VBAC: making a mountain out of a molehill

VBAC (vaginal birth after caesarean) is big. A google search for ‘vbac’ results in ‘about 795,000’ results. Reviews, guidelines, policies and statements are being produced by every organisation with an interest in birth. Support groups and networks are growing. I am not going to add to this wealth of information. Others are doing a fantastic job and I will provide some links at the bottom of this post. This post is really aimed at putting VBAC into perspective risk-wise and discussing how we can best support women planning a vaginal birth after caesarean. I haven’t personally experienced the VBAC journey and would welcome some input from mothers who have via comments, suggestions and links. This is written from my perspective as a midwife.

With a c-section rate of around 1 in 3 (Australia) a significant proportion of women approach their subsequent birth with a scarred uterus. Of those women, 84% will have another caesarean. I can’t find the stats re. how many of these repeat c-sections are planned vs emergency. But, considering the 50-90% ‘success’ rate for VBACs, I am assuming that most repeat c-sections are planned. I wonder if more women would choose to experience a vaginal birth if they had adequate information and support from care providers who believed in them?

Guidelines suggest that women should be counselled about the risks of VBAC, and they should have additional monitoring and intervention during labour. The big concern is uterine rupture, and this is what I am going to focus on. By the way – unless I provide a reference/link you can assume I am getting my numbers from the NIH Consensus Statement (US) or Having a Baby in Queensland (Aus). Both of these resources are based on current research evidence. So, if you need the original research sources check out their reference lists.

What happens during a uterine rupture?

Considering this is the risk associated with VBAC is worth briefly describing what is involved. Uterine rupture can happen at any birth, even when no scar is present (particularly if syntocinon is used). There are two types of uterine rupture associated with VBAC (Pairman et al. 2014):

  1. Catastrophic (symptomatic) – the old scar separates long its length, the amniotic sac ruptures and the baby is pushed into the abdominal cavity. This results in significant bleeding, shock and the baby is in grave danger.
  2. Asymptomatic – the scar separates partway along its length, the amniotic sac stays intact and the baby remains in the uterus. Bleeding and shock is minimal and the baby usually survives. This is the most common type.

Here is a youtube clip of what happens during a catastrophic uterine rupture. For more information about uterine rupture (including symptoms) check out this article on BellyBelly.

Risk by numbers

Risk is a difficult concept. You can have odds of 1 in a million, but if you are the 1 it is 100% for you. It’s also impossible to eliminate all risk from life (or birth) and every option has risks attached. All women can do is choose the risk that feels right for them – there is no risk-free choice. There are many ways of presenting risk and some ways may mean more than others for individuals. For example, if we look at the overall risk of uterine rupture for a woman who has had 1 previous c-section. By overall, I mean without adding or subtracting factors which increase or decrease an individual’s risk (eg. syntocinon during labour, transverse scar). The risk can be presented like this:

  • 50 out of 10,000 will rupture
  • 9,950 out of 10,000 will not rupture
  • 1 in 200 will rupture
  • 199 out of 200 will not rupture
  • 0.5% will rupture
  • 99.5% will not rupture

Which of these versions would help you conceptualise risk? I know when I look at the picture versions of risk I assume I’m the ‘red person’. Personally I like the 99.5% intact uterus odds.

As stated above these figures are the taken from the NIH Consensus Statement (US) or Having a Baby in Queensland (Aus). A more recent UK study (Fitzpatrick et al. 2012) found an even lower overall risk of rupture – 0.2%.

The risk of rupture may be even lower in labours that are not induced or augmented (the stats above are a mixture of all labours). An Australian study (Dekker et al. 2010) found that the risk of uterine rupture during VBAC was 0.15% in spontaneous labour, 1.91% in augmented labour and 0.88% in labour induced using prostin and oxytocin. Fitzpatrick et al. (2012) also found an increase in rupture with induction and augmentation. In contrast a US study (Ouzouian et al. 2011) found no different in rupture rates between spontaneous and induced labours – but found a significantly greater vaginal birth rate following spontaneous labour. Another study (Harper et al. 2011) found an increased chance of rupture during induction when the woman has an ‘unfavourable’ cervix. There are also other risks associated with induction which need to be considered before heading down that pathway.

For women who have had multiple c-sections: Landon et al. (2006) suggest the risk of rupture rises to 0.9%. Fitzpatrick et al. (2012) also found a slight increase in risk for women how had had 2 or more previous c-sections. However Cahill et al. (2010) found that: “Women with three or more prior caesareans who attempt VBAC have similar rates of success and risk for maternal morbidity as those with one prior caesarean, and as those delivered by elective repeat caesarean.”

The story looks a little different again when you look at the mortality and morbidity caused by uterine rupture.  Guise et al (2004) conducted a systematic review of research relating to VBAC and uterine rupture. They found that uterine rupture resulted in: 0 maternal deaths; 5% perinatal deaths (baby); and 13% hysterectomy. They conclude that: ‘Although the literature on uterine rupture is imprecise and inconsistent, existing studies indicate that 370 (213 to 1370) elective caesarean deliveries would need to be performed to prevent one symptomatic uterine rupture.’

So, out of the small number of women who experience uterine rupture, an even smaller proportion will lose their baby or uterus because of it. When the uterus ruptures 94% of babies survive. The RCOG guidelines state that: “Women should be informed that the absolute risk of birth-related perinatal death associated with VBAC is extremely low and comparable to the risk for nulliparous [first baby/birth] women in labour.” 

VBAC vs planned c-section: uterine rupture

Most resources and guidelines compare the risk of a VBAC with the risks of a repeat c-section. This can be a brain-twister because of the multiple and complex risks associated with c-section for mother and baby. Childbirth Connection cover them well, so I won’t. It is also important that women know a c-section increases the chance of stillbirth in subsequent pregnancies (Moraitis et al. 2015). Having a Baby in Queensland directly compares VBAC with planned repeat c-section for a number of complications.

I’m trying to stick to the risk of uterine rupture (the ‘big’ one). So, planned c-section wins with a 2:10,000 uterine rupture rate compared to 50:10,000 for a VBAC. That’s if you are happy to take all the (more frequently occurring) risks associated with c-section in exchange.

Uterine rupture vs other potential birth emergencies

A Woman’s Guide to VBAC: Navigating the NIH Consensus Recommendations compares uterine rupture with other potential complications. You are more likely to experience a placental abruption, a cord prolapse or a shoulder dystocia (not associated with previous c-section) during your vbac than a uterine rupture. Your baby is also more likely to die from the placental abruption or cord prolapse than from a uterine rupture.

Anecdotes

Anecdotes often hold more power than numbers. I can guarantee that I will get a comment telling me about a poor outcome associated with a VBAC. They do happen (see the stats above). Unfortunately when care providers have been involved in a traumatic situation, it can be hard not to let that experience colour their perspective and approach. The memory of one uterine rupture will be stronger than all of the uncomplicated VBACs they have seen. The only uterine rupture I have personally been involved with was an induction of labour – not a VBAC. So, I emotionally associate uterine rupture with induction rather than VBAC.

Obstetricians in particular have to deal with the fall out of major complications because this is their area of expertise. They also miss out on seeing physiological births which end well because this is the realm of the midwife (I know this is different in the US/private sector). This can lead to fear-based counselling and practice, and a general fear of normal birth. It is interesting that a poor outcome associated with a c-section does not seem to elicit quite the same response – ie. fear of c-section.

When parents find themselves the 1 in how ever many, it is even more devastating. Their stories are powerful and need to be heard. However, it can be difficult for other parents to contextualise the story without also hearing stories with good outcomes.

The real risks of VBAC (according to me)

I am a bit confused about why such a huge deal is made about the risk of uterine rupture during VBAC. Why are these women subjected to serious (and often biased) discussions with fearful practitioners about the dangers of attempting birth? Why are they categorised as ‘high risk’, limiting their care options and imposing additional monitoring and intervention during their labour? If we agree that this is the right approach, then we also need to treat all women like this because the risk of placental abruption or a cord prolapse is greater than the risk of a uterine rupture during a VBAC.

To be honest, as a midwife uterine rupture is the least of my worries when caring for a woman having a VBAC. I actually think the mountain that has been built out of the risk-molehill requires more energy and attention. These women do need special treatment, but not in the form of disempowering fear-based counselling or practice. They have often had a previous traumatic birth experience and are dealing with fear from family, friends, and the medical system, in addition to their own worries. They have been labelled ‘high risk’ and are constantly reminded of the potential disaster waiting to occur. They also risk ‘failing’ if they encounter any complications or end up having a repeat c-section. This impacts on their ability to trust their body, follow their intuition and allow the physiology of birth to unfold. Often these women need more nurturing, reassurance and support from those involved in their birth.

Suggestions

During pregnancy

It is important to not only help women to prepare but also their partners and/or other close family members who may be at the birth. Often the partner was present at the previous birth, which may have been traumatic to witness. For a partner their priority is the safety of the woman they love – not a particular birth experience. Winning them over may be difficult. In some cases the decision the mother makes may be that the partner should not be present. OK – some suggestions:

  • Find out the details of her previous birth experience. If she needs debriefing help her do so, or refer to someone who can. Knowing about her previous experince and her fears can help you know what she needs during her labour.
  • Offer to discuss ‘risk’ and present the statistics in a number of ways. Find out what they (mother and partner) find most useful and empowering. I could say ‘don’t mention risk’ but to be honest ,unless she is living in a cave she will already be aware that VBAC is ‘risky’ and will need to explore this. In addition, it is a legal requirement for midwives to provide evidence based information about risk.
  • Make sure she is aware that she has a very good chance of having a vaginal birth – 72-75% if she has not previously had a vaginal birth, and 85-90% if she has (RCOG). Overall, she has a greater likelihood of a vaginal birth than a woman having her first baby and no previous c-section.
  • The RCOG guidelines state that: “Women should be made aware that successful VBAC has the fewest complications and therefore the chance of VBAC success or failure is an important consideration when choosing the mode of delivery.” Therefore it is important to consider previous birth scenarios and contexts to evaluate the chance of success for the individual woman.
  • The woman also needs information about factors that can increase her chance of VBAC eg. choosing supportive care providers (and setting) and not having her labour induced or augmented.
  • Talk about the possibility of the pregnancy going beyond the prescribed ‘due date’. This is often a feature of VBAC pregnancy. Some hospitals or midwives consider this to be a risk factor because the chance of a repeat c-section is about 9% greater (Coassolo et al. 2005). However, the risk of uterine rupture is no greater.
  • Make sure she knows that having a c-section after labour has started holds more health benefits than a planned c-section. Her baby will have had a chance to initiate labour and make the physiological changes needed for life outside the uterus. They will be less likely to suffer respiratory distress and end up in special care (Senturk et al. 2015). In addition, both mother and baby will have the important cocktail of hormones that assist with bonding. Even if she chooses a repeat c-section she can insist on going into labour first.
  • Talk to her and her partner about what actually happens if the uterus ruptures. They may be imagining all kinds of horrific scenes such as the baby bursting out of an exploding abdomen.
  • If she is worried about ‘failure’ reassure her that she doesn’t need to tell anyone she is planning a VBAC. She can say she’s not sure and will decide in labour.
  • If she is planning to birth in hospital she needs to know what the hospital policies are and decide what she will or won’t go along with. This means talking about the risks of the usual interventions such as CTG monitoring. A very clear birth statement can help the staff to support her wishes. It might be helpful to find out the VBAC rates at the hospital to gain some idea about how supportive they are likely to be during labour.
  • Encourage her to talk to other women about their experiences of VBAC, read positive birth stories and watch beautiful VBAC birth movies.
  • Do not use disempowering language such a ‘trial of scar’ or constantly refer to her birth as a VBAC. She is a woman having a baby, not a disaster waiting to happen.

During labour

The physical care of a woman having a VBAC should be no different (although I know it often is in hospital). Yes, I’m watching for signs of a uterine rupture: unusual pain, unusual contraction pattern, fetal heart rate abnormalities, unusual bleeding, a change in maternal observations etc. But, those symptoms in any birthing woman would be concerning, so this is not different care. In addition, if a woman is unmedicated and connected to her body/baby she will usually be the first to notice a problem. I have found that women having a VBAC may have additional psychological needs. For example, they may request vaginal examinations, particularly if their c-section was for ‘failure to progress’ (aka failure to wait). Even with information about how poor VEs are at indicating progress they may want that dilatation number – some non-VBAC women do too. They may also want more frequent fetal heart rate auscultation to reassure them the baby is well. In general, these women, and even more so their partners need reassurance and a birth attendant who believes in them. Of course some women don’t need any of this and choose freebirth.

Is homebirth a safe  option for VBAC?

No – birth is not ‘safe’ regardless of the setting. Different risks are associated with different options. In hospital there is greater risk of unnecessary intervention and associated complications. At home, if you are the 0.2% and need to transfer, there is the risk of complications due to a delay in medical intervention (including death of baby and/or mother). Bear in mind that this delay may also occur in a private hospital out of hours when theatre staff are not on site. Women also need to be aware that when it comes to homebirth, having a uterine scar places them in a ‘high risk’ category. The Australian College of Midwives classify a previous c-section as ‘B’ ie ‘Consult’ with a ‘midwife and/or medical practitioner or other health care provider’. This does not mean that a privately practising midwife cannot provide care. And the woman can decline a consultation if she wishes. Some midwives appear to be unaware of this, and tell women that they are not allowed to attend VBAC homebirths – this is not true. However, if you choose an eligible midwife, you may have problems securing a collaborative agreement from a medical practitioner so that you can claim medicare rebates for care. Likewise, homebirth services run from hospitals or birth centres may be unable to accept you as a client. Whilst VBAC homebirth is generally not supported in clinical recommendations, many women choose to birth at home. Keebler, et al. (2015) examined women’s reasons for choosing a homebirth after caesarean and the full text is available here.

VBACs are usually immensely healing and empowering for a woman and her partner. I wonder whether this aspect of birth is discussed at the ‘risk consultations’ along with the numbers.

You can read a birth story and watch the film here. I may be biased but this is a beautifully filmed/edited birth: Madeleine’s birth

Here is another couple’s VBAC journey (have a tissue handy). This is the most likely outcome of a VBAC – particularly a homebirth:

Further Reading/Resources

Posted in birth, intervention, midwifery practice | Tagged , , , | 343 Comments

In Celebration of the OP Baby

Updated: February 2018

How many times have you heard “I had to have an epidural/c-section/ventouse/etc. because my baby was facing the wrong way”? An occipito posterior (OP) position occurs when the baby enters the pelvis facing forward with his back towards his mothers back. The back of the baby’s head is referred to as the ‘occiput’ and is in the back of the pelvis against the sacrum. Between 15-30% of babies start labour in an OP position, but less than 5% will remain in this position at birth (Sizer & Nirmal 2000). An OP position is associated with medical intervention during labour: syntocinon infusion; epidural; forceps; ventouse; c-section. This post will discuss whether an OP position is actually a problem, or if the problem lies in our beliefs about, and management of this common position.

A bit of anatomy and physiology

I’m assuming that readers of this blog are midwives, doulas, and/or birth nerds  who have an understanding of the pelvis. If you don’t, it doesn’t really matter – knowing the names of the bones doesn’t help you understand how the pelvis works. Basically, the pelvis is shaped in a way that requires the baby to rotate during labour. If you look in textbooks you will find diagrams with exact measurements of various pelvic diameters – this is nonsense as every woman’s pelvis is different. I find it is more helpful to consider that there are 3 areas of the pelvis: the brim, the cavity and the outlet. These areas have slightly different shapes, as I’ve tried to demonstrate below: The baby usually enters the brim with her head mostly facing sideways ie. transverse  (to fit the shape). It doesn’t really matter which way the baby’s head is when entering the brim – once her head is in the cavity she can rotate. The downward pressure of the contractions, and the tension and shape of the pelvic floor will guide her into a direct occipito anterior (OA) position and through the outlet. A very small number of babies will rotate to a direct OP position and come out facing the front of the pelvis (see below).

Usually the baby will take the shortest rotation into a direct OA position. So, a baby entering the pelvis in a ROA (back = front/right) does this:

Whereas a baby entering the pelvis in an ROP (back = back/right) position does this:

Of course OP and OA babies may use this turning space to do all kinds of interesting things from turning OA to OP, to rotating all the way around the back of the pelvis to end up OA. The baby will work out the best way to move through her mother – even if we don’t understand it.

Being born OP

Some babies are born in the OP position either because they stay in that position, or because they rotate into that position during labour (from OA). You can watch the birth of a big OP baby in ‘The Birth of Beau‘.

The ‘problems’

Labour pattern

It is difficult enough for a woman with a baby in an OA position to fit prescribed patterns of labour progress. A baby who enters the brim in an OP position may not fit quite so snuggly on the cervix and this may lead to:

These situations only become problematic when we apply generalised expectations about how labour should be to an individual woman, baby and situation. The solution is often to augment labour with syntocinon – increasing the risk of fetal distress and increasing pain ie. creating a problem. Another solution is to encourage the woman to get into various positions to assist with rotation. However, the use of prescribed positions to ‘fix’ an OP position is not supported by research (Desbriere et al. 2012; Science & Sensibility).

Pain and interventions

Some women will experience pain differently when their baby is in an OP position. However, it is difficult to determine if this experience of pain is due to the position of the baby, or other factors. A study by Lee, Kildea & Stapleton (2015) into back pain in labour concluded: “The assumed relationship between fetal position and back pain in labour is a dominant discourse, albeit one which is lacking in empirical credibility.” Plenty of women with an OA baby complain of back ache in labour, whilst many with an OP baby do not. Unfortunately, women are told that an OP labour is ‘worse’, and are told horror stories like the one I started the post with. Given the psychological and emotional aspect of pain perception this cannot be helpful. Every birth experience is also different. I cared for a mother during two births. Her first baby was in an OP position and she had a four day stop-start pattern before labour established. Apart from being tired she coped well with the pain throughout. Her second baby was OA and labour established quickly. She was shocked and distressed by how much more pain she experienced with her OA baby compared to her previous OP baby.

Women with an OP baby are more likely to opt for (or be pursuaded to have) an epidural. This is not surprising, considering they are led to believe their labour will be more painful. They are also more likely to be subjected to interventions that increase pain and risk. For, example, a woman with an OP baby is less likely to meet prescribed progress timeframes, and therefore, have her labour induced or augmented by ARM and/or syntocinon (pitocin). An ARM reduces the fluid surrounding the baby, making rotation more difficult, and increases pain. Syntocinon increases the risk for mother and baby in many ways, and increases pain. These interventions further increase the chance that an epidural will be needed. Once an epidural is inserted, the ability of the baby to rotate into an OA position is reduced (Lieberman et al. 2005). The woman is unable to instinctively move her body and work with her baby to rotate him. In addition, the pelvic floor is anaesthetised and loses it’s tone, taking away the resistance that assists rotation.

Early urge to push

As the OP baby descends through the pelvis the back of his head puts pressure on nerves creating an urge to push. This pushing may be the body’s way of helping the baby to rotate by increasing downward pressure onto the cervix and pelvic floor – the baby is able to pivot against this tension. However, this urge to push is managed as a problem, and the result is often an epidural. See this post about pushing before full dilatation of the cervix.

Blame

Women can blame themselves for their baby being in an OP position. They question what they did (spent too long in the car) or didn’t do (scrub floors). Often the advice they are given antenatally about ‘optimal fetal positioning’ implies that they have control over the position their baby is in, when there is no research evidence to support this notion. In fact, the little research that has been done demonstrates that hands and knees posturing in pregnancy makes no difference (Hunter, Hofmeyr & Kulier 2009Kariminia et al. 2004). I have even heard of women being told that their baby has assumed an OP position because of their unresolved emotional issues!

Suggestions

We need to stop defining OP as a problem or a ‘malposition’. It is a common variation to the more common OA position, and the OP baby is probably in that position for a good reason. When caring for a woman with an OP baby:

In Pregnancy

  • Reinforce the woman’s trust in her body and baby to birth.
  • Discuss the possibility that her labour may be different (not better or worse) and might not fit general expectations about labour patterns/progress.
  • She can try a variety of techniques to encourage the baby to turn (even though the research suggests it may be ineffective). You can find some suggestions here. However, if he doesn’t respond it’s because he has chosen his optimal position for labour. He will turn once he gets into the pelvic cavity in labour, or he may even be born OP.
  • Tell her birth stories and connect her with other women who have experienced positive OP labours.

In labour

  • Trust the mother and her baby to birth.
  • Provide an environment where she can instinctively move and work with her baby to rotate her.
  • Don’t tell her not to push if she is spontaneously pushing – regardless of cervical dilatation.
  • Back pain can be relieved by: a forward leaning position (Stremler et al. 2005); warm water; sterile water injections; gentle sacral pressure. Avoid applying strong pressure to the sacrum as this may reduce the space available in the pelvis for rotation.
  • If the woman requests help or would prefer you to ‘do’ something there are a number of techniques you can use to create more space in the pelvis. I have provided a list here. Note that these techniques/positions are about increasing the space in the pelvis rather than rotating the baby – they provide an opportunity rather than making the baby move.
  • Occasionally, despite everything a baby will become ‘stuck’… and this happens to babies in an OA position too. In this situation more invasive interventions such as digital rotation (Reichman et al. 2008); instrumental birth or c-section may be necessary.

In summary

An OP position is not wrong or a problem. It is not caused by anything the woman does or does not do. Instead, it is a common variation that occurs when a baby gets into the ‘optimal position’ for her journey through her mother’s unique body. After all, she has more knowledge about the interior of her mother’s pelvis than we do. If we want to improve the experience and outcomes associated with an OP position we need to rethink our approach to it. Let’s celebrate the OP baby’s wisdom and allow the birth to unfold as it needs to, only intervening if it is truly required.

Further resources:

You can download a review of research relating to ‘management’ of OP by Simkin (2010) here.

Posted in baby, birth, midwifery practice | Tagged , , , , , , , , | 203 Comments

The Placenta: essential resuscitation equipment

Updated: September 2019

The common practice of premature cord clamping has been challenged in recent years due to a greater understanding of how this intervention disrupts the physiology of placental transfusion (Mercer & Skovgaard 2002). Premature cord clamping results in hypovolemia (reduced blood volume) and is associated with poorer short-term and long-term outcomes (Kresch 2017):

  • Short-term (first 24 hours): lower blood volume, lower systolic blood pressure, decreased renal flow, and decreased urine output ie. major organs are not optimally functioning.
  • Long-term: lower serum ferritin levels and higher rates of iron deficiency anaemia at 6 months of age; and reduced fine motor function and social development at four years of age.

Awareness about ‘optimal cord clamping’ is increasing amongst parents and care providers (thanks to campaigns such as Wait for White). However, cord clamping during resuscitation is still an area of controversy. This post explores the the practice of premature cord clamping when a baby is perceived to need resuscitation. A recent study found that 29.1% of babies had their cord cut prematurely due to concerns for their wellbeing, either to obtain cord blood gases (13.4%), or to initiate resuscitation (15.7%) (Kearney et al. 2019). Whilst the rates of ‘concerns’ are very high in this study – the practice of cutting the cord in these circumstances is not surprising. In hospital-based newborn resuscitation workshops practitioners are taught to 1. assess the baby, 2. summon help 3. clamp and the cut cord, 4. take the baby to resuscitaire…. etc. However, this approach makes no sense if you consider the physiology of transition to extrauterine life, or the importance of the mother and the placenta in the baby’s transition and any necessary resuscitation.

The physiology of newborn transition

This is extremely complex and probably very boring for those not interested in science/physiology. If you want a full scientific version please see the article by Mercer and Skovgaard (2002). Here’s the simple version…

The baby/placenta has a separate blood system from the mother. The placenta does the job of the lungs by exchanging gas (oxygen and carbon dioxide) via the intervillous space between the baby’s and the mother’s blood system. Before birth, a third of the baby/placenta blood volume is in the placenta at any given time to facilitate this gas exchange. After birth the ‘placental’ blood volume is transferred through the pulsing cord into the baby increasing the baby’s circulating blood volume. This has two major effects:

  1. Provides the extra blood volume needed for the heart to direct 50% of it’s output to the lungs (8% before birth). This extra blood fills the capillaries in the lungs making them expand to provide support for the alveoli to open. It also aids lung fluid clearance from the alveoli. These changes allow the baby to breath effectively.
  2. Increases the number of circulating red blood cells which carry oxygen. This increases the baby’s capacity to send oxygen around the body.

The pattern and timing of the blood transfer from placenta to baby is influenced by a number of factors – in particular the baby’s breathing and/or crying (Boere et al. 2015). Textbooks and guidelines suggest the transfer takes 1-5 minutes, but some individual babies take longer. While the transfer takes place, oxygen continues to be provided by the placenta until the baby has established their breathing. Stem cells are also transferred into the baby during this time. There is a theory, and some evidence that these stem cells play an important role in repairing any damage caused during birth. They may actually protect against cerebral palsy! Dr Mercer discusses this in more detail here. You can read my opinion on ‘cord’ blood collection in this post.

A study found that healthy self-breathing newborns are more likely to die or be admitted to SCN if cord clamping occurs before or immediately after the onset of spontaneous breathing (Ersdal et al. 2014). However, most babies are able to compensate for their lack of blood volume by readjusting their circulation to direct their blood to their major organs. The effects of reduced blood volume will be subtle but present (and long-term). If you get a chance to hear Karen Strange speak about neonatal transition to extrauterine life – take it. She shows photos of the heel capillaries of a baby who has had premature cord clamping compared to a baby who has not. The small blood capillaries are collapsed – they have shut down in order to send the reduced blood volume to the important organs.

Reasons for resuscitating a baby at birth

There are two reasons that caregivers decide to prematurely cut a cord in order to resuscitate a baby. In both cases this action creates difficulties for the baby. In the first it can actually create the need to resuscitate.

1. Lack of knowledge, patience (and a bit of panic)

This often happens when a baby is slower to initiate breathing. The baby is still being oxygenated by the placenta but is waiting while the effects of an increased blood volume kick in. This is particularly common with waterbirth babies. These babies have good tone and slowly turn from bluish to pink. It can be difficult to even notice them begin to breathe. Their colour change may be the only obvious indication that they are making the transition. The cord pulses at the same rate as the baby’s heart, so feeling (or watching) it will reassure you that all is well. Unfortunately the usual response to this situation is to clamp and cut the cord in order to resuscitate the baby. The likely outcome will be that the baby responds to the interruption of placental flow and the stressful journey away from mother by crying. A worse outcome is that without the placental circulation the baby is unable to complete their transition and becomes a compromised baby requiring resuscitation.

2. A compromised baby

This is a baby who has had a rough time during birth and might require a little external support to make the transition. This situation is often a result of interventions during birth such as directed pushing, artificial rupture of membranes, syntocinon/pitocin. It may also be a result of a tight nuchal cord reducing blood flow just before birth (a loose one does not do this). A compromised baby is floppy and a blue/white colour. They may also have passed meconium during the birth, and their heart rate is slow and/or dropping. This baby could probably do with a bit of help, but most importantly they need their placental circulation. While the cord is intact the baby is still receiving some oxygen, which is better than none. In addition, the extra blood volume and red blood cells will help to circulate any oxygen the baby gets via resuscitation. You can see a very compromised baby being resuscitation with ongoing placental circulation in this movie:

Here is another film of Rixa Freeze’s unplanned unassisted birth where she resuscitates her own baby. You can read the full birth story and see part 1 on her blog. Rixa had learned newborn resuscitation:

Woman-centred, baby-centred, evidence-based resuscitation

Involvement of the mother and family

It is important that the mother, her partner and/or family members are involved in the resuscitation of a compromised baby.

For Baby: The baby has spent months inside their mother and learned her voice and smell. The baby has also learned the voice of those close to the mother ie. partner and/or other family members. To be held close, spoken to and stroked is often enough to initiate breathing. Even if further measures are needed, being held skin-to-skin with mother is less stressful than being put on a resuscitaire.

For mother and other family members: Being able to see and touch your baby is important in minimising stress. Assisting with the baby’s transition reinforces the power of the parents rather than that of the care provider. Seeing what is happening is less stressful than ‘not knowing’ what is going on. In addition, mothers often instinctively know how to help their baby. I remember one mother telling me she felt her baby needed to be in a certain position on her chest. When she moved him his breathing regulated perfectly.

Practical suggestions for resuscitation

Research is beginning to emerge in support of physiology and common sense. A recent randomised controlled trial concluded that resuscitation with an intact umbilical cord results in improved oxygen saturations and higher Apgar scores, with no negative consequences (Andersson et al. 2019). The discussion section of this article also cites research demonstrating that an intact cord improves resuscitation and reduces post-resuscitation complications.

However, most guidelines (and care providers) continue to recommend premature cord clamping for resuscitation. In contrast to most guidelines, WHO guidance on ‘delayed cord clamping’ state that “if the clinician has experience in providing effective positive-pressure ventilation without cutting the cord, ventilation can be initiated at the perineum with the cord intact to allow for delayed cord clamping.” Unfortunately this is contradicted in the WHO guidelines on resuscitation of the newborn which state that “the cord should be clamped and cut to allow effective ventilation to be performed.” As usual it will likely take many years to change a practice that was initially implemented without evidence.

Care providers often tell me they are unable to perform resuscitation without cutting the cord in a hospital setting because of how the equipment is set up (ie. fixed to a wall). However, paramedics in Queensland now resuscitate newborns without cutting their umbilical cord. If paramedics can do this in less than ideal settings, why can’t hospital staff? Hospitals need to start making equipment/staff fit around the needs of the baby and mother – not the other way around.

Another issue care providers bring up is blood gas analysis. This procedure is carried out if the baby has shown signs of distress during or immediately after birth (although some hospitals do this routinely!). It involves taking a small sample of the baby’s blood from the umbilical cord to measure the pH and other elements to determine if the baby was/is hypoxic. This is largely for litigation purposes – it does not alter the care of the baby or the outcome. Many care providers are under the impression that taking this sample requires cord clamping. This results in carrying out an intervention (clamping) known to compromise a baby, so that you can do a test to see how compromised that baby is – which is nonsense. However… if you really want to take a blood sample clamping is unnecessary.

“Sampling of cord blood for gas analysis may be performed on the unclamped cord right after birth without reducing the accuracy of the analysis.” (Thomasso et al. 2014)

I think that the next evolution of newborn resuscitation will be based around working with the placental circulation; and the following is my suggested approach to resuscitation – regardless of setting:

  • Try and ensure that the baby does not arrive compromised by minimising unnecessary interventions.
  • Do not clamp or cut the cord.
  • Give the baby time to transition – if the cord is pulsing the placenta is providing oxygen… relax and reassure the mother if she needs reassurance. Keep observing the baby for signs of circulation and respiration.
  • Do not clamp or cut the cord.
  • If the baby requires assistance, start small – gentle stimulation, talking, blowing in their face (all can be done by a parent).
  • Do not clamp or cut the cord.
  • If further measures are needed, take the resuscitation equipment to the baby and resuscitate them in their mother’s arms.
  • Did I mention – Do not clamp or cut the cord.

Note: Routine suctioning of the baby is totally unnecessary, invasive and could potentially create problems by stimulating a vagal response (a drop in the heart rate).

Summary

Babies are born with their own resuscitation equipment. The placenta not only helps the baby to transition, but assists with resuscitation if needed. There is no reason to clamp and cut the cord of a baby who needs help. Doing so will create more problems for the baby and mother. Anything that needs to be done can be done with back-up from the placenta, and the involvement of the mother.

Further information/resources

  • Mercer and Erickson-Owens (2014) – ‘Is it time to rethink management when resuscitation is needed?’ Journal article
  • On Nuturing Hearts Birth Services’ website you can see a sequence of amazing photos taken of a cord after birth as it finished transferring blood.
  • Nicholas Fogelson (Obstetrician) gives a very clear presentation of the research regarding premature clamping in a lecture. The ethics of the research is questionable but hopefully the findings will help to inform a change in practice.
  • Very interesting and thought provoking interview with Dr Mercer
Posted in baby, birth, intervention, midwifery practice | Tagged , , , , , , , , , | 114 Comments

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.

Pre-conception and Pregnancy

The commonly accepted belief that the the baby inside the uterus is sterile (whilst membranes are intact) is 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). And the unique ecosystem of bacteria in the placenta may originate from bacteria in the mother’s mouth. 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). Gum disease (bacteria) has also been linked to pre-term birth. 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. 2006Prince et al. 2014). During a vaginal birth the baby is colonised by maternal vaginal and faecal bacteria. Initial human 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. (2006) 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 antibiotic resistance when treating late-onset serious bacterial infections in infants (Ashkenazi-Hoffnung et al. 2011). A more recent study found that antibiotics given during labour or a c-section are associated with infant gut microbiota dysbiosis (Azad et al. 2016). This is concerning considering the number of women/babies given antibiotics in labour (eg. for ‘prolonged’ rupture of membranes or for ‘epidural fever’). Add to that the use of prophylactic antibiotics for c-sections = a significant proportion of women and babies being exposed to antibiotics around the time of birth. Suggestions:

  • A vaginal birth in the mother’s own environment is optimal for ‘seeding’ a healthy microbiome for the baby (Penders et al. 2006).
  • 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 baby is born by c-section… Research is currently being undertaken into the use of vaginal swabs* to ‘seed’ c-section babies. The preliminary results are that the microbiome of swabbed babies are more similar to vaginally born babies. The protocol the researchers are using is:
    1. take a piece of gauze soaked in sterile normal saline
    2. fold it up like a tampon with lots of surface area and insert into the mother’s vagina
    3. leave for 1 hour, remove just prior to surgery and keep in a sterile container
    4. immediately after birth apply the swab to the baby’s mouth, face, then the rest of the body (you can see photos of this process here)
  • If a baby is born by c-section it is even more important to encourage and support their mother to breastfeed. It may also be worth considering additional probiotic intake.

*There has been a bit of hysteria about the safety of vaginal swab seeding in the media. I will leave it to Sara Wickham to address (rant about) this one.

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 (wish I’d know this 20 years ago!). 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).
  • 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. 2006). 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

Posted in baby, birth, midwifery practice, pregnancy | Tagged , , , , , , , , , , | 119 Comments

Perineal Protectors?

Updated: September 2019

Artwork by Dana Leggett: http://bit.ly/birthart

Most women will sustain some damage to their perineum during birth (AIHW 2018). Around 50% will have a tear or graze in the skin and/or vaginal wall (1st / 2nd degree). Occasionally (1% of non-instrumental vaginal births) significant tearing occurs that extends into the anal sphincter (3rd / 4th degree). You can find out more about types/grading of perineal trauma here. This post will discuss ‘protecting the perineum’ and was initially based on a literature review. You can find the full literature review and reference list in my thesis. I have updated the post regularly since then and have added new references in the text.

Care providers often consider themselves to be ‘perineal protectors’ tasked with preventing women from tearing. There is currently a lot of effort and money being put into trying to reduce significant tearing (see this post). And of course the approach taken to ‘protect the perineum’ reflects the birth culture in general ie. that women’s bodies are dangerous, and risk management involves carrying out interventions to minimise that risk. I think the truth is the other way around. What we do is usually the risk, and risk management should be about supporting physiology and instinct. Only intervening when there is a deviation from physiology.

Before I get off my soapbox and share the research evidence…

Bear in mind – research about birth outcomes is carried out on general populations i.e primarily on women having medically managed births. These types of births often involve interventions that increase tearing eg. syntocinon, directed pushing, etc. We really don’t have any good research on what protects the perineum during an uninterrupted, physiological birth where tearing rates are much lower.

Before birth

Fixed factors

Some factors that increase the chance of tearing are impossible or very difficult to control (Dahlen et al. 2015):

  • a big baby
  • first vaginal birth
  • high weight gain in pregnancy
  • higher socioeconomic circumstances
  • older and younger maternal age
  • ethnicity (Caucasian and Asian)
  • short perineal body
  • nutritional status
  • abnormal collegan synthesis

Preparing the perineum for birth

Suggesting there is a need to ‘prepare’ for birth contradicts the fact that women’s bodies are perfectly capable of preparing for birth without intervention. However, perineal stretching massage can increase some women’s confidence in their body’s ability to stretch and open for their baby. On the other hand, plenty of women don’t prepare in this way, and whether you have confidence in your body or not, your perineum will stretch.

A number of guidelines recommend that women should be encouraged to massage their perineums during pregnancy to reduce the chance of tearing. The reference cited to support this recommendation is a Cochrane Review. However, the review did not conclude that massage reduced the chance of tearing. It found that women having their first baby who did perineal massage were less likely to have an episiotomy – not a tear. This suggests that care providers act differently in these cases – and needs further investigation. Perhaps perineal massage helps women to fit unnecessary birthing timeframes prescribed by hospitals, therefore avoid being cut?

There is a rather scary device called an Epi-No designed to use during pregnancy to stretch the perineum. A large RCT found that “antenatal use of the Epi-No device is unlikely to be clinically beneficial in the prevention of intrapartum levator ani damage, or anal sphincter and perineal trauma.” Personally I worry about potential long term effects of repeatedly stretching the perineum to the size of a babies head. Although a woman may give birth a number of times during her life, she will usually have more than a day between each baby’s head stretching her vagina. It is also a reflection of our technocratic culture that a ‘device’ is considered to be necessary in order to prepare for childbirth.

During birth

Birth is where all of the care provider activity focuses. It was seeing all of the fussing and fiddling carried out as babies were born that sent me in the direction of a PhD. I could not understand why such a physiological and instinctive bodily process required so much directing and doing. I still don’t. I suggest that before (or after) you read this post, you read supporting women’s instinctive pushing behaviour during birth. Of course, most women do not have an undisturbed birth – therefore are not necessarily connected in with what is going on in their body. In these cases it may be appropriate to intervene (with consent).

General factors known to increase the chance of tearing during birth are (Dahlen et al. 2015):

  • position of baby – larger diameter of head presenting
  • midline episiotomy (see below)
  • instrumental birth – particularly forceps
  • ‘prolonged second stage’ – likely because this results in an instrumental birth
  • syntocinon (pitocin) use in women having their second or more vaginal birth
  • shoulder dystocia

There are two main principles involved in reducing the chance of tearing:

  1. A slow birth of the baby through the vagina – allowing time for the tissues to respond and stretch
  2. Capacity for stretch and ‘give’ in the tissues

Positions

Some birth positions assist with the principles above. The two positions that involve the least chance of tearing (side lying and hands/knees) do not involve stretched wide legs and therefore perineums. In addition the pressure of the baby’s head is towards the front of the mother rather than directly onto the perineum. In contrast, positions that make the perineum tight and stretched, and place all of the pressure of the baby’s head directly onto the perineum increase the chance of tearing: semi-supine (sitting upright and reclined – the TV/film birth position); squatting; and lithotomy.

Some women will close their legs during crowing. I have seen midwives push women’s legs back open or say ‘keep your legs open’. Closing the legs, or bringing them in from a wide-open position protects the perineum. Try it yourself… open your legs wide and bring them up towards your chest – stranded beetle position – and feel what happens to your perineum. Now close your legs a little and bring them down away from your chest – feel how much more ‘give’ there is in your perineum when it is not stretched out. It can now respond to the stretch required by the baby’s head without also being stretched out sideways. As for whether closing your legs will stop a baby from coming out… it may slow it down, but that baby is coming out. I have seen a woman birth on her side with her legs crossed – her baby came out from behind.

Standing up-right can result in a quick birth – particularly for women who have previously given birth – increasing the chance of tearing. It is not a position many women stay in to birth unless they have been directed to get into it.

Guidelines and training are reinforcing the need for the care providers to ‘visualise the perineum’ during birth. I’m not sure how that is supposed to prevent tearing. However, it does increase the chance the care provider will intervene. This approach is leading to more women being directed into positions to facilitate this – unfortunately positions that increase the chance of tearing.

Directed pushing

Guidelines recommend that ‘good communication’ is required between the care provider and woman to ensure a slow birth and minimise tearing. However, this is unnecessary if the woman is birthing instinctively. The intense sensations experienced during crowning usually result in the woman ‘holding back’ while the uterus continues to push the baby out slowly and gently. Often women will hold their baby’s head and/or their vulva. I have witnessed one mother attempt to push her baby back in (you know who you are) – it was unsuccessful but gave us a giggle afterwards. Telling a woman to stop pushing, pant or ‘give little pushes’ distracts her at a crucial moment, and suggests that you are the expert in her birth, which you are not. She is the one with a baby’s head in her vagina – leave it to her. Of course, if you have been shouting at her to ‘Puuuush’ with every contraction before crowning – she will be listening to you, not her body…

Warm water

Some women find having a warm compress held against their perineum as the baby crowns helps to ease the sensations of stretching. Others, hate it and find it intrusive. A Cochrane review found that warm compresses did not increase the chance of having an intact perineum or decrease the chance for suturing. However, it did reduce the chance of a very severe tear (3rd or 4th degree).

Waterbirth is another way of bathing the perineal tissue in warm water – and unlike warm compresses, makes it difficult for anyone apart from the birthing woman to touch her perineum or baby during birth.

‘Hands on’ techniques

Hands on techniques aimed at slowing the birth of the baby and supporting the perineal tissues are routinely used by many care providers. However, a systematic literature review concluded that: “The hands-poised [off] technique appeared to cause less perineal trauma and reduced rates of episiotomy. The hands-on technique resulted in increased perineal pain after birth and higher rates of postpartum haemorrhage.” A  Cochrane Review found that ‘hands on’ techniques did not reduce the chance of tearing and increased the chance of having an episiotomy. And a recent Australian study found that ‘hands on’ increased the chance of tearing for women having their second or more vaginal birth.

No research has explored women’s experiences of a ‘hands on’ approach. And, I am yet to hear a midwife or obstetrician ask for permission before placing their hands on the woman and baby.

Perineal massage 

Massaging the perineum as the baby is trying to be born concerns me for a number of reasons. It makes me really uncomfortable to watch lots of ‘activity’ being done to a woman’s body while she is trying to birth. I have seen some very brutal versions of ‘perineal massage’ done to women; and I am guessing/hoping that most of the women in these studies had epidurals. However, the Cochrane Review above suggests that this type of massaging can reduce the chance of significant tears (3rd and 4th degree) not the usual (1st and 2nd degree). Significant tearing is rare (around 3%) – so the intervention needs to be weighed up with the risks of additional pain and disturbance to physiology. Also, in order to perform this intervention effectively the woman needs to be in a position that increases her chance of tearing ie. on her back / semi-reclined.

Episiotomy

An episiotomy involves a deep cut into the perineal muscles and skin ie. creating perineal trauma. Episiotomies used to be rare in midwifery practice. I have carried out three in my career, and with hindsight I think two were unnecessary. However, there is a resurgence thanks to a new wave of perineal focused intervention packages, and confusing research summaries and clinical guidelines.

For example, a Cochrane Review examining ‘selective’ vs ‘routine’ episiotomy concluded that: “In women where no instrumental delivery is intended, selective episiotomy policies result in fewer women with severe perineal/vaginal trauma.” This seems to have been interpreted as ‘selective episiotomy reduces severe tearing’ rather than ‘in comparison to routine episiotomy’. Interestingly, the review does not include information about what indications are included in a ‘selective’ approach, or the evidence supporting those indications.

Clinical guidelines include indications for episiotomy without citing research to support those statements. For example, NICE guidelines state that an episiotomy should only be carried out if needed for an instrumental birth, or severe fetal distress. This was the standard when I trained and resulted in very few episiotomies. However, QH guidelines have recently added in additional indicators including ‘soft tissue dystocia’. The citation for this statement is another guideline (RANZOG) – and that guidelines includes no supporting evidence for the statement. ‘Soft tissues dystocia’ refers to a perineum not stretching ‘quick’ enough ie. lack of patience. In practice, care providers are cutting women if they think they may tear or if the birth is not quick enough – believing these are appropriate indications.

There is some evidence about outcomes relating to the types of episiotomies used – mid-line (down toward the anus) vs medio-lateral (60 degree angle). A mid-line episiotomy contributes to the risk of severe perineal trauma by increasing the chance the cut will extend (Lappen & Gossett 2014). However, a medio-lateral episiotomy cuts through more nerves and perineal structures (Patel et al. 2018). We are only just beginning to understand the complex anatomy of the clitoris  – a structure that is cut during a medio-lateral episiotomy. This type of episiotomy is associated “with a decreased sexual functioning as well as sexual desire, arousal and orgasm within postpartum five years” (Dogan et al. 2017).

Even if episiotomy does reduces the chance of severe tearing (which we don’t have the evidence for) – having an episiotomy during a non-instrumental vaginal birth would be trading a 1% chance of significant tearing with 100% chance of perineal damage via a cut.

After birth

Suturing

Tearing is a normal part of the birth process, and the body usually heals well. The vaginal wall is a mucous membrane and heals very fast (like the mouth). Suturing is the most common method of perineal repair. Whether to suture or not should be the woman’s decision. In relation to 2nd degree tears (the most common) the need to suture is debatable if the tear aligns well and is not bleeding. A Cochrane Review concluded:

“…at present there is insufficient evidence to suggest that one method is superior to the other with regard to healing and recovery in the early or late postnatal periods. Until further evidence becomes available, clinicians’ decisions whether to suture or not can be based on their clinical judgement and the woman’s preference after informing them about the lack of long-term outcomes and possible chance of slower wound healing process, but possible better overall feeling of well being if left un-sutured.”

In my own experience as a midwife I have found that un-sutured perineums heal very quickly and with far less pain than sutured perineums. Now-a-days my suturing skills are mostly utilised in teaching suturing.

In summary

There is very little care providers can do to protect women’s perineums using interventions. Instead, we need to encourage women to trust that their body has an innate ability to birth their baby; that perineal tearing is a normal part of birth; and that the body will heal itself.

Further resources

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In Defence of the Amniotic Sac

Holly birthing her boy in his ‘bubble’

Artificial rupture of membranes (ARM) aka ‘breaking the waters’ is a common intervention during birth. However, an ARM should not be carried out without a good understanding of how the amniotic sac and fluid function in labour. Women need to be fully informed of the risks associated this intervention before agreeing to alter their labour in this way. This post will discuss how the ‘waters’ work in labour and the implications of breaking them. Most of the information in this blog is available in any good physiology textbook (eg. Coad & Dunstall 2011). I have included references and links for additional content.

Anatomy and physiology

By the end of pregnancy the baby is surrounded by around 500-1000mls of Fluid. This is mostly made up of urine and respiratory tract secretions produced and excreted by the baby. The amniotic fluid is constantly being produced and renewed – Baby swallows the fluid; it is passed through the gut into the baby’s circulation; then sent out via the umbilical cord through the placenta. This process continues even if the amniotic membranes have broken. So, even when the waters have ‘gone’ there is still some fluid present ie. there is no such thing as a ‘dry labour’. You can read more about amniotic fluid volume in this post.

The amniotic membrane is adhered to the chorion – the other membrane attached to the placenta that sits between the amniotic membrane and the uterus. These membranes look like one, but you can tease them apart after birth.

During pregnancy

The amniotic sac protects and prepares baby by:

  • Cushioning any bumps to the abdomen.
  • Maintaining a constant temperature.
  • Allowing the movement essential for muscle development.
  • Creating space for growth.
  • Protecting against infection – the membranes provide a barrier + the fluid contains antimicrobial peptides.
  • Assisting lung development – baby breathes fluid in and out of the lungs.
  • Taste and smell – the smell of amniotic fluid has been found to have a calming effect on newborns (Varendia et al. 1998).

After 40 weeks gestation around 20% of babies will pass meconium into their amniotic fluid as the bowels reach maturity and begin to work.  This is perfectly normal and is not a sign of distress. This meconium is diluted and processed with the amniotic fluid as described above.

During labour

Around 80-90% of women start labour with their membranes intact. This is probably because the amniotic sac plays an important role in the physiology of a natural birth.

General fluid pressure

During a contraction the pressure is equalised throughout the fluid rather than directly squeezing the baby, placenta and umbilical cord. This protects the baby and his/her oxygen supply from the effects of the powerful uterine contractions. When fluid is reduced (by escaping through a hole in the membranes), the placenta and baby get compressed during a contraction. Most babies can cope well with this, but the experience of birth for the baby is probably not as pleasant. When the placenta is compressed blood circulation is interrupted reducing the oxygen supply to baby. In addition, the umbilical cord may be in a position where it gets squashed between baby and uterus with contractions. When this happens the baby’s heart rate will dip during a contraction in response to the reduced blood flow. A healthy baby can cope with this intermittent reduction in oxygen for hours (it’s a bit like holding your breath for 30 seconds every few minutes). However, this is probably not so great for an extended period of time, or if the baby is already compromised through prematurity or a poorly functioning placenta.

Forewaters

The sac of amniotic fluid is described as having two sections – the forewaters (in front of baby’s head) and the hind waters (behind baby’s head). A ‘hind water leak’ refers to an opening in the the amniotic membranes behind the baby’s head. Often this is experienced by the woman as an occasional light trickle as the fluid has to run down the outside of the sac and past baby’s head to get out.

During labour forewaters are formed as the lower segment of the uterus stretches and the chorion (the external membrane) detaches from it. The well flexed baby’s head fits into the cervix and cuts off the fluid in front of the head (forewaters) from the fluid behind (hind waters). Pressure from contractions cause the forewaters to bulge downwards into the dilating cervix and eventually through into the vagina. This protects the forewaters from the high  pressure applied to the hind waters during a contraction and keeps the membranes intact. The forewaters transmit pressure evenly over the cervix which aids dilatation. When the baby is in an OP position the head may not flex as well to block off the hind waters = pressure is able to move into the forewaters and they may rupture. Early rupture of membranes is often a feature of an OP labour.

Lubrication

The forewaters usually break when the cervix is almost fully open and the membranes are bulging so far into the vagina that they burst. This ‘fluid burst’ lubricates the vaginal and perineum to facilitate movement of the baby and stretching of the tissues.

Born in the caul

If is fairly common for a baby to be born in the amniotic sac when labour is left to unfold without interference. The photograph at the beginning of this post is my lovely friend Holly birthing her baby in his caul.

Eventually the force of the contraction and the movement of the baby will rupture the sac as the baby’s body is born. You don’t need to worry about the sac holding the baby back. A baby and uterus are stronger than the membranes. The rupture of the sac can be rather dramatic and messy and is another good reason for the midwife not to be fiddling about at the perineum during birth. Caul births seem more common during waterbirths (in my experience) and are possibly one of the most amazing sights in the world (and less messy than on land):
(note the baby above is born in the OP position)

You can see another beautiful caul birth here.

Historically being born in the caul was considered good luck for the baby. It was also believed that a baby who was born in the caul would be protected from drowning. Midwives used to dry out amniotic membranes and sell them to sailors as a talisman to protect them from drowning. You can find out more about the social history of the caul in an old journal article by Forbes (1953).

How does birth in the caul influence the baby’s microbiota?

I don’t know the answer to this question. However, increasingly research is identifying the importance of intestinal microbiota for health, including immune development and function (Bengmark 2012). I have written about this topic in more detail in another post. During a vaginal birth the baby is colonized by microorganisms as he passes through the vagina. So, this raises questions about what happens if the baby does not come into contact with vaginal microorganisms because the amniotic sac is intact? In theory, during a waterbirth the pool water is likely to contain microorganisms from the mother, therefore the baby could become colonized. But on land – I don’t know.

C-section and the amniotic sac

There are photos circulating on the internet of babies in their caul during a c-section (google caul+caesarean or cesarean). I would like to know the background stories to these photographs. There has been a study supporting this practice for preterm babies (Wang, et al. 2013), and you can see a photo from a case study here (Prabakar & Nimaroff 2012). However, there is no research supporting this method for full term babies.

Artificial rupture of membranes (ARM) aka amniotomy

Breaking the membranes with an amni-hook is a common intervention during labour. It is usually the second step in the induction process, and also done in an attempt to speed up spontaneous labour. In an induced labour, intact membranes can prevent the artificially created contractions from getting into an effective pattern. There is also the theoretical risk of an induced contraction (that is too strong) forcing amniotic fluid through the membranes/placenta and into the blood system causing an amniotic embolism and maternal death. So an ARM is recommended before a syntocinon/pitocin infusion is started (although this may not be a worldwide practice).

In a spontaneous labour the rationale for an ARM is that once the forewaters have gone the hard baby’s head will apply direct pressure to the cervix and open it quicker. However, a cochrane review of the available research states that “the evidence showed no shortening of the length of first stage of labour and a possible increase in caesarean section. Routine amniotomy is not recommended for normally progressing labours or in labours which have become prolonged.” .

There are also risks associated with an ARM:

  • It may increase contraction intensity and pain which can result in the woman feeling unable to cope and choosing an epidural… and the intervention rollercoaster begins.
  • The baby may become distressed due to compression of the placenta, baby and/or cord (as described above).
  • Fok et al (2005) found amniotomy altered fetal vascular blood flow, suggesting there is a fetal stress response following an ARM.
  • The umbilical cord may be swept down by the waters and either past the baby’s head, or wedged next to the baby’s head. This is called a ‘cord prolapse’ and is an emergency situation. The compression of the cord interrupts or stops the supply of oxygen to the baby, and the baby must be born asap by c-section. The only cord prolapse I have been involved with happened after an ARM (not done by me  – honest!). The outcome for the woman was a live baby born by emergency c-section. Her previous 2 babies had been uncomplicated vaginal births.
  • If there is a blood vessel running through the membranes (see picture below) and the amni-hook ruptures the vessel, the baby will lose blood volume fast – another emergency situation.
  • There is a slight increase in the risk of infection but mostly for the mother (not baby). This risk is minimal if nothing is put into the vagina during labour (ie. hands, instruments etc.).

It seems that an ARM is often performed during labour without consent. The requirement for consent to be eligible includes providing adequate information about the procedure. Have any readers been given the information above prior to agreeing to an ARM? Sara Wickham explores this issue further in her post about consent.

Summary

The amniotic sac and fluid play an important role in facilitating birth and protecting the baby. There is no evidence that rupturing this sac will reduce the length of labour. While every intervention has it’s place, including ARM, midwives need to carefully consider the risks before offering it to women. Also women must be fully informed of the risks before choosing an ARM during their labour.

Posted in birth, intervention, midwifery practice | Tagged , , , , , , , , , , | 221 Comments

Cord Blood Collection: confessions of a vampire-midwife

Updated: September 2019

Archie Rigney and his mother Azure
(effective placental transfusion results in an empty white cord)

When I was a bright-eyed and bushy-tailed student midwife I was awarded with a certificate and a box of chocolates. My achievement was collecting the most ‘cord’ blood in the hospital. At that time the Local Health District was trialling a ‘cord’ blood bank. The collected blood was to be used for treating leukaemia and for research. Every woman birthing in the hospital was asked to donate ‘cord’ blood for the good cause, and many generously agreed. I was exceptionally good at collecting the blood. This post is a small attempt to repent for my sins.

‘Cord’ blood is baby’s blood

The term ‘cord blood’ is misleading. The blood collected via the umbilical cord is the baby’s blood. When adults donate blood it is collected via their arm. We don’t refer to that blood as ‘arm blood’.

During pregnancy the baby and placenta share the baby’s circulating blood. This allows the baby to receive nutrients and oxygen from the placenta. After birth the placental circulation alters, sending all of the baby’s blood into their body. You can read more about the ‘physiology of newborn transition’ in this this post. Penny Simkin provides a graphic illustration of blood re-distribution after birth in this movie:

Knowledge about the short term and long term health benefits of the baby having their full blood volume at birth is now widespread (see this post for details).

Stem cells

Stem cells can self-renew (make copies of themselves) and differentiate (develop into more specialised cells). At birth babies have haematopoietic stem cells in their blood. This type of stem cell is similar to those found in bone marrow and can regenerate red blood cells and immune system cells. The likelihood is that these stem cells play an important role in repairing any damage done during birth (Dr Mercer discusses this in a podcast). They may also play a role in longer term protection from disease.

The business of collecting babies blood

Companies are targeting parents and making big money from removing and
storing their baby’s blood. Care providers are also making money from recruiting parents and collecting blood for these companies. The sales pitch is: if your baby develops a particular type of illness in the future you may be able use their
stored stem cells as treatment. These companies are increasingly sponsoring
care provider organisations and events; and buying endorsement from
obstetricians and midwives. I have even been approached to endorse their
services – clearly they had not read this post. I also get fairly regular comments
on this post from undercover company reps (I can see their email address). I am deliberately avoiding linking directly to any company websites in this post – I don’t want to send them traffic or potential customers.

My main concern with ‘cord’ blood banking is the misleading information given to parents. This misinformation raises both ethical and legal issues. There are two main areas that require further clarity: blood collection volumes and cord clamping and the effectiveness of stem cell treatments.

Blood collection volumes and cord clamping

Parents need to be informed that baby’s blood collection requires premature cord clamping, and that the blood being collected belongs in the baby’s body

Paediatric guidelines state that ‘blood draws in infants and children should not exceed 5% of the total blood volume in any 24 hour period’. A 3.6kg newborn has a blood volume of around 280mls – so the maximum blood draw would be 14mls. 

http://www.isu.edu/cls/shields09wikis/cordblood.html
This collection bag hold a significant proportion of the baby’s blood

The collection bags for ‘cord’ blood hold 250mls (35mls already taken up with anticoagulant fluid). The minimum amount of blood acceptable for collection is 45mls, and the maximum possible is 215mls. In one procedure guide it states “collect as much cord blood as possible [in bold].” Another company reports that the median volume they collect is 60mls. I wonder how many parents would consent to someone coming onto the postnatal ward and sticking a needle into their baby to collect 6 adult vials of blood. Cord blood collection is the equivalent to this… only the needle is in the umbilical cord rather than the baby.

http://www.bmj.com/content/333/7575/954/F1.large.jpg
This diagram from the British Medical Journal shows the transfer of blood volume from placenta to baby after birth

In response to publicity about the importance of ‘delayed’ cord clamping. The latest marketing ploy is to tell parents they can have both ‘delayed’ cord clamping and collect ‘cord’ blood. Some of the websites even include a page on the benefits of ‘delayed’ cord clamping. However, they define delayed as 30 seconds to 1 minute. It generally takes longer for the full blood volume to transfer (see diagram). If all of the baby’s blood has transferred into the baby – however long that takes for that individual baby – then there is minimal, if any blood left to collect. Look at the picture at the top of this post. If you can get blood out of that cord you deserve a certificate and chocolates! At least one website acknowledges this, and states that the risk of ‘delayed’ cord clamping is “reducing the volume of a cord blood collection such that it cannot be banked…”. Note that public cord banks require larger volumes of blood than private at present.

In contrast one company refers specifically to ‘optimal’ cord clamping ie. waiting until the cord is white. They suggest that their company can effectively process 10-20mls of ‘cord blood’. I’d like to see evidence of that eg. photos or a movie of collection from a white cord. And, further information about the effectiveness of a small sample, as most other companies state that effective processing for storage is determined by the size of the sample.

The effectiveness of stem cell treatments

Parents need to be informed about the lack of evidence regarding the usefulness of cord blood for future treatment of their baby

There is currently no research evidence demonstrating the effectiveness of ‘cord’ blood stem cells (haematopoietic) in the treatment of disease or disability. Many company websites hint at this by using the terms ‘potential’ or ‘may’ or ‘future’ or ‘hope to’. Sites also claim that ‘cord’ blood stem cells are being used to treat ’80 diseases’ – with no mention of whether those treatments are effective or not. Some sites refer to the treatments as ‘alternative’ ie. not being used in mainstream medicine. However, others include claims of successful treatment, citing case studies or anecdotal news articles (often about stem cells in general rather than ‘cord’ blood specifically). In addition, all of the research (I can find) is being conducted on ‘public’ stem cells ie. used to treat ‘strangers’ rather than the baby who donated, or their family.

I was recently in correspondence with a representative of a cord blood company and asked for some research evidence to support his claims of successful treatments. He sent me a collection of unreferenced statements (marketing) on the company website and two feasibility studies. Feasibility studies are carried out to demonstrate that a treatment is ‘safe’, and a study is possible… they do not test the effectiveness of a treatment. I pointed this out and have not heard back. Whilst there may be a number of trials underway with ‘public’ donations, I am yet to see any actual results relating ‘cord’ blood stem cells and treatments. Send me any you may have (research articles only please).

The European Commission released a press statement about this situation stating:

“If commercial cord blood banks are allowed, appropriate information should be given to the consumers willing to use their services, including the fact that the likelihood that the sample may be used to treat one’s child is currently negligible, that the future therapeutic possibilities are of a very hypothetical nature and that up until now there is no indication that the present research will lead to specific therapeutic application of one’s own cord blood cells. Therefore, information has to be particularly explicit that the auto conservation has little value in the current state of scientific knowledge. This information should be made clear on all media, including Internet, and in any contracts linking commercial banks to their customers.”

Many companies also offer umbilical cord tissue collection as an alternative, or in addition, to ‘cord’ blood collection. Umbilical cord tissue contains mesenchymal stem cells and can be collected alongside optimal cord clamping. However, there is no evidence that this type of stem cell offers effective treatments either.

Summary

I am not suggesting that baby blood banking shouldn’t be an available option. All I am suggesting is that parents need adequate information before they make a decision to remove a significant amount of their baby’s blood volume. They need to be able to weigh up the definite benefits of full blood volume at birth vs a possible treatment for an unlikely future illness. Cord blood is baby’s blood. Parents also need know if their care provider will benefit financially from persuading them to collect and bank blood.

PS: I no longer participate in stealing babies blood. We live and learn.

Further information

Private cord blood collection and cerebral palsy – is there a connection

Is it worth storing your baby’s cord blood? – youtube

Mythbusting:

Posted in baby, birth, intervention, law | Tagged , , , , , , | 177 Comments