However, like most research into birth, women’s voices are missing (you can read about research bias in maternity care here). This study is the first to specifically explore the birth of placenta from the perspective of women.
A huge thank you to the women who shared their experiences for this study.
Overview of findings
The quotes that illustrate these themes can be found in the journal article. I particularly like the descriptions of birthing the placenta! Here are a couple:
“The actual birth of the placenta was just weird, just because it was so soft. It felt like my insides were coming out but not in a painful way. I guess it’s like birthing a squid or something”
I received the following from an Australian midwifery student who has agreed for me to publish the post anonymously. Whilst it can be confronting, it is so important to listen to midwifery students with open ears and hearts. They see maternity care through fresh eyes. As midwives we need to nurture students and role model woman-centred care and strong advocacy. If we lose our midwifery students, we lose our next generation of midwives – Rachel
This piece is not an evidence based article. There is no science or rationale, no Cochrane review, to be found in these words. Just honest thoughts on the student midwifery experience, an individual narrative and nothing more. Yet, I must believe that these thoughts stand for something. They mean something and are worth sharing. In the hope that one student midwife feels a little less alone or one midwife reflects on their practice with women and how they support students.
As student midwives, we begin bright eyed and bushy tailed, with a passion for natural birth, for normal birth. We believe in the innate abilities of women, the knowing that she knows her body, her baby. That the woman is the expert and we trust in the seeming simplicity of this. Our university education aims to facilitate this passion, underpinned with feminist theory, enabling critical thinking, the use of evidence and the ability to learn how to apply clinical skill with heart and soul. Then, at some point, the on-the-ground practice begins. We set foot into the hospital. Here we fall into the deep chasm between theory and practice and experience the raw and visceral realities of the midwifery culture which exists at present. Where we thought we would be supporting women and the spectacular physiology of birth, we find the technocratic perspectives in full force. At every turn, in every space, be it antenatal, birth suite or postnatal, we view women being actively disempowered, intervened with and unsupported. Every damn day.
The excuses are rampant – women are unhealthier today, women don’t want natural births, women don’t know or don’t care and yes, perhaps it may be called naive to step into this world thinking it was all to be experiences of babies being breathed out into warm water and then snuggled up into the loving arms of their new parents. But let’s stop blaming the women and take a hard look at maternity culture right now. To be explicit, student midwives are constantly bearing witness to the atrocities of birth in some hospitals today – poor information sharing, cultural practices rather than evidence based, disrespectful communication, women being held down in labour, being told off, lied to, having care providers do all manner of procedures without true informed consent at different points in the process such as stretch and sweeps, vaginal examinations, episiotomies, the instigation of inductions without application of the research and the cascade of intervention which ensues…the list is too huge and exhaustive to mention. The crushing reality is that physiological birth is so far from the norm that it is somewhat unbelievable. The medicalisation of birth has hit an all-time high. Yet student midwives are called naïve. To have thought that the professional codes of conduct and the international definition of the midwife would be upheld and that amazingly, women would be treated with basic kindness and respect.
This is not about pushing a natural birth agenda. This is a human rights issue.
I have not yet become desensitised to what I see every time I walk into the hospital, to be with woman, with birth and that is a very challenging space to be in. The emotional work of being with women is immense and what we see and come to embody is that birth is now a battle ground, leaving bruised, battered and traumatised women in its wake, with many midwives the witness or the handmaids of the hospital birth machine.
As a student midwife, I thought that midwives love women and would be their advocates. That they would stand with women and acknowledge and support their inherent power. And yes, I cannot possibly speak for all midwives but my personal experience is that majority midwives are not speaking up for women and they are not speaking up for themselves. We understand that the paradigm is powerful and that you are overworked, run off your feet; you are burning out. Yet we can’t learn midwifery and the art of being with-woman if we don’t see it from you. We need to see your kindness, bravery and compassion with women, for yourself and with us. We need to see you standing up for women and bucking the dominate culture. We need to see you not playing nice anymore. No longer playing the good girl.
Students can be clumsy and time consuming in our learning but ultimately we want to be you, we want to be midwives. We look to you to show us the way, to show us midwifery but most often we are bullied, unsupported, gossiped about, made to feel insignificant or downright hazed. Too often student midwives are voiceless, dwelling in the liminal space between woman and practitioner- we exist in no woman’s land, a nebulous other-world where we are not the layperson nor the practitioner.
It is my solemn plea that you remember that student midwives are also women and please be with us too. Please remember why you got into midwifery in the first place and remember you were once like us.
Midwives, we see you and we know that you are powerful, and can be the instruments of profound change for women right now. Simply by rising up together, joining as one and saying,
“No more, I will not participate in these practices, in this culture, a second longer!” For if enough midwives do this then it would change.
Stand with and for women. All women. For in the end, we are all women and we are powerful together beyond measure.
In the words of Lucy Pearce:
“We do not need to wait for permission before we open our mouths. We do not need to wait for others to make space for us, we can take it. We do not need to read from others’ scripts or style ourselves in weak comparison. We do not need to look to another’s authority because we have our own. Down in our cores. We have waited so long for permission to know that it was our time, our turn on stage. That time is now. Our voices are being heard into being. They are needed.”
Around 1 in 4 women have their labour induced (1 in 3 in the UK and Australia). This book is for women who are trying to make decisions about induction, or who have already decided to have an induction. It is also a great resource for those who support women – midwives, doulas and obstetricians.
The book includes a decision making framework that can be worked through when considering whether induction is the right option for for you. It also includes a chapter on creating a birth plan for a positive induction experience.
A ‘panel of experts’ (women with experience of deciding about induction and/or having an induction), contributed to the development and content of the book. This allowed me to include women’s experiences throughout, alongside research and clinical guidelines. I am immensely grateful to these wonderful women for their words of wisdom.
Making decisions about induction: an overview of decision-making and evaluating risk; and a decision-making framework for readers to work through – directing them to relevant sections of the book and posing questions to consider.
Complications of pregnancy: individual complications are discussed in relation to induction (eg. pre-eclampsia, growth restricted baby, diabetes, etc.).
Variations of pregnancy: individual variations are discussed in relation to induction (eg. post-dates, advanced maternal age, suspected big baby, etc.)
Spontaneous labour: this short chapter provides the basis for discussing how induction differs to spontaneous labour in the next chapters.
Medical Induction: ripening of the cervix and breaking the waters: an explanation of what happens during this phase of induction and what it feels like from the woman’s perspective.
Medical Induction: inducing contractions: an explanation of what happens when syntocinon (pitocin) is used to create contractions and what it feels like from the woman’s perspective.
Alternative methods of induction: an A to Z overview of alternative methods of induction and their efficacy; and women’s experiences of these methods.
Creating a birth plan for a medical induction: this chapter is for women who are planning to have their labour induced. It includes a comprehensive list of options and things to consider, and includes tips and advice from women who have had inductions.
“Why Induction Matters might be a compact read (it’s only just over 150 pages, excluding the reference section), but it packs a punch and is full of the latest, evidence-based research related to induction of labor. It is a fantastic and worthwhile addition to any Lamaze educator’s reference library and an equally great book to recommend to your clients, students, or to have as part of your lending library.”
– Tanya Strusberg, Lamaze International
“The essential guide that all pregnant women should read when considering induction of labour, and what all midwives and doctors should be giving to women when offering induction of labour… The author uses clear, easy-to-understand language, but goes into enough depth for midwives to learn something new as well.
For each issue discussed… women’s stories in their own words are included at the end to bring the reader back to the human experience. The viewpoints are varied, including women who have had a positive, neutral and negative experience of the same issue. This provides a balanced, non-judgemental tone to the book…
Every midwife who cares for women in the antenatal and intrapartum period should have this in his/her toolkit. It really is a great resource to share with women. It could facilitate a two-way conversation between a woman and her midwife, to empower her to come to an informed decision about whether or not to have their labour induced.”
– Hilary Rorison, Australian Midwifery News
I’ve tried to avoid tackling this issue for months now but it won’t go away. It seems that the ‘bundle’ is one of the main topics of concern amongst midwives and students at the moment. So here goes – my answer to “what can we do about the bundle?”
The OASI Bundle
Women’s Healthcare Australasia (WHA) is implementing a “range of initiatives to support members to achieve the highest possible standards of maternity & newborn care, including benchmarking, networking, and collaborative improvement projects.” One of the initiatives is a WHA National Collaborative Improvement Project aimed at “reducing by 20% the number of women harmed by a third or fourth degree tear [OASI] by the end of 2018”. This is much needed with rates of around 3-4% in some hospitals. The WHA state that: “Teams from twenty six maternity services… are participating. Teams are receiving regular coaching and support to reliably implement a bundle of evidence based practices known to reduce risk harm from tears.” Unfortunately, the WHA webpage does not describe what the ‘evidence based practices’ are. and the page specific to the bundle requires a log-in (not very transparent). A similar project is underway in the UK. However this post focuses on the Australian bundle.
The bundle has been rolled out in hospitals across Australia and is significantly changing midwifery practice and the experience of birth. The bundle is not adequately supported by evidence and the WHA did not obtain ethical clearance for this experiment.
Before we go any further it is important to note what ‘controllable’ factors are known increase the chance of OASI during birth according to research: hospital birth, particular positions (supine, lithotomy, squatting); directed pushing; syntocinon with multips; hands on for multips; and instrumental birth. See this this post for more information, discussion and references about particular interventions. None of those evidence-based factors are included in the OASI bundle.
Dahlen et al. (2015) comment on why interventions that cause of OASI have been ignored: “The cascade of intervention in hospital (induction of labour, epidural use, instrumental birth, episiotomy) as a probably cause of higher rates of [OASI] is often not considered in the obstetric discourse around this issue. Perhaps philosophical frameworks and deeply held beliefs around women’s bodies and capacity carry a greater weight at the end of the day than does scientific evidence. Perhaps it is ultimately through this lens of ‘belief’ around women and birth that we select the evidence [or not] that fits most comfortably within our paradigmatic positioning.”
I will address each of the 5 practices in the OASI bundle:
1: Apply warm perineal compresses during the second stage of labour at the commencement of perineal stretching (for all women).
A Cochrane Review = “Moderate-quality evidence suggests that warm compresses, and massage, may reduce third- and fourth-degree tears but the impact of these techniques on other outcomes was unclear or inconsistent”. It would be nice if it was worded a little differently ie. ‘offer all women…’ You can find more information about how to apply warm perineal compresses here. Unfortunately, anecdotal reports suggest that women are being told to get into a semi supine position (which increases tearing) so that the midwives can apply the compress and ‘view’ the perineum.
2: With a spontaneous vaginal delivery [birth!], using gentle verbal guidance, to encourage a slow controlled birth of the fetal head and shoulders: a) support the perineum with the dominant hand; b) apply counter pressure on the fetal head with the non-dominant hand; c) if the shoulders do not delivery spontaneously, apply gentle traction to release the anterior shoulder; d) allow the posterior shoulder to be released following the curve of Carus.
Slow birth does reduce the chance of tearing – supporting physiology assists with this. However, ‘hands on’ does not reduce tearing according to a Cochrane Review. (best evidence). In addition, a recent study conducted in Australian hospitals found that ‘hands on’ made no difference for primips, and increased the chance of tearing for multips. The study concluded that: “A hands poised/undirected approach could be utilised in strategies for the prevention of moderate and severe perineal injury.” The ‘hands on’ recommendation also contradicts Queensland Health Normal Birth Guidelines – which state that ‘hands on’ makes no difference to tearing and increases the chance of an episiotomy.
Of course there are always situation in which ‘hands on’ is appropriate. You can see me using hands on at this birth. However, ‘hands off’ ie. non-intervention should be default as per evidence and midwifery professional standards.
3: When episiotomy is indicated it should be performed: a) at crowning of the fetal head; b) using a medio-lateral incision; c) at a minimum 60 degree angle from the fourchette. NB. An episiotomy is indicated for all women requiring a forceps or vacuum assisted delivery having their first vaginal birth.
An episiotomy wound is more painful and heals less well than a spontaneous tear. There is insufficient evidence to support claims that episiotomy reduces the chance of OASI. A mid-line episiotomy actually contributes to the risk of severe perineal trauma (Lappen & Gossett 2014). Whereas a medio-lateral episiotomy cuts through more nerves and perineal structures than mid-line (Patel et al. 2018). We are only just beginning to understand the complex anatomy of the clitoris – a structure that is cut during 60 degree episiotomy. It is not surprising that a medio-lateral episiotomy is associated “with a decreased sexual functioning as well as sexual desire, arousal and orgasm within postpartum five years” (Dogan et al. 2017). The rising rate of episiotomy – in part fuelled by this bundle – needs to be carefully reviewed in relation to long term outcomes for women. Unfortunately, in some hospital settings midwives are being told that the episiotomy rate is too low and education sessions have been implemented to ‘up-skill’ midwives in cutting women along with expensive new equipment to do the job. A study carried out in Denmark examining outcomes related to the implementation of a formal ‘hands on’ program concluded: “we found that the episiotomy rate increased significantly after implementation of the formal prevention programs.”
In relation to instrumental birth… this is an obstetrician directed recommendation. I’m sure there are some OBs a bit miffed at being told to cut every woman during instrumental births rather than use their clinical judgement for individual women. I’ve worked with many OBs who are able to do a ventouse with an intact perineum. However, instrumental birth does increase the risk of OASI. It is interesting that there is no recommendation to avoid adherence to non-evidence based timeframes for ‘progress’ that result in unnecessary instrumental births and perineal tearing (WHO).
4: Genito-anal examination following birth needs to: a) be performed by an experienced clinician; b) include a PR [rectal] examination on all women, including those with an intact perineum.
Rectal examination has always been part of assessing a perineal tear, particularly a 2nd degree tear – to identify if it is a 3rd or 4th degree. If clinicians are missing 3rd / 4th degree tears then they need to be supported to improve their assessment of tears. The main issue with this recommendation is doing a rectal examination on a woman with an intact perineum. I have been unable to get any stats on the incidence of 3rd/4th degree tears with an intact vaginal wall. I have never seen this. I have heard rumours that it has happened. However, it must be extremely rare. Considering only around 1% of women having non-instrumental vaginal births have OASI – the proportion of those women who have a ‘hidden’ OASI must be less than 0.5%. The incidence of this rare situation needs to be shared with women who have an intact perineum so that they can make an informed decision to consent to a rectal examination. Anyone with the stats – please share them! A blog post by Jim Thornton (an OB) about this invasive intervention concludes: “Routine rectal examination in the presence of an intact perineum fails all the criteria of a useful screening test. Most midwives wisely don’t do it. Those that do, should stop.”
5: All perineal trauma should be: a) graded according to the RCOG grading guideline; b) reviewed by a second experienced clinician to confirm the diagnosis and grading.
As midwives we are supposed to adhere to professional and legal standards. Our professional standards require us to be woman-centred, evidence-based and promote and support physiology (ICM; NMBA – Australia). The ICM position statement on the ‘appropriate use of intervention childbirth’ provides guidance about the use of intervention by midwives and states that: “Women have the right to make informed decisions about the use or non-use of intervention” and “urges midwives to only use or promote the use of intervention during childbirth when indicated.” The law requires us to gain consent for any proposed intervention, consent involves providing adequate information. The mother-midwife relationship requires that midwives share information with women and support their decisions. This is where midwives and students are struggling. Aspects of the bundle conflict with their professional responsibilities.
So back to the initial question “what can we do about the bundle”. The recommendations that are causing the most upset are the ‘hands on’ approach for all births, and the rectal examination with an intact perineum.
Suggestions re. ‘hand’s on’ for all births
We could just refuse to comply with ‘hands on’ based on our professional and legal requirements for evidence-based care. Our professional and legal standards trump any workplace directive or employee contract. If all midwives supported each other in this stance practice would change.
Ensure that women are given adequate information to consent to this intervention – preferably in the antenatal period so that their wishes can be clearly documented before labour. This information needs to include the fact that the intervention is not supported by evidence, and for multips it may increase the chance of them tearing.
Suggestions re. rectal examination for intact perineum
Demand the evidence to support this intervention ie. the incidence of 3rd / 4th degree tearing with an intact perineum. Without this we cannot…
Ensure that women are given adequate information to consent. Including a statement along the lines of (after initial assessment of the perineum post birth): “Your perineum is intact and I can’t see any evidence of a tear. In rare circumstances (quantify here eg. 1: 1000) there is a tear in the rectum despite the perineum being intact. I can check your rectum for you if you’d like, or I can leave you to get on with x [feeding baby, etc.]. What would you like me to do?”
We could also use the bundle as an opportunity to get back to basics (woman-centred, evidence-based care) and reclaim midwifery as an autonomous profession (ICM). It is about time that midwives said ‘enough’ to the bombardment of non-evidence based medicalisation of birth. Solidarity (with each other and women) and activism is long overdue in maternity care.
Backlash to this post by WHA
Since the publication of this post – WHA have publicly challenged my critic of the bundle. Below is a record of this ‘debate’:
Media Release from WHA (May 2018)
In May WHA responded to this blog post with a public media release . The media release later required a log-in (transparency is not on the agenda of WHA). Essentially the media release re-iterated the intention of WHA to improve outcomes. It did not provide any evidence for the bundle or address any of the issues I raised. It did state that financial penalties for hospital have been removed for 3rd and 4th degree tears. However, these penalties are being implemented – reinforcing the rise in episiotomies as there is no fine for cutting rates. I responded to WHA with the questions below, which remain unanswered:
Which members of the expert panel had the final say regarding which interventions were included in the bundle? Were all of the experts in agreement about the final bundle?
Could WHA provide a statement from the consumers involved that they approved the final bundle; and provide information about whether consumers withdrew from the working party (and what proportion withdrew)?
WHA state that they are “happy to share any of the evidence reviewed by the expert panel in the development of the bundle” – Could you please share the evidence relating to a ‘hands on’ approach for all women during birth, and explain why this recommendation contradicts the QH Normal Birth guidelines.
Why were other evidence-based approaches that align with clinical guidelines not included in the bundle eg. spontaneous pushing, encouraging/discouraging particular birthing positions?
Will WHA monitor episiotomy rates during this intervention. Anecdotally midwives and students are reporting increased use of episiotomy during normal birth, particularly for primips.
Could WHA provide an estimated risk of a 3rd/4th degree tears WITH AN INTACT PERINEUM. It is the rectal examination with an intact perineum that is problematic re. informed consent.
Readers – please email WHA (firstname.lastname@example.org) with your concerns and experiences relating to the bundle. It is important that WHA are made aware of how the bundle is impacting on the care of women in the clinical setting.
Update (December 2018)
WHA have made the media release about this post public again due to ‘ongoing interest’ (see comment below by Adele ? WHA). The comment also provides a link to a promotional video of various professionals marketing the bundle. A very different perspective to the one I am hearing from practitioners on the ‘shop floor’! Unfortunately WHA have still not answered the questions posed above.
WHA also provide an update on progress (apologise they have made this page log-in only). The update is rather brief, and in places misleading, for example:
The compliance rate ie. practitioners carrying out the bundle = 17%: There is no critical analysis about why the compliance rate is so low. Is it because midwives and doctors are unhappy with the bundle and/or women are not consenting?
Since the time the bundle was introduced 3rd/4th degree tear rates fell by 25%:
This cannot be considered a causal relationship ie. that the bundle caused the reduced rate. It can barely be called an association considering the low compliance rate (see this post for more about research reporting bias).
The initial rates of 3/4 degree tearing were 6.4% across instrumental and no-instrumental vaginal births. Therefore, a 25% reduction in this rate = 1.6% ie. a reduction from 6.4% to 4.8%.
The update declares a 30% reduction in 3/4 degree tearing for spontaneous vaginal births. Sounds great… but what were the initial rates for this group? The update only provides the combined rates of 6.4%. As instrumental birth significantly increases the chance of 3/4 degree tearing the rates for spontaneous birth would likely be much lower. Therefore 30% in real terms may be less than 1%.
Most importantly, there is no data shared about the episiotomy rates post bundle implementation. Why? They most certainly will have collected this data. Anecdotally the rates are rising. Episiotomy is perineal damage and needs to be included in any evaluation of a bundle aimed at reducing perineal damage.
How will this data be published in a peer reviewed publication? In order to publish research in a journal you need to demonstrate you have obtained research ethical approval from a board. I can find no evidence that this project has ethical clearance.
I have written this blog post in response to readers’ requests. Trying to make sense of the research and guidelines hurt my brain, and I almost gave up a few times. So, for those who asked – I hope this post meets your expectations! The post explores blood glucose levels (BGLs) in pregnancy, and attempts to make some sense of the fairly nonsense diagnosis and management of ‘gestational diabetes’ (GD). This post is not about Type 1 or Type 2 diabetes, and I am assuming you already know about the relationship between blood glucose (sugar) and insulin – if not do some googling.
Blood glucose and insulin in a healthy pregnancy
Babies needs glucose to grow, and the demand for glucose increases as pregnancy progresses and the baby develops. From around 20 weeks, placental hormones cause insulin resistance in the mother’s cells. Insulin resistant cells are less able to convert glucose into energy, resulting in a peak of blood glucose after eating a meal which goes through the placenta to ‘feed’ the baby. In response to this peak, the woman’s pancreas increases the production of insulin to bring BGLs back down to a healthy pre-meal range. So, during pregnancy the woman’s body needs to bump up insulin production to counteract the effect of insulin resistant cells. Once the baby is born, the placental hormones stop entering the woman’s circulation and her insulin metabolism returns to her pre-pregnant state.
High blood glucose in pregnancy
[NOTE: the clear as mud definition of ‘high’ is discussed below in ‘parameters of normal’]
Some women’s bodies are unable to produce the additional insulin required during pregnancy. This results in high levels of glucose remaining in the blood instead of being converted into energy by insulin. The exact cause of this situation is not clear. However, pregnancy places additional demands on the body’s metabolism, and pre-existing health issues influence the ability of the body to meet these demands. High BGLs in pregnancy are associated with an increased chance of health problems during pregnancy (eg. pre-eclampsia) and later in life (eg. cardiovascular disease and Type 2 diabetes). Therefore, pregnancy may offer a glimpse into the general health of a woman, and her ability to meet physical challenges. Rather than causing ill health, abnormal BGLs may reflect underlying ill health.
What is known is that high maternal BGLs influence the development of the baby. In early pregnancy (before 14 weeks) high BGLs are associated with an increased chance of miscarriage, congenital abnormality and subsequent stillbirth (Murphy et al. 2017). This is because the structural development of the major organs is taking place at this time, and any toxin, including excessive glucose can cause damage. However, BGLs are only high in early pregnancy in poorly controlled, pre-existing diabetes.
In contrast, ‘pregnancy induced’ high BGLs do not occur until after 20 weeks when insulin resistance kicks in. By 20 weeks all of the baby’s major organs have formed, and the baby grows mostly in size rather than in complexity. Therefore, pregnancy induced high BGLs primarily effect the weight/shape of the baby. In response to maternal high BGLs passing through the placenta, the baby increases their own insulin production. This insulin converts the excess blood glucose into additional fat stores resulting in a heavier baby. This extra fat is concentrated around the baby’s upper body, in particular around the shoulders. Chunky shoulders increase the chance of shoulder dystocia and perineal tearing during birth. Insulin can also delay the production of surfactant, which prepares the lungs for breathing. This can cause breathing issues at birth, particularly if the baby is born early (eg. by early induction or c-section – which are more common when GD is diagnosed).
Once the baby is born, they no longer need to produce high insulin. However, adjusting and re-balancing insulin and BGLs can be a bit of a bumpy ride for the baby. The withdrawal of high BGLs is sudden (as soon as the placenta stops functioning); but it can take some hours before the baby’s insulin levels drop. During this time the high insulin can covert too much of the baby’s blood glucose into energy resulting in low BGLs (hypoglycaemia).
The baby’s high insulin levels during pregnancy also increase their red blood cells. After birth the baby needs to break down and excrete these additional red blood cells. A by-product of breaking down red blood cells is bilirubin. If there is a lag between breaking down the red blood cells and excreting them out of the body, bilirubin builds up causing jaundice. Jaundice is common in babies who produced high insulin in the uterus.
The effects of high BGLs and high insulin in utero may also cause long term epigenetic changes to the baby’s metabolism. These babies have an increased chance of developing obesity and Type 2 diabetes later in life.
If you want a more in-depth explanation watch this movie:
In summary high BGLs in pregnancy are not ideal, and can alter the growth and development of the baby.
In an attempt to identify and manage women with high BGLs, the maternity system has defined a disease and created a label that clinical guidelines can be based around. When high BGLs are identified for the first time during a pregnancy it is referred to as ‘gestational diabetes’ (GD) or ‘gestational diabetes mellitus’ (GDM). Most cases of GD are pregnancy induced ie. caused by an inability to meet the additional insulin needs of pregnancy – as described above. Occasionally, Type 2 diabetes was already present but only identified in pregnancy. Either way – high BGLs will be termed GD until proven otherwise ie. after pregnancy when BGLs fail to return to normal in the case of undiagnosed Type 2.
However, due to inconsistencies in who is tested, and how and what parameters are applied, there is a huge variation in whether an individual woman gets diagnosed and labelled with GD or not. For example, the incidence of GD varies globally from 2% to 26% depending on the definition used, the approach to screening, and the population of women tested.
Applying the label
There are two main approaches to screening for GD – universal screening (every woman is offered a test) and risk factor-based (only women with an increased chance of developing GD are offered a test). There is no evidence to demonstrate that either approach improves outcomes for mothers and babies. A Cochrane Review concluded: “There is not enough evidence to guide us on effects of screening for GDM based on different risk profiles or settings on outcomes for women and their babies… Low-quality evidence suggests universal screening compared with risk factor-based screening leads to more women being diagnosed with GDM.”
TYPES OF TESTING
The Oral Glucose Tolerance Test (OGTT) is offered between 24 and 28 weeks gestation, or earlier for women considered ‘at risk’ of GD. It is the standard recommended test for GD diagnosis in most clinical guidelines worldwide. It involves fasting overnight, then drinking a glucose solution, followed by a blood test to assess BGLs. The dose of glucose can vary from 50g, 75g to 100g; and the timing of the blood test varies from 1 hour, 2 hours or 3 hours afterwards. There is no evidence to support any of these variations, however most guidelines recommend 75g of glucose and a 2 hour blood test. The OGTT assesses how well a woman’s body responds to a huge bolus of glucose (and chemicals – read the label).
The Glucose Challenge Test (GCT) was previously recommended as a screening assessment (24-28 weeks) to determine which women went on the have the OGTT. The test involves drinking a 50g glucose solution and having a blood test 1 hour later. However, the test lacks both sensitivity and specificity and is no longer recommended (except in the US).
The Glycated haemoglobin (HbA1c) is only recommended for identifying pre-existing diabetes during the first trimester of pregnancy. The results of the blood test provide an indication of what the average BGLs have been over a 2-3 month period. This test cannot effectively identify pregnancy induced diabetes – only previously undiagnosed Type 2 diabetes.
Self testing is not recommended in any guidelines – however some women choose to do this rather than an OGTT. The woman tests her own BGLs over a few days to get an idea about what her BGLs are doing when she is following her usual diet and lifestyle.
PARAMETERS OF NORMAL
It is generally agreed that the normal range of blood glucose for non-pregnant people is 4.0 to 6.0 mmol/L (millimoles per litre) when fasting, and up to 7.8 mmol/L two hours after eating. Diagnosis of non-pregnant diabetes occurs when an OGTT identifies fasting BGLs ≥ 7 mmol/L or BGLs ≥ 11.1 two hours after 75g glucose.
However, when it comes to pregnancy, definitions and parameters of normal are not so clear. Various organisations advocate differing diagnostic parameters, and Bonventura, Ernest & Dee (2015) describe a number of them. However, I’ll stick to the most commonly used criteria initiated by the International Association of Diabetes and Pregnancy Study Group (IADPSG). In 2010 the IADPSG Consensus Panel lowered the threshold for GD diagnosis. This move was based on the findings of one study – the HAPO study. This was an observational study looking at the risk of ‘adverse outcomes’ (see above) associated with 7 different categories of fasting BGLs; and with 1 hour and 2 hour BGLs after 75g glucose. The findings identified an association between fasting BGLs and the frequency of particular ‘adverse outcomes’ (see association vs causation in this post). The study reported: “frequencies in the lowest and highest [of the 7 fasting BGL] categories, respectively, were 5.3% and 26.3% for birth weight above the 90th percentile, 13.3% and 27.9% for primary [first ie. not VBAC] cesarean section, 2.1% and 4.6% for clinical neonatal hypoglycemia [low BGL], and 3.7% and 32.4% for C-peptide level [which reflects baby’s insulin levels] above the 90th percentile .” The amount that the 1 hour and 2 hour BGLs went up also influenced the frequency of ‘adverse outcomes’ – although the associations for primary c-section and neonatal hyperglycaemia (low BGLs) were weak.
The IADPSG Consensus Panel concluded that: “because associations were continuous with no obvious thresholds at which risks increased… a consensus was required to translate these results into clinical practice.” And so the new GD diagnostic threshold was created: OGTT results of BGL ≥ 5.1 mmol/l fasting or ≥ 8.5 mmol/l two hours after 75g glucose load. These thresholds are based on the average BGL values that increased the odds of a big baby by 1.75 times. Whilst this threshold may reduce the rates of babies over 4kg, there is no evidence that it will reduce the rate of birth/newborn complications Bonventura, Ernest & Dee (2015).
WHO changed their recommendations to align with IADPSG’s. WHO even state in the recommendation that the quality of evidence to support this new threshold is ‘very low’, and the strength of the recommendation is ‘weak’. This threshold results in up to 18% of pregnant women meeting the criteria for GD (previously 5%). Kevat et al. (2014) raised a number of concerns about the impact of the lower threshold for Australian women – many of which can be applied to other populations. However, despite an initial wave of concern from care providers, consumers, maternity organisations and researchers – these new thresholds made it into clinical guidelines and practice worldwide. A recent Australian study examined the impact of introducing the new thresholds and found that: “There was an increase in annual incidence of GDM of 74% without overall improvements in primary health outcomes. This incurred a net cost increase of AUD$560 093. Babies of women with GDM had lower rates of neonatal hypoglycaemia and special care nursery admissions after the change, suggesting a milder spectrum of disease.”
Treating the label
Once a woman has been labelled with GD she is usually diverted into ‘GD-centred’ antenatal care. There is often stigma attached to having GD, and additional medical surveillance and restricted choices regarding birth setting. Management of GD centres on keeping the BGLs within a certain range via diet and exercise, and/or insulin medication. The issues around dietary recommendations are a whole other issue that I can’t fit into this blog post. Long story short – the usual GD recommendations involve a high carb (ie. sugar) diet. Alternatively, Lily Nichols has written a couple of great books about diet in pregnancy and for GD (see below in further resources).
Although there are varying opinions about what BGLs should be maintained by women diagnosed with GD (Bonventura, Ernest & Dee (2015). In general the fasting BGL target is around 5.0-5.5 mmol/l fasting and the 2 hour post meal BGL is 6.7-7.1 mmol/l (by capillary blood, ie. finger prick test). Not surprisingly, hypoglycaemia (low BGLs) is a common problem for women trying to keep their BGLs within this range.
WHO summarised the evidence into the effectiveness of GD treatment. The only outcome categorised as ‘high quality’ is that treatment for GD reduces the chance of having a baby 4kg+ (number needed to treat NNT = 11.4 to prevent 1 large baby). However, the evidence indicating a reduction in shoulder dystocia is of ‘low quality’ (NNT = 48.8 to prevent one shoulder dystocia). There is ‘moderate quality’ evidence that treatment reduces the chance of hypertension (NNT 18.1) and pre-eclampsia (NNT 21). For all other outcomes evidence was ‘moderate’ to ‘low’ quality. Bear in mind the research in the WHO summary was carried out before the new lower GD thresholds were introduced. A more recent Cochrane Review compared lifestyle interventions (diet and exercise) with ‘usual’ care or another intervention and found no difference in any outcomes except the size of the baby.
Labour and birth care for women labelled GD
The IADPSG Consensus Panel acknowledged that the “bias of caregivers toward expectation of adverse outcomes may increase morbidity due to increased intervention” for women diagnosed with GD. Women are often coerced into early induction of labour or even c-section because they have been diagnosed with GD. By coerced, I mean they are advised to have an intervention, rather than discussing the risks and benefits of various options, and their individual situation, then making their own decision.
Large-scale research exploring birth outcomes for GD tends to focus on the label rather than on BGLs. This results in 3 groups of women being mixed into the research sample:
women with pre-existing diabetes only diagnosed in pregnancy
women diagnosed with GD who had high BGLs during pregnancy
women diagnosed with GD who maintained normal BGLs during pregnancy
For this mixed up group of GD women a Cochrane Review concluded: “There is insufficient evidence to clearly identify if there are differences in health outcomes for women with gestational diabetes and their babies when elective birth is undertaken compared to waiting for labour to start spontaneously or until 41 weeks’ gestation if all is well.” (the ’41 weeks’ is because induction at this gestation tends to be standard for all women).
However, things look different when we consider women based on what their BGLs have been in pregnancy rather than their GD label. In this case there are 2 distinct groups:
1. Women with normal BGLs (and a GD label)
These women do not have babies effected by high BGLs – because they didn’t have consistently high BGLs during pregnancy. Their babies are as likely to be over 4kg as women without GD. They should be cared for in the same way as women without a GD label because their ‘risk profile’ is the same. For this group of women induction is not supported by evidence or clinical guidelines. WHO recommend that induction of labour should not be offered for GD unless there is evidence of other abnormalities occurring, such as abnormal blood glucose levels. ACOG (US) state that “women with GDM with good glycemic control and no other complications are commonly managed expectantly until term.” Queensland Health (Australia) recommend that if blood glucose is well managed, there is no indication for induction for gestational diabetes. Despite this clear guidance women, are often booked in for an early induction by their care provider based simply on their GD label.
2. Women with abnormal BGLs (and a GD label)
This group of women are at increased chance of experiencing complications associated with high BGLs during pregnancy (see above). However, even for this group of women there is a lack of evidence to support induction. A paper by Berger and Melamed (2014) discusses the research relating to the timing of birth for women with GD, including the risks of induction for women and babies with GD. Like the Cochrane review above, they found inadequate evidence to support induction of labour for women with GD and concluded that “until such data are available, the clinician should consider the maternal, fetal and neonatal implications of induction of labour versus expectant management, involve the patient in the decision process and as usual follow the maxim of ‘‘first do no harm.’’
The main concern regarding high BGLs in pregnancy is the size of the baby (see above). This is often used as the reason for recommending induction. Babies with big shoulders are more likely to experience shoulder dystocia. For example, in non-GD pregnancies, shoulder dystocia occurs with around 1% of babies weighing less than 4kg compared to 5-9% of babies weighing over 4kg (Politi et al. 2010). These figures may be higher for babies subjected to high BGL in pregnancy because of the distribution of their additional weight (ie. upper body and shoulders). However, increased shoulder dystocia rates may also be partially due to the interventions women with suspected big babies experience. For example, if a care provider suspects a ‘big baby’ the woman is more likely to experience interventions (syntocinon, c-section, instrumental birth, etc) and complications regardless of whether her baby is actually big (Sadeh-Mestechkin et al. 2008; Blackwell et al. 2009).
Not surprisingly, induction before 40 weeks does reduce the chance of shoulder dystocia. A baby will be smaller before 40 weeks than after 40 week, and therefore statistically less likely to get stuck. A Cochrane Review comparing induction of labour before 40 weeks for a suspected big baby with waiting for spontaneous labour, found that induction decreased the incidence of shoulder dystocia from 6.8% to 4.1%. However, they also found an increased rate of severe perineal tearing in the induction group of 2.6% vs 0.7% in the spontaneous labour group; and an increase in the treatment of jaundice for the baby (11% vs 7%). Both NICE guidelines and WHO guidelines state that induction of labour should not be carried out simply because the baby is suspected of being big. Which is interesting because both guidelines support induction in the case of GD with high BGLs where the only significant risk factor for birth is a suspected big baby.
Women with high BGLs in pregnancy need to consider the risks of possible shoulder dystocia with the risks of induction (see Berger and Melamed 2014 ) and their own individual situation and preferences. Many women with abnormal BGLs can and do have physiological births, however most follow care provider recommendations and have their labour induced. The following are some suggestions for reducing/managing complications associated with birth for women who had high BGLs in pregnancy. Most of these suggestions can be applied to physiological labour or induced labour – although an induced labour is likely to result in a smaller baby.
Maximise the size of the pelvis – avoid positions that restrict the movement of pelvic bones (eg. don’t sit on the back of the pelvis)
Maximise the ability of the baby to rotate – A mobile mother offers lots of opportunities for baby to move – water immersion is good for this. Resting space between contractions also allows the baby to move when the uterus is relaxed. If syntocinon is regulating contractions, make sure there is a good ‘resting space’ between the contractions (no more than 4 contractions in 10 mins). If the woman has an epidural her care providers / support people will need to assist her to move her pelvis (eg. pelvic rocking using the drawsheet or towel).
BG management – if the woman is insulin dependent it may be necessary to check BGLs during labour.
Avoid interventions that cause wounds eg. c-section or episiotomy. High BGLs can interfere with healing and increase the chance of infections.
Avoid any interventions that interfere with instinctive behaviour as the woman pushes her baby out. If she has an epidural then avoid directed pushing until the baby’s head is on the perineum – and then keep it gentle with spaces in between for re-oxygenation of mother/baby and a chance for baby to rotate and move. Do not pull on the baby’s head immediately after it has birthed – this can wedge the shoulders into the pelvis before they have had a chance to rotate. If there is no change with the next contraction (no rotation or descent) – then suspect shoulder dystocia. and manage accordingly.
After birth do not remove the baby from their mother – this will result in a stress response that will burn up the baby’s glycogen (glucose stores). These stores will be needed as the baby re-balances their metabolism. Any resuscitation should be done with mother and baby together.
How to reduce the chance of hypoglycaemia (low BGLs)
Prolonged skin-to-skin with mother will stabilise the baby’s heart rate and temperature; reduce stress; and encourage early breastfeeding – all great for maintaining BGLs.
Ensure the baby feeds early and often. Colostrum provides a nutrient dense package of glucose to help the baby keep their BGLs within a normal range. Even a few drops can increase the baby’s BGLs significantly. Woman can express and store colostrum at the end of pregnancy to provide additional colostrum for the first hours after birth.
The baby may have their BGLs monitored as they adjust to the withdrawal of high maternal BGLs. Any monitoring and/or management can be done with mother and baby together. Separating mother and baby is detrimental for all kinds of reasons, including BGL stabilisation.
Observe the baby during the first week for jaundice. As discussed above, significant jaundice is fairly common for babies who produced high insulin during pregnancy. The baby may need light therapy to resolve their jaundice.
High BGLs in pregnancy alter the growth and development of the baby, increasing the chance of particular complications occurring. However, the label ‘gestational diabetes’ is problematic because it is poorly defined and there is a lack of evidence to demonstrate that labelling and treatment improves outcomes. Guidelines do not support induction of labour for GD unless BGLs are high. Inducing women before 40 weeks with high BGLs reduces the chance of a large baby and shoulder dystocia, but increases the chance of other complications. Labour and birth care for women with high BGLs should centre on minimising the chance of shoulder dystocia, and supporting the baby to regulate their own BGLs after birth.
I have previously written about how the current framework for understanding and assessing labour progress is inaccurate, not supported by evidence, and fails to incorporate women’s experience of birth. This post is in response to readers asking me to write about how to assess labour progress without vaginal examinations or palpating contractions.
The elements required to assess labour progress are:
An understanding physiology – knowing what is going on inside.
Facilitating and supporting (not disturbing) physiology.
Being focused on the woman and engaging all of your senses: sight, hearing, smell, touch and intuition to read the signs (this requires you to be quiet and receptive rather than busy and ‘doing’).
Ideally knowing the woman beforehand – this assists you to assess her individual behaviours and understand her experience better.
Accepting that any assessment can be inaccurate, and that individual women may not display the ‘usual’ signals of progress.
The following is a general guide only. Please note that this post is about physiological, undisturbed birth ie. does not apply to women who have altered physiology eg. induction, epidural, etc. Women who are being medically managed require medical assessment.
I am using ‘childbirth as a rite of passage’ as a framework for understanding what is going on during the birth process. The physiology in this post is really an overview and does not delve deeply into the complex hormonal interplay during birth which includes the baby. If you want to know more please see the bibliography/reference list at the end of the post.
Glossary / Overview of key players
Oxytocin (OT): love, bonding, reduction of stress; healing; uterine contractions
Beta-endorphins (BE): pain relief; activation of reward centres in brain, altered state of consciousness – ‘transcendence’
Epinephrine and Norepinephrine (E-NE) aka adrenaline and noradrenaline : stress hormones (shorter-term activation)
Cortisol: stress hormone (longer-term activation)
Prolactin (PRL): mothering hormone; lactation
Eustress: beneficial / physiological stress as opposed to pathological stress
…the first phase of separation comprises symbolic behaviour signifying the detachment of the individual or group either from an earlier fixed point in the social structure or a set of cultural conditions (a ‘state’).
– Turner 1987, p. 5.
The first phase of the childbirth rite of passage involves the mother separating from the outside world and focussing within. Towards the end of pregnancy women begin to focus inwards in preparation for the birth. Physical separation occurs particularly in early labour when the mother secludes herself in her birth space and seeks to minimise distractions (external stimulation). Ritual separation from society during pregnancy and birth is common throughout history, and across cultures.
Physiology (what is happening inside)
Levels of PRL, progesterone and BE rise during pregnancy reaching high levels at the beginning of labour. In addition the maternal stress response decreases. This supports feelings of calm, and a focus that is inwards and towards family.
It appears that the baby initiates labour and the mother’s body responds. OT levels rise and uterine contractions become stronger and noticeable to the mother (the uterus contracts during pregnancy before labour). Initially they can be irregular in length, strength and the time in-between. The cervix is softening and opening, and the baby may begin to rotate and settle into the pelvis. BE increases further in response to the pain of contractions. The excitement/anxiety/anticipation (eustress) of early labour increases the release of E-NE. The balance between inward focus (OT + BE) and alertness (E-NE) allows the woman to remain aware of her surroundings and keeps her neocortex active. This facilitates her ability to do what is needed to ‘separate’ eg. organise her other children, call her midwife, travel to hospital, etc. If her OT + BE / E-NE balance tips towards E-NE her contractions may stop altogether until the balance is restored. This mechanism enables women in early labour to stop contracting in response to danger in the same way as other mammals do.
It can take many hours or even days for this early labour phase to tip over into established labour.
Assessment (what you might see)
Eyes open between and during contractions.
Evidence of neocortex functioning – the ability to hold a conversation and answer questions and/or to engage with external activities eg. using her iphone to time contractions.
Excitement and anxiety.
She may be keen to get settled into her birth space (see this post).
Contractions slow or stop in response to a journey to hospital or other stressful/distracting situations.
A bloody-mucousy show may occur as cervix opens.
Posture remains the same as in late pregnancy (pelvis still stable) ie. able to easily walk upright between contractions.
The attributes of liminality or a liminal personae (“threshold people”) are necessarily ambiguous, since this condition and these persons elude or slip through the network of classifications that normally locate states and positions in cultural space. Liminal entities are neither here nor there; they are betwixt and between the positions assigned and arrayed by law, custom, convention, and ceremonial.
– Turner 1969, p. 95.
After the separation phase, a person undergoing a rite of passage enters the liminal phase (or transitional phase) where they are often said to ‘be in another place’ (Turner 1967, p. 98). The intense experience of labour requires mothers to ‘undo’ their usual state of consciousness, behaviours, and their connections to the external world. They often describe being ‘in their own world’, in an altered state of consciousness. This space is located within the labouring mother. As mothers progressively move more deeply into this internal world they shut out the external world further, maintaining and increasing separation. The physiological processes involved in birth create a naturally liminal state – the rhythmic contractions + birthing hormones. Both mother and baby are journeying in this ‘in-between’ world.
During the liminal phase, Turner (1987, p. 5) suggests that a person is unstructured, at once both de-structured and pre-structured. Women in labour act in ways that reflect their unstructured nature. The extreme physical process of birth involves the body functioning in a way that is unlike the everyday functioning of the body. In addition, behaviours are often inconsistent with the ‘everyday’ cultural norms. For example, making ‘animalistic’ noises, as being naked in front of strangers, lying down in hospital corridors, etc.
As the liminal phase peaks there is an undoing, dissolution and decomposition of self (Turner 1987). This point in labour is traditionally known as ‘transition’.
Physiology (what is happening inside)
As OT increases contractions become stronger and more powerful. In response, cortisol and BE increase to very high levels to relieve pain and reduced stress. The natural BEs (opiates) help to create a trance-like state where the woman’s focus is within and she is drowsy and less aware of her surroundings. Her neocortical functioning is reduced and her limbic system (instincts) are heightened. Her labour is now established.
The baby is rotating around and moving down through her pelvis. The Rhombus of Michaelis moves up and backwards to increase capacity in the pelvic mid cavity and outlet. As the pelvis ‘opens up’ it becomes unstable – and the woman moves instinctively to accommodate the movement of her pelvis and baby. The waters may break as the cervix opens enough for the forewaters to bulge into the vagina.
As labour progresses and reaches it’s powerful ‘peak’ there is a surge of E-EN to counter-act some of the BE effects. This prepares the mother to be alert enough protect her baby immediately after birth. The body’s response may be the fetal ejection reflex resulting in very powerful contractions and a quick birth. However, for most women this surge of E-EN is experienced as ‘transition’ – a feeling of fear, overwhelm and general freak out.
Once the cervix is fully open there may be a lull in contractions as the uterus ‘reorganises’ itself around the baby as he/she moves down. As the baby descends further pressure is applied to nerves deep in the pelvis resulting in spontaneous pushing. Contractions become increasingly expulsive as soft tissue stretches increasing the release of OT. The pain generated from the perineal tissues stretching initiate instinctive behaviours that protect the perineum. PRL, OT and E-EN levels increase further as the birth approaches ready to assist the initial bonding process.
Once the baby’s head is born there is likely to be a pause allowing the baby time to rotate or change position to get the shoulders through the pelvis. The baby is usually born with the following contraction.
Once labour has established a strong pattern you would usually expect the baby to be born within 18 hours (depending on contraction pattern and the individual situation).
Assessment (what you might see)
Her contraction pattern becomes increasingly stronger (based on her response to them). Note that contractions may not necessarily become closer, but they will become increasingly powerful. There should be a shift in the pattern/power every 2 hours (as a general rule).
She will be in ‘her own world’ – she may have her eyes closed and doze off between contractions ie. look stoned. She may cover her eyes with a cloth or bury her head into something (eg. pillow).
She is less able to respond to questions or anything else that requires her neocortex to function. Her communication (if there is any) will be short and to the point eg. ‘water!’ rather than ‘Can you please pass me the water’. If you ask a question (best not to) it might take a while for her to answer and she will not speak during a contraction.
Her movements and sounds will be instinctive and rhythmical. She is likely to vocalise during contractions – often the same noise with each one, and/or make the same movements each time.
Her inhibitions reduce. It is during this phase that the previously shy woman rips all her clothes off and crawls about naked.
At this point the hormonal symphony is in full swing and it is very, very difficult to stop or slow contractions. A significant stress at this point may generate a fetal ejection reflex but it is unlikely to stop contractions.
As the baby moves downwards and her pelvis becomes less stable (opening), her posture will change. She will want to hold onto things (and people) when standing/walking. She will not be able to sit directly on her bottom. She will walk leaning slightly with a ‘waddle’ as the pelvis tips.
If she is in an upright/ forward leaning position, you may be able to see / feel the ‘opening of her back’ as the Rhombus of Michaelis moves.
A purple line might be visible between the woman’s buttocks as the baby’s head descends.
During transition you may see fear as she reaches out for reassurance and support. However, some women do not, and instead feel this on the inside without their care provider being aware of it.
During transition E-EN can cause a dry mouth and she might suddenly be very thirsty. High levels can also cause vomiting as the stomach empties in the fight or flight response.
As the cervix opens to its full capacity you might see a bloody/mucous show and the waters break.
There may be a ‘rest and be thankful’ phase after transition where contractions slow and the woman rests as the baby descends into her pelvis.
She might mention pressure in her bottom, or that she need’s to poo. And you may see poo as the baby compresses the rectum and squeezes it out.
Contractions become expulsive and the pattern will change. Her noises and behaviour will also change.
If you are able to visualise her perineum (and you really don’t need to) you will see signs of the baby’s head descending through the vagina – gaping anus and vulva, flattened perineum, bulging bag of waters (if still intact), the baby’s hair/head, etc.
As the baby’s head stretches her perineal tissue she will hold back her pushes, gasp, scream, close her legs, and/or hold her baby’s head in – protecting her perineum.
One the baby’s head is born you may see him/her rotate or wriggle then be born with the next contraction (there should be some movement or change with the next contraction).
Undoing, dissolution, decomposition are accompanied by the processes of growth, transformation, and the reformulation of old elements in new patterns.
– Turner 1987, p. 9.
In all rites of passage, the third phase involves re-assimilation or incorporation of the person back into society in their new state (van Gennep 1909/1960). The state of motherhood and personhood (for the baby) happens immediately following birth. However, the reintegration of mother and baby back into society occurs progressively. In some cultures women have extended periods of separation from society following birth before being reintegrated. However the transformative nature of birth is not limited to a change of status to ‘mother’. Turner (1987) also identified the power of the liminal phase as a process for inner growth and transformation. Mothers incorporate the birth experience into their sense of self, resulting in empowerment, and for some, healing.
Physiology (what is happening inside)
At the moment of birth both mother and baby have high levels of BEs, OT and E-NE. Along with PRL, this combination provides the perfect recipe for mother-baby bonding and connection – BEs (pleasure, reward, dependency) + OT (love and bonding) + PRL (mothering behaviours) + E-NE (alertness). Skin-to-skin contact and mother-baby interactions enhance the production of OT and PRL priming the breasts for milk production. High BEs contribute to the euphoria that many women experience following birth.
The placenta transfers the baby’s blood to the baby and the process of placental separation begins. The baby instinctively seeks his/her mother (looking into her face) and crawls to the breast – feet stimulating the uterus to contract. Skin-to-skin contact regulates the baby’s temperature, breathing and heart-rate and provides a sense of safety reducing stress hormones produced at the end of labour.
After birth E-NE declines quickly but cortisol declines slowly. Cortisol may promote PRLs effects on milk production (extreme stress levels inhibit milk production).
Assessment (what you might see)
Immediately following birth the mother may appear ‘stunned’ and there may be a moment (or 2) before she picks up her baby and brings him/her towards her.
Baby is alert and instinctively interacts with mother and seeks the breast
Mother and baby interact.
You may see a gush of blood as the placenta separates (more about placental birth here).
After some time focussing on baby, the mother may begin to shift her focus back to the outside world; often beginning with her partner/family, then other birth support (including midwives etc), before moving on to those outside the room.
The above information is not rocket science, and anyone who has spent time with women during physiological birth will already know it (even if using the technocratic approaches to assessment). I think it is time to own our (women’s) knowledge and start shifting the discourse of ‘stages of labour’ and cervical measurements. This means changing how we talk/write about labour with women, other care providers and students.
Turner, V 1967, The forest of symbols: aspects of Ndembu ritual, Cornell University, New York.
Turner, V 1969, The ritual process: structure and anti-structure, Transaction Publishers, Rutgers, New Jersey
Turner, V 1987, ‘Betwixt and between: the liminal period in rites of passage’, in LC, Mahdi, SF Foster, & M Little (eds), Betwixt and between: patterns of masculine and feminine initiation, Open Court Publishing Company, Illinois, pp.3-19.
The childbearing experience has always been unpredictable and potentially dangerous. In response, humans have sought ways to create a sense of control and minimise danger. Practices (actions) aimed at creating a sense of control reflect the culture from which they arise. Historically, women relied on a spiritual connection to the Goddess/es, rituals (rites of passage and rites of protection); wisewomen and remedies from nature. The current approach emerges from Science and Research (the new religion?) and sustains a technocratic approach to birth. Risk and danger are considered to be located within the woman (rather than her environment or others) and practices aim to identify danger and control it from the outside. This new approach claims to be rational, effective and underpinned by research evidence.
From evidence-based-practice to research-based-practice
By the end of the 1900s ‘evidence based practice’ was an established concept in medicine and health care in general. However, it was never meant to be purely ‘research based practice’: “Evidence based medicine is not restricted to RCT and meta-analyses. It involves tracking down the best external evidence with which to answer our clinical questions” (Sackett et al 1996). Whilst the emphasis was on ‘external’ evidence it did involve taking account of the individual ‘patient’ and the experience and skill of the practitioner.
Along with the shift towards research based practice came an increasing emphasis on quantitative research. If you are unsure about the different between quantitative and qualitative research – see this summary and this cartoon:
Quantitative research purports to be objective and is underpinned by Popperian philosophy and principles. Popper’s (1961) philosophy of science maintains that scientific knowledge develops in an incremental and linear fashion whereby ‘truths’ are systematically tested. Truths or hypotheses cannot be proven, only falsified, and scientific theories can be objectively tested to measure how much truth or falsity they contain. How neat and tidy!
In keeping with this idea of being able to objectively measure humans and their experiences the Pyramid of Evidence was devised. This pyramid illustrates the hierarchy of ‘quality’ relating to research evidence. As you can see the more (allegedly) objective the research, the greater the quality and the greater the weight given to the findings. However, reality is a lot more complex and subjectivity and bias permeate all research:
“Research is carried out within paradigms of knowledge. Everything from the research question; the research framework; the methodology; the interpretation of findings; and the implementation of the findings into practice is influenced by the paradigm of knowledge in which the research is conducted.” (Kuhn 1970)
This blog post takes a critical look at quantitative research – the purported foundation of modern maternity care. There are also issues with qualitative research, however qualitative philosophy and methodology acknowledges the element of bias as part of the research design.
1. Choosing a research topic
Researchers do not generally carry out research in their spare time funded by the goodness of their heart. Research requires money to pay for time and resources. Competitive grants are offered by a variety of organisations – government, charity and industry. Research topics are influenced by the requirements and criteria dictated by grant providing organisations. For example, government funded grants will usually focus on government health priorities such as the treatment of diabetes, heart disease, etc. Therefore, it would be much easier to obtain a grant to study the management of gestational diabetes than to study psychosocial outcomes of maternity care. Government health priorities reflect culture (and health lobby groups eg. industry). For example, the joint leading cause of maternal death in Australia is psychosocial morbidity (cardiovascular disease is the other). There is a clear link between how women are treated by care providers and mental health outcomes (Reed, Sharman & Inglis 2017). However, women’s mental health is not a cultural priority in Australia.
Another source of funding for research comes from the industries that develop and sell interventions (eg. technology and medications). This has resulted in major issues in the area of pharamacology (see Ben Goldacre’s book). In the maternity context there are no companies offering grants to find out about the benefits of birth without medication or intervention – there is no profit in physiological birth.
Research plans and grant applications require the identification of a ‘problem’ – there is usually a section subtitled ‘describe the research problem’. This creates a focus on pathology rather than on wellness. For example, a study aiming to investigate why ‘x’ institution has a high rate of physiological births and great outcomes is less likely to get a grant than a study aimed at trialling a medical intervention to reduce the high PPH rates in another institution. However, former study may result in important findings that could help to improve the latter.
Most government grants require a government health employee to be listed as a researcher on the grant application. Frequently this results in a manager from the institution becoming a named ‘researcher’ (although sometimes they contribute nothing to the research process). This looks great on the managers CV and allows the rest of the research team to access samples (women) and data (whatever information they are collecting/measuring). However, as a representative and employee of the institution they may have a vested interest in ensuring that the research topic and findings do not reflect badly on the institution. This can influence the research topic because some topics (the interesting ones) will be off the agenda of the institution… more on this later re. disseminating the findings.
2. Formulating a research question
Once a research topic/problem has been identified, a research question is created. Again, the question that arises reflects the cultural paradigm in which the research is taking place. A study by Phipps, Charlton and Dietz (2007; 2009) provides a perfect example of this. The problem: high rates of intervention due to first time mothers being unable to push their babies out within the (non-evidence based) hospital prescribed timeframe. The question arising from this problem became ‘can women be taught how to push more effectively’ and women were randomly allocated to antenatal education sessions aimed at teaching them how to push effectively. This reflects a paradigm in which women’s bodies are considered the problem. An alternative paradigm would have resulted in examining the problem of using prescriptive timeframes to define individual birth processes.
3. Designing the research
Physiology as experimental
Usually in quantitative research the control group is the group that does not get an intervention. This control group is compared to the experimental group that gets the intervention. However, this is usually the opposite in maternity care, reflecting a culture in which intervention is the norm. Initially routine interventions during birth were introduced as part of the general medicalisation of childbirth, without any supporting research evidence (Donnison 1988). These interventions continue to be carried out until research is conducted to support a change in practice. Therefore, research in maternity care is often carried out to support not performing an intervention that was initially introduced without research evidence. For example, women were routinely subjected to vulval shaving, enemas and episiotomies until research demonstrated it was safe to not abuse women this way. In such studies, the control group is the group subjected to the intervention, with the experimental group not receiving the intervention.
Confounding factors in complex human experiences
Research is often conducted with the assumption of simplicity as a framework. The origin of this assumption is Descartes’ concept of dualism, that the body could be studied as a separate entity to the social, psychological and spiritual aspects of a person. This approach ignores the complexity of cause and effect in individual human subjects and varying situations.
Confounding variables are factors that influence the relationship between x and y. Research design aims to reduce confounding variables. This is easier when carrying out research in laboratory conditions where you can control the environment and any interactions with the subject (eg. bacteria in a petri-dish). However, pregnancy, birth, breastfeeding, mothering, and maternity care are incredibly complex. In most cases it is impossible to limit confounding factors. For example, when designing research comparing active management of placental birth vs physiology, it is not possible to isolate the effects of administering an oxytocic medication or not. The ‘management’ is being carried out on a complex human, by a complex human, in a complex environment, all of which may influence the outcome. For example, a practitioner who is used to active management but now has to carry out physiological management may find this challenging… their approach and interactions are likely to be influenced by their feelings. This partly explains the different outcomes in different studies with different participants and settings (see this post).
RCT, blind arms and ethics
It can be argued that the gold standard or research – randomised controlled trials – are often unethical in maternity care. For example, it would be unethical to randomly allocate a woman to a particular birth setting (and her feelings about her birth setting would alter her outcomes). Considering what we know about placental transfusion immediately after birth, and the importance of adequate blood volume for newborns, it would be unethical to randomly allocate newborns to have premature clamping of their cords (and many mother’s would refuse consent).
It is also considered good research design for both the practitioner (person administering the intervention) and the subject (person getting the intervention – or not) to be ‘blind’ to this ie. not know. This works well in the case of medications ie. neither the doctor nor the patient know whether the pill is the experimental medication or a placebo. However, it is virtually impossible to ‘blind’ practitioners or women to interventions. Women and their care providers will know if an intervention is carried out or not eg. active management of the placenta, episiotomy, premature cord clamping.
4. Interpreting the results
The cultural paradigm also influences how researchers and the media interpret the results of studies. In particular, the creation of links between factors assumed by cultural understandings to be linked ie. presenting correlations as causations. The classic example of this is the relationship between ice-cream sales and shark attacks. There is an correlation between increased ice-cream sales and increased shark attacks. However, ice-cream does not cause shark attacks – both of these factors are influenced by how the weather effects human behavior (eating ice-cream and swimming in the ocean).
In relation to maternity care identifying cause and effect are even more difficult due to the complex nature of the issues. For example, there is a general consensus that obesity is associated with poor outcomes for women and babies and the solution is to reduce BMI. However, this raises further questions: is obesity the direct cause of poor outcomes? Is obesity a symptom of some other heath related disorder that is the causal factor of obesity? Is the treatment of obese women the cause of poor outcomes (increased stress/shaming, surveillance, intervention)?
5. Recommendations arising from the findings
Once a study has been concluded the researchers offer recommendations arising from their study. Again, these recommendations are influenced by the cultural paradigm. An example of this is the recommendations resulting from research into early labour (discussed in this post). Women admitted to hospital in early labour = increased intervention and decreased normal birth. The recommendation is therefore to limit the time a woman is exposed to the hospital system… not change the hospital system to better accommodate the needs of women in early labour.
6. Dissemination of findings
The aim of research is to publish the findings and contribute to the evidence-base for practice. However, whether, and how research findings are disseminated is influenced and controlled by a number of factors. In particular the ‘interested parties’ (see above ‘research partners’) can prevent or manipulate publication. For example, to access data held by an organisation the researcher is likely to have signed an agreement that publications relating to that data must be approved by the organisation. I know more than one researcher who has been unable to publish interesting results because they have been blocked by the organisation they had an agreement with. The Union of Concerned Scientists have published a report detailing how corporations obstruct, distort and supress research. Techniques include: terminating and suppressing research; intimidating or coercing scientists; ghost writing scientific articles; publications bias ie. only allowing certain results to be published (Ben Goldacre also discusses this in his book).
Good journals use a peer review process to ensure quality research dissemination. However, peer reviewers are humans and are also influenced by the cultural paradigm and their own emotions. An article that is not aligned with the philosophy/views of a journal or a particular reviewer will be more likely to be rejected. For example, an article reporting findings that demonstrate midwifery continuity of care resulted in poor outcomes (I am making this up) would be more likely to be published in a medical journal than a midwifery journal. And some topics are difficult to publish anywhere.
7. Implementing recommendations into practice and decision making
Evidence based practice?
The final step – implementing evidence into practice is perhaps the least successful step in maternity care research. The discipline of obstetrics was awarded the ‘wooden spoon’ by Archie Cochrane in 1979. In response Iain Chalmers et al. published the first edition of ‘effective care in pregnancy and birth’ in 1989. However, it seems that not much has changed.
“Despite claims of EBP, practices are underpinned by an established hierarchy of understanding and practice, rather than by research.” (McCourt 2009)
Organisations and the staff working in them rely on clinical guidelines to guide practice. However, so called ‘evidence based guidelines’ are anything but. If you take a look at most clinical guidelines and follow the reference trail you will find that they cite another clinical guideline, which cites another clinical guideline… and you end up at a dead-end with no actual research in site. Prusova et al. (2014) published an article about this situation: RCOG ‘Green-top Guidelines’: 9-12% based on Grade A evidence. Whilst the article focuses on the RCOG – this is widespread across maternity care guidelines.
Evidence based decision making?
When it comes to how individual women make decisions about their maternity care – research is also fairly low on the list. Below is a quote from a previous post that is relevant here:
Many factors influence decision making, and the information a midwife provides is only one piece of the puzzle. Humans are active seekers and interpreters of information. We pick and choose, using and discarding information according to internal and external constraints and considerations. Embodied knowledge, personal experiences and other people’s experiences influence the selective designation of knowledge as authoritative or not. We often start with a conclusion, then rationalise it with evidence. We surround ourselves with people who have beliefs and opinions aligned with our own. The internet has increased our access to information and people who will reinforce our beliefs and choices.
A way forward?
I am not advocating discarding research. I am a researcher myself and believe that this type of evidence can, and does shift practice. Midwives need to contribute to, and understand the evidence-base for practice from the woman’s perspective. The International Confederation of Midwives position statement ‘The Role of the Midwife in Research’ provides guidance on this:
…all midwives have a role and a responsibility in advancing knowledge within the midwifery profession and the effectiveness of midwifery practice…
Research on the childbearing cycle maintain a holistic approach that includes the physiological, psycho-social, cultural and spiritual aspects of the health of women and babies
Midwives design/participate in studies that support and promote holistic care as well as evaluating the effects of using technology as an intervention during pregnancy and birth
We also need to be able to discuss research with women – not just quote statistics. More importantly we need to acknowledge and respect all the other forms of evidence that operate when a woman makes a decision about what is best for her – in particular her own embodied knowledge.
Cochrane AL (1989). Foreword. In: Chalmers I, Enkin M, Keirse MJNC, eds. Effective care in pregnancy and childbirth. Oxford: Oxford University Press.
Donnison, J 1988, Midwives and medical men: a history of the struggle for the control of childbirth, 2nd edn, Historical Publications, London.
Kuhn, TS 1970, The structure of scientific revolutions, University of Chicago Press, Chicago.
Phipps, H, Charlton, S & Dietz, HP 2007, ‘Can antenatal education influence how women push in labour? A pilot randomised control trial on maternal antenatal teaching for pushing in the second stage of labour (PUSH STUDY)’, paper presented to Big Bold & Beautiful: Australian College of Midwives 15th National Conference, Canberra, Australia, 25-28 September 2007.
Phipps, H, Charlton, S & Dietz, HP 2009, ‘Can antenatal education influence how women push in labour? A pilot randomised control trial on maternal antenatal teaching for pushing in the second stage of labour (PUSH STUDY)’, Australian and New Zealand Journal of Obstetrics and Gynaecology, vol. 49, pp. 274-278.
Popper, KR 1961, The logic of scientific discovery, Basic Books, New York.
Prusova, K, Tyler, A, Churcher, L & Lokugamage 2014, ‘Royal College of Obstetricians and Gynaecologists guidelines: how evidence based are they?’ Journal of Obstetrics and Gynaecology, DOI: 10.3109/01443615.2014.920794
Sackett, DL, Rosenberg, WMC, Gray, JAM, Haynes, RB & Richardson, WS 1996, ‘Evidence-based medicine: what it is and what it is not’, British Medical Journal, vol. 312, pp. 71-72.