebirths/PPMs buying the product); working out the probability of a claim; and working out the size and type of a potential claim. The report includes a lot of discussion about ‘risk’ and ‘risk assessment’. It also suggests that an option could be to make any PII product only available for medicare eligible midwives to ensure ‘confidence and certainty’ within the insurance market about PPM practice. It is likely they will also dictate further requirements for cover such as women must undergo particular screening tests (bloods, u/s, etc.) and be classified as ‘low risk’. These issues are already being faced in the United Kingdom by women and PPMs.

So far there has been no official response to the insurance report from the ACM. The recent Maternity Coalition magazine included this divisive statement in relation to protecting midwives and women’s choices:

“Many midwives feel that they are in a vulnerable legal position. This is often because they are not doing these things [following professional standards re. scope, information giving and documentation]. If we could confidently demonstrate that homebirth midwives as a group were practising in this manner then it would be easier to secure insurance for intrapartum homebirth care and resist the push to regulate homebirth more strictly.” (Ann Catchlove)

It is the NMBA’s role is to regulate midwives… all midwives, including homebirth midwives. All midwives must follow professional standards, provide adequate information, and keep adequate documentation. Yes, individual homebirth midwives may fail to do this… and so might individual hospital midwives. Some would argue that information giving by hospital staff is often below the legal standard for consent (e.g. ARM, induction). Either way, there are already mechanisms in place to hold midwives accountable for their practice via NMBA and civil law. Indeed, considering the number of vexatious reports submitted to the NMBA against PPMs, it could be argued that the mechanisms are working too well (Jo Hunter is presenting about this issue at the Homebirth Conference in March). Unfortunately, we are never going to ‘confidently demonstrate’ that all midwives within any model of care or birth setting are practising in a particular way. Aligning midwifery with medicine and allowing medicine to regulate midwifery practice will not reduce risk. Evidence-based, woman-centred care will reduce risk. How about requiring all midwives to undergo a regular consumer-led ‘midwifery practice review’ assessing their practise against evidence and midwifery philosophy?

The future of midwifery and homebirth?

The following predictions are from my own crystal ball, and some optimists may consider them pessimistic. I think that in 2015 a PII insurance product will be made available that will cover homebirth, but only for eligible midwives accredited by hospitals, and for women booked into the hospital system for shared care and who meet particular ‘low risk’ criteria. PPMs without eligibility will no longer be able attend homebirths – to do so would mean practising without insurance ie. breaching their registration. Women who are not classified as ‘low risk’ will be unable to have a registered midwife at their homebirth (eg. previous c-sectiongestating beyond 41 weeks). I think that the professional midwifery organisations will go along with this in order to gain the mandatory insurance and protect private midwifery practice (limited) at homebirth. These changes will have a significant impact on a minority of midwives and women:

Midwives: Non eligible midwives will either become eligible; or stop providing PPM services; or hand in their registrations and become unregulated ‘birth workers’ (however, in South Australian this could lead to criminal charges). Newly qualified midwives will struggle to gain the experience required to become eligible due to limited continuity of care within the maternity system. PPM practice will be dictated by the constraints of an insurance product who’s focus will be on eliminating risk based on medicalised notions of ‘risk’.

Women: Access to midwives and options for care will be limited. Women who do not meet the requirements for insurance cover will be unable to have a registered midwife at their birth. Many women will go along with the requirements (including to switch to hospital birth) but others will not, and their only option will be to freebirth (this is already happening in Ireland). There is a big difference between choosing to freebirth and feeling there is no other choice.

I think we have lost sight of what is important - the essence of midwifery, being ‘with woman’ regardless of where or how the woman chooses to birth, or with whom she chooses to birth. Unfortunately, I think we have come too far down the track and midwifery has become entangled with medicine and the needs of insurance companies. I can’t see a way out of this mess can you? What I find most frustrating is the lack of discussion about these issues within the Australian midwifery profession. In contrast, in the UK where PPMs face the same insurance issues there are protests, marches and campaigns – even support from a Professor of Obstetrics and Gynaecology. Either, Australian midwives don’t know what is going on, or they agree with the changes, or they don’t care – I’m not sure which. I’d love to know your thoughts.

Posted in midwifery practice, opinion and thoughts, uncategorized | Tagged , , , , | 80 Comments

Midwifery Practice During Birth: rites of passage and rites of protection

Finally I have completed my Phd! It took me six years – the last two mostly writing… and writing… and rewriting. Entire chapters did not make the final ‘cut’. There is so much more I wanted to say (and did) about authoritative knowledge and the ritual nature of midwifery practice. Hopefully I will share this work another way in the future.

My aim was to contribute to an understanding of birth, and midwifery practice, grounded in women’s experience. I believe we need to develop (reclaim?) our own birth knowledge in order to shift the current medical paradigm that is failing women.

The Phd journey has been a rite of passage itself, and I pushed myself to my edge and beyond. I thought about giving up at times, and felt self-doubt about my ability (I left high school with no qualifications and a baby in my belly). I accepted my fears and kept going one step at a time. In the process, I learned not only about my topic, research, and writing; but also about myself.

The abstract is posted below, and you can download the full thesis here. I’d welcome comments, questions and discussion about the research.

Big THANKS to the participants – mothers and midwives – who generously shared their birth stories.

Abstract

This study explored midwifery practice during birth. In particular, the experiences, actions and interactions between midwives and women during uncomplicated, normal births.

Most of the existing literature focuses on outcomes associated with individual practices; and there is a lack of research evidence supporting many of the common midwifery practices carried out during birth. There is also limited research exploring midwives’ experiences and perceptions of their practice during birth; although it seems that the context of midwifery practice, and cultural norms influence practice. Studies exploring women’s experience of birth have identified an altered state of consciousness, and issues of control as key factors. However, there has been very little research specifically examining women’s experience of midwifery practice during birth. This study sought to explore the experience of midwifery practice from both the perspective of the midwife and the woman.

The study is a narrative inquiry, and a feminist approach was taken throughout the research process. Birth stories were gathered from mothers and midwives during in-depth interviews. The participants had either experienced or attended an uncomplicated vaginal birth, and were encouraged to share their story of this experience. Narratives were created from the interview transcripts and analysed to identify common themes. An explanatory framework ‘rites of passage’ was then applied to further illuminate the narrative of midwifery practice during birth.

The findings are presented in three chapters. The first focuses on the mothers’ experiences of birth as a rite of passage. This chapter provides the foundation for the following chapters that present midwifery practice during birth. Midwives enacted ‘rites of passage’ during birth that tended the boundaries of aloneness, and nurtured self-trust and inner wisdom. Midwives also enacted ‘rites of protection’ which contradicted rites of passage, but tended the needs of the institution. Tensions arose between these two types of rites, and conflicting cultural values were transmitted and reflected through their performance.

Findings are discussed in relation to the literature, and the thesis concludes with recommendations for midwifery practice, midwifery education, and further research. Recommendations centre on a model of midwifery practice as ‘ritual companionship’ as the basis for developing midwifery practices that are aligned with women’s experience of birth.

Conceptual map of findings

Posted in birth, midwifery practice | Tagged , , , , , , | 57 Comments

Amniotic Fluid Volume: too much, too little, or who knows?

This post is in response to readers asking me to cover the topic of induction for low amniotic fluid volume (AFV). Most of the content is available in textbooks, in particular Coad and Dunstall 2011 and Beall and Ross (2011), and I have provided references/links for research where I have stepped outside the textbook sources. I use the word ‘may’ quite a bit in this post because little is known about AFV, therefore a lot of the available information is theoretical. In fact, this post probably raises more questions than answers! Also note that I am focussing on AFV at term.

Amniotic fluid volume regulation

Amniotic fluid is in a constant state of circulation. In the second half of pregnancy the main sources of fluid production are from the baby:

  • urine (700mls per day)
  • lung secretions (350ml/day)

And the main sources of fluid clearance are:

  • the baby swallowing fluid and passing it back into mother’s blood stream
  • direct flow across the amnion (placental membrane) into placental blood vessels

The balancing act required to maintain a healthy AFV may be influenced by hormones (prolactin and prostaglandins), osmotic and hydrostatic forces, and the baby. Maternal hydration is also associated with AFV (Patrielli et al. 2012). From day to day there is little change in AFV, however volume decreases towards term. This is normal. Perhaps this reduction reflects reduced lung secretions as the baby nears term?

The amniotic sac and fluid play an important role during pregnancy and birth – you can read more about that in an earlier post.

Abnormalities in AFV occur when there is an imbalance between fluid production and clearance. Too much fluid is called ‘polyhydramnios’ and too little fluid is called ‘oligohydramnios’. However, measurement and thresholds of normal/abnormal are not clear.

Accurate Measurement?

Here is the first problem… there is no accurate method for measuring AFV. The two ultrasound tests aimed at assessing AFV are:

  • Amniotic Fluid Index: four ‘pockets’ of fluid are measured by ultrasound and added up resulting in an Amniotic Fluid Index (AFI) eg. AFI = 10cm.
  • Maximum Pool: The ‘single deepest vertical pocket’ of fluid is identified by ultrasound and measured in centimetres.

Neither of these methods are supported by research (that I can find). However, studies comparing the two conclude that the ‘maximum pool’ measurement is the ‘better choice’ (Nebhan & Abdelmoula 2008Magann et al. 2011). The reasoning for this is interesting… AFI increases the detection of oligohydramnios resulting in increased rates of induction without improving outcomes for babies. So the best method is the one that does not detect the ‘problem’ you are looking for?

Measurement of AFV by AFI or ‘maximum pool’ is part of the Biophysical Profile assessment which aims to identifying babies with inadequate oxygenation via the placenta. However, it is unclear whether there is any benefit to this test. Indeed, an umbilical artery doppler test may provide a better assessment of placental function, and therefore how well oxygenated the baby is (Alfirevic, Stampalija & Gyte 2010) – which is what everyone is worried about.

There is of course the old fashioned method of assessment, also not well researched. Abdominal palpation is usually carried out during antenatal visits. In addition to working out what position the baby is in, a midwife assesses the amniotic fluid volume. When you have palpated lots of pregnant bellies, ‘real’ polyhydramnios and oligohydramnios are usually pretty obvious. Mothers are also experts regarding their own body/baby and notice differences themselves – particularly if they have been pregnant before and can compare pregnancies. What you may find:

  • Oligohydramnios: baby is very easy to feel – in some cases you can see limbs; the uterus is smaller than expected; the mother may notice reduced movements.
  • Polyhydramnios: baby is difficult to palpate and floats away as you apply pressure; the uterus is bigger than expected; the baby’s heart rate may sound muffled; the mother may notice breathlessness, vulval varicosities, oedema and gastric problems.

When you are working as a midwife in a continuity of care situation you get familiar with the individual woman’s bump over time, and it is easier to notice changes. Measuring (with a tape measure) is often used to assess uterine growth – particularly when care is spread between a number of practitioners. Whilst measuring can assist with identifying polyhydramnios, it is unreliable in identifying oligohydramnios (Freire et al. 2013).

Here is the second problem… there is currently no agreement about what constitutes ‘high’ or ‘low’ levels of AFV. Megann et al. (2011) conclude that: ‘high and low levels [of amniotic fluid] have yet to be established in the literature and are difficult to directly link to adverse pregnancy outcomes.’ So we are busy finding measurements that we don’t really understand the implications of?

Most of the time there is no known cause for the ‘high’ or ‘low’ volume of fluid, and there is are complications caused by it. However, there are some factors worth considering if you are labelled with oligohydramnios or polyhydramnios.

Oligoydramnios - too little

The definition of oligohydramnios is usually less than 500mls of fluid; <2cm maximum pool; or AFI <5. Around 3-5% of pregnant women are diagnosed as having too little fluid. Because of the complexities of measurement and the diagnosis of oligohydramnios, I have differentiated between what I believe are two types:

Physiological oligohydramnios

Most cases of ‘oligohydramnios’ are an outcome of 2 factors:

  1. The normal physiological changes that occur to AFV as term approaches (see chart above) and/or the ‘normal’ level for the individual mother/baby is comparatively low to the general ‘norm’.
  2. Women having routine scans for ‘post-dates’ which then identifies this normal ‘low’ AFV.

There is a lack of evidence supporting induction for oligohydramnios in ‘low risk’ pregnancies ie. when there is nothing else ‘abnormal’ going on with mother or baby (Quiñones et al 2012). Driggers et al. (2004) concluded that: “evidence is accumulating that in the presence of an appropriate-for-gestational age fetus, with reassuring fetal well-being and the absence of maternal disease, oligohydramnios is not associated with an increased incidence of adverse perinatal outcome.’’

A recent review of the literature (Rossi & Prefumo 2013) found that in term or post-term pregnancies oligohydramnios (with an otherwise healthy pregnancy/baby) was not associated with poor outcomes. However, it was associated with increased risk of obstetric interventions… probably because the diagnosis leads to intervention.

Pathological oligohydramnios

Pathological oligohydramnios is generally a consequence of reduced urine output (baby) which can indicate a redirection of blood flow away from the kidneys to the vital organs in response to reduced oxygenation. This usually occurs alongside pregnancy complications such as pre-eclampsia. In this case the low fluid volume indicates inadequate placental circulation to the baby. These babies often have significantly low AFV (easily identified by palpation), and are often growth restricted i.e. small and with limited glycogen supplies. These babies are at significant risk and further assessment and intervention should be offered. As a midwife there are few things more concerning than being able to see baby’s form though their mother’s abdomen.

Management?

Induction of labour is the usual management for oligohydramnios (regardless of type) because there is concern that the baby has inadequate placental circulation (which is correct in relation to pathological oligohydramnios). However, women need to consider that the induction procedure is associated with reducing placental circulation and causing hypoxia and fetal distress. In addition, if the baby is post-dates he may have already passed meconium, and/or will if he becomes hypoxic due to the induction process. Oligohydramnios = less fluid to dilute the meconium = increased risk of meconium aspiration. Therefore, it is very likely that the baby will become distressed during labour before birth occurs. This is why electronic fetal monitoring is important – in clinical practice I saw the inevitable fetal distress and rush to theatre resulting from induction for oligohydramnios over and over again. So, the mother must be prepared for, and informed of the likelihood of c-section. The other alternatives are planned c-section or awaiting spontaneous labour. Whilst spontaneous labour is more gentle on the baby than an induction, waiting for labour with a baby who is not being well supported by their placenta requires serious very consideration (and nerve) – time will not improve the situation, only worsen it. Even spontaneous labour is likely to result in fetal distress once contractions start – these babies are already struggling. Pathological oligohydraminios is a serious complication.

Polyhydramnios – too much

The definition of polyhydramnios is usually around 2000mls of fluid; >8cm maximum pool; or AFI >25cm. Around 1-3% of pregnant women are diagnosed with having too much amniotic fluid. In 60% of cases there is no known cause, but factors that increase fluid volume include:

  • The baby producing too much urine
  • Decreased fetal swallowing (baby)
  • Increased water transfer across the placenta by the mother

These factors may be influenced by the general well being of mother and baby ie. may occur if there are complications present such as diabetes, rhesus isoimmunisation, congential abnormalities, etc. But, usually no complication is present.

Complications associated with polyhydramnios

  • Preterm birth – as the uterus become over stretched with fluid.
  • ‘Unstable’ position of the baby – the baby can float about into helpful and not so helpful positions.
  • Cord presentation or prolapse – because the baby is floating about the cord can get between his head and the cervix.
  • Placental abruption – may occur with a sudden change in fluid volume and therefore size of uterus/placental site.

Management?

Tests may be suggested to see if a cause can be identified (although nothing can be done at this point). Induction of labour with a ‘controlled’ artificial rupture of membranes may be suggested to manage the risk of an unstable lie and/or cord prolapse. This involves breaking the waters whilst holding the baby in place… and with quick access to theatre as the procedure can result in a cord prolapse. Alternatively, the woman may choose to wait until labour begins, and assess her baby’s position once contractions have started. Either way – the risk is the woman’s therefore she must be the person to decide which risks are best for her – induction or waiting.

In Summary

  • The exact mechanisms involved in regulating AFV are still unknown.
  • AFV reduces significantly after 37 weeks – this is normal.
  • There are no accurate methods of measuring amniotic fluid.
  • There is no agreement about what measurements indicate ‘high’ or ‘low’ AFV.
  • The intervention used to manage polyhydramnios or oligohydramnios ie. induction also carries risks which need to be taken into consideration.

So, as you can see this topic creates more questions than answers which is why I previously avoided it!

Further Resources

Science & Sensibility – What is the evidence for induction for low amniotic fluid in a healthy pregnancy?

Posted in birth, intervention, pregnancy | Tagged , , , , , , , | 67 Comments

Feel the Fear and Birth Anyway

http://keepcalmandloveon.wordpress.com/2011/08/09/keep-calm-and-fill-in-the-blank/

This is just a little post to ease me back into the blogging world (thesis finally submitted). As usual, the content is in response to a reoccurring issue and discussions with mothers and midwives. And I welcome your experiences and comments on this topic…

In a backlash against the medicalisation of birth women are beginning to reclaim birth (yay!). Partly thanks to the availability of information via the internet, a counter culture has emerged. Movies, images and stories of empowered birthing mothers circulate through social media – women birthing in beautiful calm environments (usually in water, surrounded by candles), looking like Goddesses whilst gently and quietly ‘breathing’ their baby out. Women are able to see how birth can be, and many are inspired and driven to create a birth experience like those they watch.

Whilst these images can assist in building self-trust for mothers as they approach birth, they do not tell the whole story.

Fear, losing control, and the birth process

Labour is hard work – hence the word ‘labour’ (and I know some people don’t like the word… neither do I). But the work is not just physical, as women birth their babies, they are journeying through a life changing rite of passage into motherhood. At this time a woman is at her most powerful, and her most vulnerable. Historically and globally, childbirth is a time of danger for both mother and baby. Rituals are enacted in an attempt to ensure the safety of mother and baby. The nature of these rituals reflect the culture in which they are enacted. In medicalised cultures these rituals are technological and medical, focussing on surveillance and intervention (Davis-Floyd 2003) – which often create danger but that is a whole other post/s. Regardless of attempts to ensure safety, deep down, like our ancestors we know we step into the unknown during birth. Fear is a normal part of birth. It is normal to fear for yourself and your baby. It is normal to fear the changes that will come when this new person enters your life. It is normal to fear how you will cope/are coping with the enormous physiological changes and sensations in your body.

It is unusual and unhelpful to be extremely fearful throughout labour, and prolonged high levels of adrenaline can reduce contractions and placental blood flow. However, most women experience a point in their labour where they feel out of control, frightened and overwhelmed. Some call this ‘transition’, and it is usually a sign that birth is close. Victor Turner (1987, p.9) described the middle phase of a rite of passage as an ‘undoing, dissolution’ and a ‘decomposition’ [of the self] which is accompanied by the ‘processes of growth, transformation, and the reformulation of old elements in new patterns’. I think this is a good description of the transitional phase of labour. In addition, Michel Odent suggests that the intense fear and sense of ‘losing it’ experienced near the end of labour facilitates the physiological process of birth. You can read more about the phases of the childbirth rite of passage in Chapter 4 and 5 of my Phd thesis.

Most women will verbalise their fear, reaching out for reassurance, becoming loud and/or angry… often later apologising for their behaviour. Others remain externally calm, and those around them are oblivious to their turmoil. I have previously written about how women are judged by how they behave in labour. Women who manage to remain calm and serene whilst birthing are admired for maintaining control. In contrast, those who are loud, and appear to ‘lose it’ are considered to be out of control. However, appearing calm, and feeling calm are entirely different things. Only the woman knows what is going on inside her head – and body.

We have created a culture (and birth culture) that seeks to avoid and minimise extreme emotion and pain, and encourages being in control. We use medications and/or skills, methods and techniques to remain in control and dampen the emotions – or at least the expression of those emotions. In some cases women are told that they should not experience fear, or pain, during birth… that these are conditioned feelings that can be controlled. I think it is a shame that this powerful aspect of the birth experience remains hidden and suppressed. Birth movies rarely include footage of women visibly ‘losing control’ (are these scenes edited out?). Women rarely share with others their experiences of feeling fearful and out of control – possibly they are worried about being judged, or think that they are unusual.

Getting real – acknowledging fear

I realise that my perspective/suggestions go against many childbirth preparation programs which aim to give women skills and techniques to control their fear (and behaviour). Whilst these techniques can be helpful… particularly during early labour… they are unhelpful for some… particularly during the intense transitional phase of labour. Women have told me they felt like failures because the techniques stopped working for them and they ‘lost it’. One woman recently told me that the practitioner who taught her various techniques informed her she had not done them properly because she felt pain and fear! In addition, suggesting that the baby suffers long-term emotional issues if fear is experienced during labour is unhelpful (seriously, women are told this).

An alternative approach is to open up the discussion about fear and losing control during birth.  Rather than trying to eliminate fear, it seems more helpful to acknowledge it is part of birth (for most) and to embrace it. Some suggestions:

During pregnancy

  • Explore fear – What are you afraid of? Is there anything you can do to help alleviate specific fears (eg. researching, talking, planning)?
  • Reinforce that it is OK if fear surfaces during birth… even if you think you have ‘worked through’ a specific fear during pregnancy it may resurface.
  • If you want to, learn relaxation/coping techniques – these may help, particularly in early labour – but don’t rely on them to work throughout (they might if you are lucky). Also don’t be persuaded that you need to master particular skills to birth well… you already have everything you need within you.
  • Create/plan a safe birth environment where losing control and feeling fear will be OK. Anyone who you plan to have in your birth space should be able to ‘be with’ your fear, and support you through it. You should feel comfortable about losing it in front of them without being judged.

During labour

Get on with birthing – as fear arises let it come, feel it, accept it, and deal with it however you need to (be loud, be angry, be quiet, reach out for reassurance, shut yourself in the toilet, breathe, whatever). It will pass, and you will birth.

Posted in birth, opinion and thoughts | Tagged , , | 109 Comments

Early Labour and Mixed Messages

Artwork by Amanda Greavette: http://www.amandagreavette.com

Edited and updated: November 2013

This post is about early labour and the mixed messages women are given about this important part of the birthing process.

Defining the indefinable

The concept of ‘early’ or ‘latent’ labour emerged as a result of the birth process being broken down into stage and phases – the diagnosis of which relies on clinical assessments of contraction pattern and cervical dilatation. The notion of being able to determine the future progress of labour from such clinical assessments is not supported by research, yet it underpins maternity care. What research does show is that concepts of stages and phases of labour does not align with women’s perception and assessment of their own birth process (Gross et al. 2009; Low & Moffat 2006; Dixon et al. 2012).

In addition ‘early’ is only ‘early’ with hindsight. At one point in time (the clinical diagnosis of early labour) there is no way of knowing if labour will result in a baby in 30 minutes or 24 hours. If a labour is 2 hours long… when did early labour occur? As previously discussed an individual woman’s body is unique and so is her labour pattern.

Labour is basically the process by which a baby moves from the inside of a woman to the outside of a woman. Sounds simple, but it is incredibly complex and involves a complicated interplay of physiological, psychological and emotional factors. Women’s experience of labour often involves a sense of separation from the external world, focussing within, and becoming immersed in the act of giving birth. The hormones released during birth support this ‘altered state of consciousness’ (see the work of Sarah Buckley). During early labour the woman is beginning to move into this birthing state. Many midwives, including myself use the changes in behaviour displayed by women as they move into, and through the ‘birthing state’ to estimate how close the birth is. Of course, just like clinical assessments this is not entirely reliable as some women do not follow the usual scenario.

Despite the fact that concepts such as ‘early labour’ and ‘established labour’ are constructed, and not very helpful… I need to use these terms in this post because they are used consistently in the literature I am discussing (apologies).

Hospital perspective: early labourers are not welcome

Women admitted to hospital in early labour are more likely to end up experiencing complications and interventions, including caesarean section (Klein et al. 2004; Bailit et al. 2009; Rahnama et al. 2006). There are two explanations for this:

  1. That these women already have a dysfunctional, prolonged labour which is why they are coming to hospital in early labour. This explanation is favoured by a local hospital, and their response is to augment (ARM and IV syntocinon) all women who are admitted in early labour who do not establish labour within 2 hours. The rationale is to avoid a prolonged, complicated labour… and according to the obstetrician ‘women don’t want to be in labour for a long time’. I wonder if the women are consenting to these procedures based on adequate information… or just being asked if they want a shorter labour (hands up!)
  2. That exposure to the routine interventions involved with care in a hospital setting increase the chance of complications occurring (Bailit et al. 2009) ie. the longer the woman is in the system, the more opportunity there is to ‘do stuff’ to her.

Women admitted to hospital in early labour also cost the institution more money because they are on the ward for longer which increases demands on services and staffing. Therefore, great efforts are made to deter women from settling themselves into hospital during early labour. Antenatal classes warn women to stay away from the hospital for as long as possible to avoid intervention. When women ring hospital to enquire about coming in they are advised to “take a paracetamol, have a bath then ring back in an hour” (guilty). Women are also told to only come to hospital when their contractions are coming every 5 minutes or less – which is concerning because the pattern of contractions is not necessarily an indicator of when the baby will be born. Entire services have been devised (phone support/home visits) to support women to stay at home during early labour (Janssen et al. 2009). When women arrive at hospital they are subjected to invasive clinical assessments to diagnose ‘established labour’ before they are ‘cleared’ for admission to labour ward (Cheyne et al. 2008).

If a woman does manage to get admitted whilst in early labour she is considered a burden by staff. She is likely to be put in a room and checked on occasionally and referred to as ‘not doing anything’, ‘niggling’, ‘she should go home’, etc. The midwife who admits her will be questioned and ridiculed at handover. The midwife allocated to her will most likely also be caring for a woman in ‘real labour’, and that woman will take priority. This is not to bag hospital midwives… I’ve been there myself, and it is very frustrating dealing with a woman in early labour whilst also caring for 1 or more women in ‘advanced’ labour. Whilst not condoning the hospital perspective on early labour – I can understand it from a cost/staffing perspective.

Women’s perspective: seeking reassurance and safety

Findings from qualitative studies suggest that staying away from hospital during early labour can be challenging for women. It seems that women want to be in hospital. And the experience of being assessed as ‘not in labour’ and sent home can be distressing and result in women feeling unsupported (Baxter 2007; Barnett et al. 2008; Scotland et al. 2011). A study of first time mothers found that women experienced embarrassment when they arrived at hospital too early to stay (Eri et al. 2010). They also felt vulnerable when negotiating with midwives to stay. The need to be in hospital is not necessarily about needing pain relief or support. Cheyne et al. (2007) found that women wanted to be in hospital during early labour despite feeling that they were coping well at home. Some participants reported feeling uncertainty about the safety of their baby whilst at home. Carlsson et al. (2009) also found that women were concerned for the wellbeing of themselves and their baby whilst labouring at home. They identified the theme ‘handing over responsibility’ as the core category emerging from their data. Women were keen to transfer to hospital in order to hand over the responsibility for safety to midwives.

Another concern associated with staying at home during early labour is uncertainty about identifying when established labour begins. Women in Cheyne et al.’s (2007) study expressed concern about not knowing how advanced their labour was while at home. Beebe et al. (2006) also found that first time mothers struggled to identify the onset of active labour themselves. Women worried about going to hospital too soon or too late, and were unsure of how to know if their labour was ‘the real thing’. Their main concern about staying at home was not being able to have their labour assessed by hospital staff. In Eri et al.’s (2010) study women perceived midwives as ‘gatekeepers’ with whom they had to negotiate their credibility with in order to gain access to the hospital. Gross et al. (2009) found that women’s own assessment of how and when their labour began was varied and did not match midwives’ clinical diagnosis of labour onset. A study of first time mothers by Low and Moffat (2006) found that women were perceived as abnormal by hospital staff if their experience of labour onset did not fit clinical definitions. Themes identified from the data included ‘this is not right’ and ‘don’t trust your body, trust us’

Physiology and contradictory messages

Let’s take a look at physiological explanations for early labour behaviour. Like all other mammals, labouring women seek a private and safe place where they can avoid distraction and immerse themselves in the act of birthing. During early labour women seek a place to settle and ‘nest’. This makes perfect sense because the neocortex is still engaged and can slow contractions (by reducing oxytocin) in response to thinking, talking, etc. - the woman can think clearly and do the practical things involved in a physical move. Once the woman is settled and her neocortex is not being stimulated, increased oxytocin release re-establishes contractions. This explains why labour often slows down in response to the move to hospital. However, as labour progresses the limbic system takes over and it becomes more difficult – and dangerous from an evolutionary perspective – to move from place to place. The neocortex is suppressed and the woman is deeply in an altered state of consciousness. This is the women who arrives at hospital already ‘separated’ from the external world, nothing stops her contractions, and she is often unaware of those around her until after the birth. So, the need to settle into the birth place during early labour is a normal response to the physiology of the birth process. It is also common for women to call on the support of other women during labour – women they know and who they feel safe with – relatives, friends, midwives, doulas. Early labour is a woman’s signal to get settled somewhere safe and to gather her ‘women-folk’ around her.

What is considered a ‘safe place’ is influenced by the culture in which the birth is taking place. I am not getting into the debate of hospital vs home re. safety. One, because I am totally over it, and two because I am a slightly biased homebirth midwife. Here is a Cochrane Review if you feel the need to head into the debate. Women in Australia (and many other parts of the world) are urged to birth in hospital because the cultural concepts of ‘safe’ involve medicine and technology. The experts in birth are the people who know how to use the medicine and technology, and who can carry out clinical assessments to determine wellness and progress (Davis-Floyd 2003). This message begins in pregnancy as women undergo routine clinical assessments with an emphasis on professional experts providing reassurance of wellbeing. Women are also bombarded with fear-based media about the dangers of birth, and the hospital-based Knights in Shining Armour who will gladly rescue any Damsel in Distress (and her baby). Therefore, it is not surprising that women head for the safety of the hospital when they are in early labour. Our culture has replaced the home/birth hut + well known women-folk with the hospital + unknown medical staff.

The emphasis on hospital as a place of safety whilst also encouraging women to stay away results in some very contradictory messages and ideas (please note these statements do not represent my own views):

  • We are the experts in your labour progress, only our clinical assessments can determine what is happening… but we’d rather you do not come in to be assessed, and instead stay at home not knowing what is going on.
  • Trust us – we want you to have a good birth experience… but if you come in too early we are likely to create complications which will require intervention… so keep away from us as long as you can.
  • We are the experts in your labour progress, our clinical assessments can predict your future labour progress… we will send you home if you are found to be in early labour… if you then birth your baby in the car park it is not our fault as birth is unpredictable.
  • This is a safe place to labour…. but you can only access this safety when you reach a particular point in your labour… preferably close to the end of your labour i.e. you should do most of it on your own away from safety. This contradiction results in a very annoying double standard: A women who labours at home and comes into hospital ‘fully and pushing’ is praised – ‘she did a great job’. However, she laboured (perhaps for many hours) without the attendance of a professional and without any monitoring (eg. fetal heart rate auscultation, etc.)…. On the other hand, a woman who homebirths intentionally is considered to be doing something unsafe despite the constant attendance and monitoring of her midwife.

Suggestions

Rather than considering ‘how to prevent women in early labour being admitted to hospital’, instead it may be better to explore how women’s needs during early labour can be accommodated by the maternity system. I would be interested to know what your experiences and/or suggestions are. Here are some thoughts, as usual I’m ignoring constraints of the system and money in favour of fantasy:

  • Antenatal care should centre on building self trust and reinforcing the woman’s own expertise in birthing her baby. If she relies on herself to determine wellbeing and progress she may be less likely to head to hospital early for reassurance. A study by Carlsson et al. (2012) found that first time mothers who managed to remain at home during early labour expressed a sense of power. Maintaining power was the central focus for these women and involved a sense of authority over their own body. Something to be encouraged I think!
  • Give early labour respect. It is an important part of the birth process and women deserve recognition for it… ie. don’t use the term ‘latent’ or ‘not in established labour’. The woman has begun the birth process. She has her signal to seek a safe place – help her do this.
  • Women’s access to their birth space should not rely on them meeting arbitrary measurements which involve invasive clinical assessments. They should be able to use early labour to get to their ‘safe place’ and settle for birth.
  • If you are planning to head to hospital while deeply in the altered state of labour – it might be useful to take along a doula who can advocate and use her neocortex while yours is suppressed.

Of course if a woman is birthing at home with a known and trusted midwife it is a different kettle of fish. She doesn’t need to concern herself with ‘when to go to hospital’ – and her midwife can (should) attend based on when the woman needs her…  not when she meets particular criteria. Then again in the real world not all women want to birth at home, or can get the support to do so. Therefore, the systems in which they birth need to change. The essential problem is that maternity care has developed in response to the needs of institutions – not the needs of women. More research is being done… and reports published about what women want from their maternity system. Unfortunately what they want (woman-centred, continuity of care) is the opposite to what is already deeply embedded in our society (hospital-based, fragmented care). To turn this around is a huge undertaking… and change will undoubtedly meet resistance from those who benefit from the way things are.

Posted in birth, intervention, midwifery practice, uncategorized | Tagged , , | 112 Comments

An actively managed placental birth might be the best option for most women

The birth of the placenta is my least favourite part of the birth process. I know I have ‘issues’ and I’m working on them. Hopefully writing this blog post will be therapeutic as well as informative. I am going to refrain from referring to the birth of the placenta as the ‘third stage’ of labour because I don’t believe in the concept of stages of labour.

What’s the big deal?

Postpartum haemorrhage is historically and globally the leading cause of maternal death (World Health Organization). The most dangerous time for a woman during the birth process is after her baby is born, around the time the placenta is birthed. Whilst the mother and baby meet face to face, and the family greet their new member, there is a lot of important work going on behind the scenes (ie. inside the woman).

The physiology of placental birth

This is an overview of what happens to ensure the placenta is born and the blood vessels feeding the placenta stop bleeding. If you want references, the information is available in any half decent anatomy and physiology text book (eg. Coad & Dunstall 2011Rankin & Stables 2010)

Before the baby is born

Birth does not happen in distinct stages and the birth of the placenta is part of a complex process that begins before the baby is born. Oxytocin makes the uterus contract. Oxytocin is released by the posterior pituitary gland (in the brain) during labour to regulate contractions. It is one of the key birthing/bonding hormones. I really don’t have the space here to get into any depth about birth hormones, so check out the work of Sarah Buckley to find out more. As the birth of the baby becomes imminent, high levels of oxytocin are circulating in the mother’s blood stream. This creates strong uterine contractions which move the baby through the vagina, and prepare the mother and baby for post-birth bonding behaviours.

Separation of the placenta

 After the birth of the baby the contraction pattern is interrupted. The placenta transfers it’s blood volume to the baby ‘handing over’ the job of oxygenation to the lungs – the placenta is now emptier and less bulky. Instinctive mother-baby interactions stimulate further oxytocin release and the uterus responds by contracting. These interactions involve smell, touch (skin-to-skin), taste, sound… the baby ‘crawls’ on the mothers abdomen, his feet stimulating her uterus to contract. He may attach to the breast and feed, however this is not essential. The placenta is compressed and the blood in the intervillious spaces (the interface between mother’s blood system and the placenta/baby’s blood system) is forced back into the spongy layer of the decidua (uterine lining). Retraction of the uterine muscle fibres constrict the blood vessels supplying the placenta, preventing blood from draining back through the maternal vascular tree (mother’s blood vessels feeding the placenta). This congestion results in the veins rupturing and the villi shearing off the uterine wall. A clot forms behind the placenta. The non-elastic placenta is unable to remain attached and peels away – usually starting from the middle.

At this point you may notice a small gush of blood as the placenta separates and the umbilical cord lengthen as the placenta moves downwards.

After separation

The placenta leaves the upper segment of the uterus and further strong contractions bring the walls of the uterus into opposition – compressing the blood vessels. At the same time the contracted uterine muscle fibres act as ‘living ligatures’ to the blood vessels running through them preventing further blood flow. An increase in the activity of the coagulation system means that clot formation in the torn blood vessels is maximised and the placental site is rapidly covered by a fibrin mesh.

As the placenta leaves the uterus the mother may feel the urge to push again and birth her placenta. Or, she may be far too busy with her new baby and the placenta will sit in her vagina until she moves.

A mother birthing and catching her own placenta

This process is usually complete within an hour of the baby’s birth. However, sometimes it takes longer ie. hours… and hours. If you waited a long time to birth your placenta please post your story in the comments.

Pathology – when it doesn’t work

The bottom line is that the birth of the placenta and haemostatsis (prevention of excessive bleeding) relies on effective uterine contraction. Ineffective uterine contraction is the main cause of post partum haemorrhage (PPH). The other causes are perineal/cervical damage, or even more rarely clotting disorders.

There are 2 main causes of ineffective uterine contraction after birth:

  1. Hormonal – Inadequate circulating oxytocin or inadequate uterine response to oxytocin. Inadequate response is often because the oxytocin receptors in the uterus have become saturated eg. by large doses of syntocinon over a long period of time during an induction (Belghiti et al. 2011; Phaneuf et al. 2000).
  2. Mechanical – something is in the way and the uterus cannot contract. Most often this is a full bladder taking up space in the pelvis and stopping the uterus from contracting down. It can also be a large clot in the uterus or a partially detached placenta.

Most PPHs occur after the placenta is out. PPH can and does occur after a c-section too. In a future post I will discuss the management of bleeding, however this post focuses on physiological vs active management of placental birth and how this relates to PPH.

Another complication can be a retained placenta ie. the placenta remains attached. The definition of a retained placenta varies – and I’m not game to put a timeframe on it. However, once you have done something (such as given an oxytocic drug – see below) you need to finish the job and get the placenta out. If you have not, and there is no bleeding then… how long is a piece of string?

Active management of placental birth

In the 1950s syntocinon (pitocin) hit the birth scene. Syntocinon is an artificial version of oxytocin and is now used extensively for induction of labour, augmentation of labour and to ‘actively manage’ the birth of the placenta. It differs from endogenous oxytocin in the way it is released into the blood stream – ie. in a consistent dose rather than in pulse like waves. Syntocinon is also unable to cross the blood-brain barrier and influence instinctive bonding behaviour (check out Moberg’s book about how oxytocin influences behaviour).

When used to actively manage placental birth, syntocinon mimics the physiology described above by initiating uterine contractions. How active management is carried out varies considerably and this drives student midwives mad. Different practitioners do their own thing, and the literature is also inconsistent. Essentially syntocinon (10iu) is given to the mother by injection after the birth of the baby. The cord is clamped and cut, and the placenta is usually pulled out using controlled cord traction – see the horrible picture above. The order and timing of these interventions varies, although obviously pulling the placenta out comes last. The areas of debate/negotiation are:

  • Timing of injecting syntocinon: Originally syntocinon was given with the birth of the baby’s anterior shoulder. Nowadays it seems to be given after the birth of the baby. There is no research determining the best time. Syntocinon takes around 3 mins to work when given IM (into muscle) – so in theory to mimic physiology it probably should be given soon after the baby arrives.
  • Timing of clamping and cutting the cord: The risks of premature cord clamping are now well know. Most midwives I know (regardless of where they work) wait until the cord has stopped pulsing before clamping. This may have implications if the cord is not clamped before the syntocinon works… there is a theory that the strong contraction will shunt excess blood from the placenta to baby… I’m not so sure. Some midwives wait until after the cord has stopped pulsing before giving syntocinon to avoid this.
  • Whether to ‘drain’ the placenta: If the cord has been prematurely cut, some of the baby’s blood is trapped in the placenta – this makes the placenta bigger and more bulky, and in theory/experience more difficult to get out. There is no research to support this… but many midwives will leave the placenta end of the cord unclamped and drain the trapped blood prior to attempting to delivery the placenta. Personally, this is my preference as I notice it is much easer to get an empty placenta out. Something I learned while collecting cord blood.
  • Whether or not controlled cord traction is used and when: It is standard practice to pull the placenta out after syntocinon has been injected, and the umbilical cord has been cut. Some midwives wait until they have seen signs of placental separation before pulling. I think it is this part of active management that causes the most problems. If you pull on a placenta that has not yet separated you can partially detach it = some blood vessels are ‘torn and open’ but the uterus cannot contract because the placenta is in the way. Or, you can detach it before the syntocinon is working i.e. no contractions to stop the bleeding. Or worse case, and very rare scenario you can pull the uterus out! You can also, more commonly snap the umbilical cord – which often freaks everyone out. But a snapped cord is not a big drama. It just means the mother will have to get up and push her placenta out… Which brings me around to the idea of not pulling at all. A study by Gülmezoglu et al. (2012) found that the ‘omission of controlled cord traction’ did not increase the risk of severe haemorrhage (they only looked at severe). So, women should have the option of getting upright and pushing, or having someone pull their placenta out for them. Or even perhaps pulling their own placenta out?

Active management is usually (not always) quicker than physiological. This is probably another reason it is favoured in hospital settings. Less time waiting for a placenta = less time stressing out about a potential PPH, and you can get the woman to the next station (postnatal ward) quicker.

Occasionally syntometrine is used for active management. This is a mix of syntocinon and ergometrine. It is not generally used nowadays because the ergometrine acts on smooth muscle – all smooth muscle. Therefore the side effects are vomiting, raised blood pressure and potentially a retained placenta due to the cervix shutting… although I’m not convinced about the cervix closing firmly enough to trap a squishy placenta.

What the research tells us – and doesn’t tell us

The physiological vs active management of the ‘third stage’ has been going on since I was a student midwife (I did a literature review on it as an assessment). Today I am doing it the easy way and relying Cochrane to review the studies for me (Begley, et al. 2011Cotter, Ness & Tolosa 2010). In summary the reviews note that there is a ‘lack of high quality evidence’ but conclude that active management reduces the risk of haemorrhage. They also raise concerns about side effects – increased blood pressure, afterpains and vomiting (probably due to the use of syntometrine in some studies); reduced birthweight for baby (probably due to reduced blood volume following premature clamping); more women returning to hospital with bleeding (?). In regards to the last side effect – anecdotally midwives report greater blood loss on the post natal ward after the syntocinon or syntometrine has worn off but this is not measured in studies.

The important thing to remember when interpreting these findings is that all of the studies included were conducted in a hospital setting. The experimental group were those having ‘physiological’ management. The practitioners attending the ‘physiological’ placental births were most likely doing something that was not their usual practice, and they may have been unprepared for, or uncomfortable with this approach. A study that compared active vs holistic physiological care had very different findings (Fahy, et al. 2010). In this study the midwives attending the physiological placental births were familiar and comfortable with this approach. In contrast to previous studies active management was associated with a seven to eight fold increase in PPH rates compared to a holistic physiological approach. Another retrospective study (Davis et al. 2012) found a twofold increase in large PPHs (1000mls+) for low risk women having an actively managed placental birth in New Zealand compared to those having a physiological placental birth.

Back to my initial title statement

A safe and effective physiological placental birth requires effective endogenous oxytocin release. This is generally facilitated by:

  • A physiological birth of the baby: No interventions during the birth process eg. induction, augmentation, epidural, medication, instructions or complications.
  • An environment that supports oxytocin release: Privacy, low lighting, warmth and comfort. No strangers entering the birth space eg. paed or extra midwife.
  • Undisturbed skin-to-skin contact between mother and baby: others must not handle the baby or engage the mother in conversation (no patting, no chatting and no hatting – Carla Hartley). These interactions may result in breastfeeding, but this should not be ‘pushed’ as not all babies want to breastfeed immediately.
  • No fiddling: No feeling the fundus. No clamping, cutting or pulling on the umbilical cord. No clinical observations or ‘busying’ around the room.
  • No stress and fear: Those in the room must be relaxed. The midwife needs to be comfortable with waiting and have patience. The mother must not be stressed as adrenaline inhibits oxytocin release. This is why a PPH often occurs after a complicated birth (eg. shoulder dystocia) and when the baby needs resuscitating.
  • No prescribed timeframes: Many hospital policies require intervention within half an hour if the placenta has not birthed. This is not helpful and generates anxiety which is counter productive.

Of course this is a general list and some women are perfectly capable of birthing their placentas amongst the chaos of siblings and noise etc. Probably because it is their own, familiar chaos and they are relaxed in the midst of it. Others want the cord cut after it has stopped pulsing eg. if it is short. I think the most important factor in ensuring a safe physiological birth of the placenta is a physiological birth of the baby.

However, in Australia (AIHW 2011) only 21% of women go into spontaneous labour and continued to labour without augmentation. Out of that % how many labour without an epidural or other medication? Out of that % how many are birthing in the conditions described above? I pose the question because these stats are not presented. I don’t need to ask the question because I am familiar with hospital practice… and most women are birthing in hospital.

Until hospitals are able to provide care that facilitates a physiological birth process, women choosing to birth in them may find that the safest option is active management of their placental birth. There are further options within this that can be negotiated (see above). Physiological placental birth is an option and possible if you manage to avoid induction, augmentation, an epidural or complications – but be aware of how difficult it may be, and don’t beat yourself up if it doesn’t happen.

Further reading/resources

Belghiti J, Kayem G, Dupont C, et al. Oxytocin during labour and risk of severe postpartum haemorrhage: a population-based cohort-nested case-control study. BMJ Open 2011;1: e000514. doi:10.1136/ bmjopen-2011-000514

Hastie C, Fahy KM. Optimising psychophysiology in third stage of labour: Theory applied to practice, Women Birth (2009), doi: 10.1016/j.wombi.2009.02.004

On Birth and Bleeding – Science & Sensibility

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