Asynclitism: a well aligned baby or a tilted head?

Asynclitism is when the baby’s head is moving through the pelvis ‘tipped’ to one side. This is usually diagnosed by a vaginal examination in labour. However, asynclitism is rarely caused by the baby having his/her head tilted to one side and rarely a real problem. Instead, like the anterior lip, it is a normal part of the physiological process of birth.

Disclaimer: Routine vaginal examination has NO place during a physiological birth. Unfortunately vaginal examinations continue to be commonly used to determine progress despite the lack of evidence supporting this invasive intervention. In addition, most women do not experience a physiological birth and instead have their labour induced or augmented. Once an intervention is implemented it’s effects need to be monitored ie. assessment of cervical dilation. Therefore, the following explains what is felt during an examination in relation to what is happening as the baby descends and rotates through the pelvis.

Asynclitism: normal birth physiology

The baby enters the pelvis through the brim/inlet. The easiest way to do this is with the head in the transverse position (facing sideways to mother). However, the baby is not lying in a perfecting vertical position. The woman’s pelvis is tilted and her uterus/baby are also sticking out at an angle – check out a pregnant woman for confirmation. If at this point in the birth process you put your fingers into her vagina, you will feel the side of the baby’s head near the symphysis pubis. If you dig further you will feel the saggital suture towards the back of the pelvis. The baby’s head is not tilted… it is perfectly aligned with the baby and the pelvis.

Once the baby has descended into the cavity/mid-pelvis he will use the space and the counter pressure of the pelvic floor (unless the muscle tone is reduced by an epidural) to rotate an anterior position (facing towards mother’s back) to fit the shape of the pelvic outlet. It is not until the baby has made this rotation that you will feel the centre of the head in the middle of the pelvis. If the baby’s head is well flexed, you will also be able to feel the occiput, the posterior fontanelle and the lambdoidal suture (I love that word – lambdoidal).

As usual the text book depictions of a perfectly central saggital suture reflect our cultural need to keep birth neat and orderly. It fits in with the clean and clinical depictions of birth in which the woman is replaced by diagrams and graphs. The reality of a vaginal examination is very different and involves bodily fluids, squishy bits, hair, caput (swelling on baby’s head), moulding, the amniotic sac, difficult to distinguish parts of the head… and is usually an unpleasant experience for the woman (yes, she is involved). When birth becomes complicated there may be an indication for a vaginal examination (eg. to determine position), but in the absence of a complication there is no point. Telling a woman that her baby is asynclitic is at best pointless and at worst stress inducing… OK I’ll shut up about VE’s and save it for dedicated post later on. Moving on…

Asynclitism: a variation or complication

Occasionally the baby enters the pelvis with his/her head tilted down towards their shoulder (a variation). If the baby continues to descend in this position it can alter the progress of the birth process. The woman may experience irregular contractions without change over many hours. Most of the time the baby will sort themselves out, particularly with an actively mobile mother. Techniques to create more space in the pelvis may help to provide additional room for head wriggling and repositioning. I have found that techniques which help the baby move back out of the pelvis are very effective (eg. mother on all fours, bottom in the air + rebozzo work). Once baby is up and out  a little, he can reposition and come down again with his head better aligned. Unfortunately a common response to this situation is to start IV syntocinon (pitocin) and create stronger contractions. It doesn’t take a genius to work out what happens if you have stronger contractions pushing the baby through the pelvis even harder and faster. The baby needs space to realign his head rather than more pressure and compaction (and the additional risk of syntocinon). Very occasionally the baby is unable to adjust his position and the birth becomes complicated – the baby becomes increasing compacted in the pelvis and begins to show signs of distress. In this situation the woman may require assistance to birth (instrumental birth or c-section).

Summary

Asynclitism is a normal part of the birth process. When it is caused by a tipped head it can alter the pattern of labour and may require additional work and support. It can be difficult to work out which type of asynclitism is happening via a vaginal examination (normal or a tilted head). Therefore it is best to keep fingers out of the vagina and focus on the woman and what she does or does not need from you.

Further resources

Spinning babies

I would love to hear your experiences of asynclitism.

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Supporting women’s instinctive pushing behaviour during birth

Artwork by Amanda Greavette

This article was published in The Practising Midwife journal in June 2015 along with ‘practice challenge’ questions for midwives (not included here).

Introduction

Clinical guidelines recommend that women should be guided by their own pushing urges during birth (National Institute for Health and Care Excellence (NICE) 2014). However, directing women’s pushing behaviour has become a cultural norm within maternity care. Women are still told when to push, when not to push and how to push. In order to promote and support physiological birth we need to reconsider the assumptions underpinning this practice. In addition, we need to reflect on how this practice influences women’s experience of birth. This article discusses supporting instinctive pushing behaviour during uncomplicated, physiological birth.

The current discourse around pushing and cervical dilatation is underpinned by a mechanistic understanding of the birth process: that the cervix opens first, then the baby is pushed through the vagina. However, this does not reflect the multidimensional and individual nature of birth physiology. Descent, rotation and cervical dilatation happen at varying rates, and are not necessarily related.

The urge to push is initiated by the position of the baby’s head within the pelvis (Roberts et al 1987). Therefore, the cervix can be fully dilated without the baby descending deep enough to initiate an urge to push. Alternatively, spontaneous pushing can begin before the cervix is fully dilated. Directing a woman to push or not to push fails to support the individual physiology of her body and birth process. In addition, it contradicts the notion that women are the experts in their own births.

Directing women to push

Once full dilatation of the cervix is identified or suspected, it is common practice to direct women’s pushing behaviour in an attempt to aid descent of the baby. Pushing directions usually involve instructions to use Valsalva pushing, or a variation of this method which includes: taking a deep breath as a contraction begins; holding the breath by closing the glottis; bearing down forcefully for eight to ten seconds (into the bottom); quickly releasing the breath; taking another deep breath and repeating this sequence until the contraction has ended (Yildirim and Beji 2008). Directed pushing was introduced in an attempt to shorten the duration of the ‘second stage of labour’ in the belief that this would improve outcomes for women and babies (Bosomworth and Bettany-Saltikov 2006). This type of pushing has been found to have a number of detrimental consequences for women including alterations to circulation (Tieks et al 1995), and increased perineal trauma and long-term effects on bladder function and pelvic floor health (Bosomworth and Bettany- Saltikov 2006; Kopas 2014).

Valsalva pushing may also reduce oxygen circulating via the placenta to the baby (Aldrich et al 1995). Current research reviews do not identify a significant impact of directed pushing on fetal wellbeing, but further research is needed (Kopas 2014; Prins et al 2011).

In addition, Valsalva pushing does not reflect how women push instinctively (Kopas 2014). Instinctive pushing does not commence at the start of contractions, and women do not take a deep breath before pushing: women alter their pushing behaviours, and use a mixture of closed glottis and open glottis pushing. The number of pushes per contraction also varies, with women not pushing at all during some contractions. Women also instinctively alter pushes according to their contraction pattern. For example, if contractions are infrequent women tend to use more pushes per contraction, and if contractions are frequent they push less often. This individual and instinctive pattern of pushing helps to oxygenate the baby more effectively than Valsalva pushing.

Directing women not to push

Some women will instinctively push before their cervix is fully dilated. This is often treated as a complication, and a common approach is to encourage the woman to stop pushing due to fear that cervical damage will occur. However, there is no evidence to support this concern. Two studies examined pushing before full dilatation and found that between 20-40 per cent of women experienced an ‘early urge to push’ (Borrelli et al 2013; Downe et al 2008). Borrelli et al (2013) found that the sooner the midwife performed a vaginal examination in response to a woman’s urge to push, the more likely they were to find an undilated cervix. They also found that ‘early pushing’ was much more common for primiparous women, and occurred in 41 per cent of women with babies in an occipito posterior position. Both studies conclude that an ‘early urge to push’ is a normal variation and is not associated with complications. Perhaps there is a physiological advantage for ‘early’ pushing in some circumstances? For example, additional downward pressure may assist the baby to rotate into an anterior position, or assist with cervical dilatation.

The impact of telling a woman not to push when her body is pushing also needs to be considered. Once the baby is applying pressure to the nerves in the pelvis that initiate pushing, the woman is unable to control the urge. Attempting not to push at this point is like trying not to blink or breathe. In addition, telling a woman not to push when her body is instinctively pushing suggests that her body is wrong, and that she needs to resist her urges. After resisting her body’s urges, she may find it difficult to switch into trusting and following her body once given the ‘go ahead’ (Bergstrom et al 1997). Encouraging a woman not to push when she is instinctively pushing can be distressing and disempowering for her.

Another situation in which women are encouraged not to push is during crowning. The rationale is to minimise the chance of perineal trauma by slowing down the birth of the baby’s head. A slow birth of the head reduces the chance of tearing as it allows the perineal tissues to gently stretch over time (Aasheim et al 2012). A number of techniques have emerged aimed at slowing down the birth of the baby’s head, including instructions and hands-on approaches. However, these approaches fail to acknowledge instinctive birthing behaviour. There is one study examining what women do during birth when following their instincts (Aderhold and Roberts 1991). This very small study of four women birthing without instructions found that they altered their own breathing and stopped pushing as the baby’s head crowned. This is consistent with my own observations of undisturbed birth. 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. In addition, women will often hold their baby’s head and/or their vulva during crowning. Some women will bring their legs closer together, not only slowing the birth but also providing more ‘give’ in the perineal tissues. Telling a woman to ‘stop pushing’, to ‘pant’ or to ‘give little pushes’ distracts her at a crucial moment and suggests that you are the expert in her birth. Instructing her to open her legs to ‘give the baby room’ contradicts her instinct to protect her own perineum by closing them.

Conclusion and suggestions for practice

Evidence supports the notion that women instinctively push in the most effective and safe way for themselves and their babies during birth. A birthing woman is the expert regarding when and how she pushes. Providing directions implies she needs our guidance and that we are the experts. Facilitating women’s instinctive birthing behaviours rather than directing them is evidence based and reinforces women’s innate ability to birth.

Suggestions for practice:

  • Include information about the physiology of birth in antenatal education/preparation. Reinforce the message that women have an innate ability to birth without direction.
  • Provide an environment that facilitates physiological birth and instinctive behaviour – low lighting, minimal disturbance, comfortable furniture that supports mobility and movement (floor mats, beanbags, birth pool, shower).
  • Avoid asking the woman if she needs to push, or feels ‘pushy’ as this may suggest that she should and could interfere with her inward focus and instinctive behaviour.
  • If the woman tells you she feels the urge to push, reassure her that this is good, but don’t encourage her to push. There will come a point when she is spontaneously pushing rather than feeling an urge to.
  • Avoid vaginal examinations to ‘diagnose’ full dilatation. If you are not going to provide instructions about pushing based on cervical dilatation, there is no benefit in knowing this information.
  • Do not disturb the woman’s instinctive pattern of pushing and breathing. Avoid directions and, if you must speak, gently reinforce her ability to birth.
  • Avoid directions or distractions as the baby’s head is emerging to facilitate the woman’s instinctive perineal protecting behaviours (such as gasping, screaming, closing her legs, holding her baby and perineum).

Related posts: perineal protectors; pushing: leave it to the experts; the anterior cervical lip: how to ruin a perfectly good birth.

References

Aasheim V, Nilsen ABV, Lukasse M et al (2011). ‘Perineal techniques during the second stage of labour for reducing perineal trauma’. Coch Data Sys Rev, 12: CD006672. DOI: 10.1002/14651858.CD006672.pub2.

Aderhold K and Roberts JE (1991). ‘Phases of second stage labor: four descriptive case studies’. Jour Nurse- Midwif, 36(5): 267-275.

Aldrich C, D’Antona D, Spencer JAD et al (1995). ‘The effect of maternal pushing on fetal cerebral oxygenation and blood volume during the second stage of labour’. Brit Jour Obs Gyn, 102(6): 448-458.

Bergström L (1997). ‘”I gotta push. Please let me push”: social interactions during the change from the first to second stage of labour’. Birth, 24(3): 173-180.

Borrelli SE, Locatelli A and Nespoli A (2013). ‘Early pushing urge in labour and midwifery practice: a prospective observational study at an Italian maternity hospital’. Midwif, 29(8): 871-875.

Bosomworth A and Bettany-Saltikov J (2006). ‘Just take a deep breath: a review to compare the effects of spontaneous versus directed Valsalva pushing in the second stage of labour on maternal and fetal well- being’. MIDIRS Midwif Dig, 16(2): 157-165.

Downe S, Trent Midwives Research Group, Young C et al (2008). ‘The early pushing urge: practice and discourse’. In: Downe S (ed.). Normal childbirth: evidence and debate, 2nd edition. London: Churchill Livingstone: Elsevier.

Kopas LM (2014). ‘A review of evidence-based practices for management of the second stage of labour’. Jour Midwif Wom Health, 59(3): 264-276.

NICE (2014). Intrapartum care: care of healthy women and their babies during childbirth. NICE clinical guideline 190, London: NICE.

Prins M, Boxem J, Lucas C et al (2011). ‘Effect of spontaneous pushing versus Valsalva pushing in the second stage of labour on mother and fetus: a systematic review of randomised trails’. BJOG, 118(6): 662-670.

Roberts J, Goldstein S, Gruener JS et al (1987). ‘A descriptive analysis of involuntary bearing-down efforts during the expulsive phase of labor’. Jour Obs, Gyn Neon Nursing, 16(1): 48-55.

Tieks FP, Lam AM, Matta BF et al (1995). ‘Effects of valsalva maneuver on cerebral circultation in healthy adults: a transcranial doppler study’. Stroke, 26(8): 1386-1392.

Yildirim G and Beji NK (2008). ‘Effects of pushing techniques in birth on mother and fetus: a randomized study’. Birth, 35(1): 25-30.

Posted in birth, midwifery practice | Tagged , | 54 Comments

Shoulder Dystocia: the real story

kytriallaw.com

Updated: August 2019

There is a lot of unwarranted fear about ‘big babies’ getting stuck. The media reflects the usual story – that women are creating a problem that doctors have to fix. The incidence of shoulder dystocia does increase with the size of the baby. However, it is not possible to accurately estimate the size of a baby before they are born. And the complications associated with big babies are not necessarily about the size of the baby. For example, if a care provider suspects a ‘big baby’ the woman is more likely to experience interventions and complications regardless of whether her baby is actually big (Sadeh-Mestechkin et al. 2008Blackwell et al. 2009). This post will discuss how to avoid a shoulder dystocia (if possible), and deal with the situation if it occurs.

What happens during a shoulder dystocia?

Basically the baby’s shoulder/s get caught in the pelvis. This movie shows a baby becoming stuck on symphysis pubis (the pubic bone) at the brim of the pelvis. However, a baby can become stuck in any part of the pelvis (more info about the pelvic brim, cavity and outlet in this previous post). Unfortunately variations of shoulder dystocia are generally ignored in emergency training, and instead the focus is on the symphysis pubis scenario. This misunderstanding can result in problems with resolving a shoulder dystocia as particular actions are ineffective for particular types of shoulder dystocia.

Avoiding shoulder dystocia

A lot of midwifery and obstetric learning resources focus on how to manage complications or problems, rather than on how to prevent them happening. Although in some cases shoulder dystocia is unavoidable, there are a number of ways to reduce the chance of it occuring:

Undisturbed birth

When women are able to birth instinctively without direction or intervention they are capable of intuitively fixing problems themselves. I have seen some bizarre birth positions and movements that made perfect sense once the baby emerged. And, in the case of a stuck shoulder, instinctive pelvic movements can release the baby without drama. The first step in risk management is to promote and support instinct and physiology. (see this post)

Patience

The baby needs time to get into the best position to move through their mother’s pelvis. When we try to hurry birth, the baby may be unable to make these adjustments. Directed pushing can force the baby into the pelvis without allowing time for subtle adjustments to happen. Syntocinon (pitocin) induced contractions can do the same. And I am also convinced (but have no research to back me up) that pulling babies out can wedge their shoulders against the pelvis. Waiting for a contraction when the head is out can feel like forever (could be 5+ minutes), and it is tempting to tell the mother to push or pull the baby’s head. But, the baby may be using this time to make the adjustments necessary for the shoulders to birth. As long as there is some change with each contraction, and the baby is well, you can wait – bite your tongue and sit on your hands if you have to. Usually the shoulders will be born with the next contraction following the head, but not always. The next contraction may rotate the baby, then the next contraction birth the shoulders. Watch and see. I have noticed that many babies do not follow the textbook description of the ‘mechanism of birth’ and instead emerge with their shoulders lateral or oblique to the pelvis rather than anterior-posterior. It is probably best not to force a ‘mechanism’ on an individual baby/situation.

Being proactive with epidurals

An epidural will completely alter the physiology of birth and the instinctive behaviour of the mother. Once an epidural is inserted ‘active birth’ often goes out the window. In my opinion ‘active birth’ is not necessary when a woman is undisturbed – she will instinctively get into positions that work for her without prompting. However, active birth becomes essential for a woman who has an epidural. Looking after a woman with an epidural should be hard work. As a care provider you now have to help the baby through the pelvis by prompting and assisting maternal movement and position. This is where the ‘creating space’ tricks‘ become important.

Birthing in a semi-recumbant position increases the chance of shoulder dystocia because the pelvis is unable to open ie. sacrum move back and coccyx uncurl. This is often the default position for women with epidurals. However, most women are able to get into an alternative position with assistance, and most hospital beds are adjustable. It is possible to get into a squat using a bar attachment to hold, and women can kneel up and lean over the back of the bed despite a lack of feeling in their legs. A lying lateral position is always available if movement is really difficult. Lots of position changes during pushing may be difficult but can make a huge difference to the outcome.

Management of a shoulder dystocia

Despite anything and everything mothers and care providers do – some babies will still get stuck. Even though shoulder dystocia is relatively uncommon (1:200), knowing what to do is useful. Firstly, it is important not to make a bad situation worse, therefore:

  • Do not pull the baby as this will impact the shoulder further. Initially diagnostic traction may help you know if the baby really is stuck ie. gentle firm traction – if the baby is stuck on tissue rather than bone they will move… if not stop. Pulling is the most common mistake people make because they panic. Excess traction can result in brachial plexus injury to the baby. Unfortunately the care provider can then find themselves facing litigation. An article by Johnson outlines the medico-legal perspective ‘…for many years it has been accepted that OBPP [obstetric brachial plexus palsy] is an injury caused by excessive traction on the head when the anterior shoulder is impacted above the symphysis pubis.’ 
  • Do not cut the umbilical cord if it is around the baby’s neck. While the cord is intact there is still a chance that the baby is receiving oxygen which gives you more time, and assists with resuscitation afterwards.
  • Communicate with the mother. You always have time to explain what is happening and why you are doing what you are doing.

Here is a video illustrating why pulling babies out is bad practice:

We all learn and retain information differently. As a lecturer I teach two types of approaches – ‘standardised/general’ and ‘situational’.

Standardised / general approaches

These structured approaches are good for those who find it easier to remember systematic step-by-step information and prefer to systematically work through set techniques.

HELPERR:

This is the standard approach taught within the hospital system to doctors and midwives.

I have a strong aversion to mnemonics. I get particularly frustrated by mnemonics that don’t fit the letters to actions = actions being crow-barred into the word, or another letter being added so it is no longer an actual word. In the case of HELPERR the first E is for ‘evaluate for episiotomy’ – which I am yet to see anyone seriously do in real life. Firstly, you would have to be very brave to attempt putting scissors in such a tight space next to a baby’s head/face. Secondly, if you really need to get your hands in – you will, and a tear will be the least of your worries in that moment. I have recently heard that ‘E’ is now used for ‘explain’, which is much better. Another problem with HELPERR is that it assumes the woman is on her back – which I guess she usually is if the baby is stuck. The first two manouvres ‘McRoberts’ and ‘suprapubic pressure’ are only effective when the shoulder is stuck on the symphysis pubis. Otherwise they are a waste of precious time.

OK, rant over. I know that some people find mnemonics assist them to remember sequences, and that hospital staff are expected to follow them. I can see the place of this approach within a hospital setting where a range of practitioners with a range of skill and experience may be dealing with an emergency. At least everyone knows what comes next and I have seen it work well for a ‘group’ approach to the problem. In addition, for legal purposes (see above article) it looks good if you have documented evidence of working through the HELPERR sequence. Because HELPERR is the standard approach I will not list ‘how to’ here – you can watch this youtube explaining the medical approach to shoulder dystocia.

However the limitations of the HELPERR approach become apparent when assumptions about position (reclining/on back) and environment (on a hospital bed) are removed. If a shoulder dystocia occurs in a small toilet cubical with an upright woman – how do you perform McRoberts? Or, if the baby’s shoulders are stuck mid pelvis, or on the ‘sit bones’, the first techniques in HELPERR will be ineffective.

FlipFLOP (Gail Tully):

This is another standardised/general approach that works well with a mobile un-epiduralised woman. There are less steps in this to remember and it makes more sense from a physiological perspective because it allows you to make the most of the space in the back of the pelvis.  You can find information, about this method here.

A situational approach

Considering the range of positions, environments and situations birth takes place in; and the variety of places shoulders can get stuck, another approach is to think and act beyond a mnemonic. We also need to keep it simple and quick. When a shoulder dystocia occurs one or both of 2 things need to happen to release the shoulders:

1. Change the size and position of the pelvis (mother)

This can be done by encouraging the mother to move and change position. The best option will depend on the position she is already in. Often just the movement of getting into a position will release the baby. You can ask or assist a mother to change her pelvis by:

  • Lifting a leg up and/or outwards eg. onto the side of the birth pool or chair. This can be accompanied by a rocking back and forward of the pelvis (thrusts).
  • McRoberts is easy if the mother is already reclining. If on all fours, flipping over onto her back might be possible and the baby may release during the movement.
  • Gaskin manoeuvre – rotating onto all fours from a reclining position (a bit like a reverse McRoberts). If upright, dropping to all fours might work.
  • German approach – this focuses on moving the mother rather than the baby. Pictures and a translation can be found here.

2. Change the size and position of the shoulders (baby)

Adducting the shoulder/s will make the diameter of the shoulders smaller. Rotating the shoulders into the oblique diameter of the pelvis will make use of the extra space available (see pelvis info in previous post). Explanations of the following manoeuvres are provided in the movie link above in the HELPERR section.

  • Suprapubic pressure (sometimes called Rubin’s I)
  • Rubin’s manoeuvre (sometimes called Rubin’s II because it is attempting to do the same as the above manoeuvre only internally)
  • Woodscrew manoeuvre
  • Reverse Woodscrew manoeuvre
  • Removal of the posterior arm
  • Axillary traction (not included in HELPERR)

There is no particular order in which you can try the above positions and actions. It will depend on how well the mother can move; the position she is in; and the access you have into her pelvis ie. how and where you can get your fingers in (if needed). For example, Rubins (II) will be easier to do than suprapubic pressure on a forward leaning mother. Bascially there is more room in the back of the pelvis… and this room is best accessed when a woman is forward leaning.

It really doesn’t matter what the manoevres are called, or where exactly you place your fingers. Or even where the baby is stuck – if you don’t know. Essentially, put your hand in, find the baby (shoulder, back, chest) and push him/her round and out. Ideally you will be applying pressure to the back of the shoulder, but if not the baby is still likely to rotate… the shoulders/chest are all connected and will move together. The important thing is to get the baby out and getting caught up in exacts can create more stress and delay.

A situational approach assesses the holistic situation and uses the appropriate movement or action at the time. I have created a list that combines manouvres and when they are appropriate. I use this when teaching workshops and demonstrating the manouvres. So, unless you attend one of my workshops you will have to do without the visuals!

You can watch a movie of a shoulder dystocia occurring during a home waterbirth here

Podcast interview

Big Babies and Should Dystocia – Birthful Podcast

Posted in birth, intervention, midwifery practice | Tagged , , , , , | 191 Comments

Nuchal Cords: the perfect scapegoat

Updated: February 2018

To get this blog going I decided to write about a slight obsession of mine: The fear of, and routine midwifery management of nuchal cords at birth (umbilical cord around the neck). I have written and presented about this topic and have bored the pants off many a person who has made the mistake of mentioning the subject. So, despite telling my colleagues that I had put away my ‘nuchal cord’ soap box I am bringing it out to launch this blog. The content of this post is based on part of a literature review I carried out for my PhD thesis. If you are interested in finding out more you can download a journal article here, a poster here, or my full literature review in my thesis here.

Why and how babies end up wearing their cord around their neck

The presence of a nuchal cord is a very common occurrence during birth. Around a third of all babies are born with the umbilical cord around their neck (Sheiner et al. 2006). How and when it ends up there will be different for individual babies. Interestingly, it is more common with boy babies (Martin et al. 2005) – perhaps because they are more likely to have longer cords (Rogers et al. 2003). It also becomes more common with increasing gestation – I suppose there is more time to get wrapped the cord. If a nuchal cord does not occur in pregnancy it can occur during labour. As the baby moves through the pelvis he/she rotates and can spin the cord around their neck. See this post to see how rotation works.

A versatile scapegoat

The nuchal cord has become the perfect scapegoat because it lays blame with the mother/baby rather than the careprovider/system. This has resulted in fear about nuchal cords becoming embedded within our culture. Whenever I read a story about an unexpected birth outside of hospital it always seems to involve a nuchal cord. The story being about how lucky the baby was to survive the dangers of a nuchal cord away from the experts who can manage such a complication. In addition, I have heard too many birth stories where the complications were unfairly blamed on the presence of a nuchal cord.

Before I tackle some of the myths – some quick anatomy and physiology: The cord is covered in Wharton’s jelly and coiled. This protects the 3 blood vessels from the kind of stretch and compression involved in being attached to a mobile baby. The umbilical cord is also long enough (average 55cm) to be comfortably wrapped around the neck with plenty of left over length. Essentially the umbilical cord is ‘designed’ to be worn around the neck without causing a problem.

Pregnancy

Research has found that a nuchal cord is not associated with morbidity or mortality for the baby during pregnancy (Carey & Rayburn 2000; Aksoy 2003; Clapp III et al. 2003; Gonzalez-Quintero et al. 2004). Unfortunately some babies die before labour begins, and there is often no known reason, which can add to the devastation for the family. When these babies are born they are often found to have the cord around their neck (like a 3rd of all babies). Although I can understand the need to find a reason and to pick the obvious, I don’t think this is helpful in the longer term. Parents need honest answers about the loss of their baby, even if the answer is ‘we don’t know’.

Labour

During labour a nuchal cord does not cause a problem. There is no indication to undergo a c-section if a nuchal cord is identified antenatally (RCOG 2017). The baby is not ‘held up’ by the cord because the whole package – fundus (top of the uterus), placenta and cord are all moving down together. The uterus ‘shrinks’ down (contracts) moving the baby downwards, along with their attached placenta and cord. It is not until the baby’s head moves into the vagina, that a few extra centimetres of additional length are required (see ‘birth’ below).  However, when a c-section is done for ‘fetal distress’ or ‘lack of progress’ during labour, the presence of a nuchal cord is often used as the reason… “ah ha, look – your baby was stressed because the cord was around his neck” or “…the cord was stopping her from moving down”. The cord is unlikely to have had anything to do with the stress or lack of progress. Most likely other interventions carried out during labour led to the end scenario (in particular the use of syntocinon).

Birth (the last bit of labour)

The nuchal cord remains around the baby’s neck as his head moves out of the uterus and through the vagina. Usually the cord remains loose as there is lots of ‘give’ in it. A loose nuchal cord does not cause any problems (Reed et al. 2009). Blood continues to flow through the vessels just as it did during pregnancy and labour. Occasionally a cord becomes stretched and tight during this last bit of labour – as the head is born. Either there is not enough ‘give’, or the cord is trapped against the pelvis by the baby’s body. This may happen with a shorter than average cord that is wrapped around the neck a number of times. However, the baby is not ‘strangled’ because he/she is not breathing oxygen. Their oxygen is provided by the cord, not their airway. Whilst the cord is stretched and compressed the blood vessels transfer less blood (but still some). This results in short-term hypoxia (reduced oxygen supply) which resolves once the cord is loosened after birth and full blood flow resumes. These babies may arrive a little compromised but quickly recover – if the cord is left alone. Unfortunately the way in which the situation is managed (see below) can create further problems. The resulting need for resuscitation is then blamed on the nuchal cord rather than what was done to it by the care provider.

Risks associated with clamping and cutting a tight nuchal cord

Once the cord is clamped, blood flow between the baby and placenta ceases, reducing the baby’s blood volume and oxygen supply. This makes resuscitation more necessary and difficult once the baby is born. Any delay in the birth of the baby (eg. shoulder dystocia) will further increase the risk of hypoxia. While waiting to be born the baby now has NO blood supply rather than a limited one that can be re-established after birth. There have been successful malpractice actions against obstetricians in the US who cut nuchal cords prior to shoulder dystocia (Iffy et al. 2001).

One study (Sadan et al. 2007) found that neither cutting nor leaving a nuchal cord adversely affected the outcome for babies. However, they did not look at tight nuchal cords, and the cords were cut after the anterior shoulder had birthed. The damaging effects of cutting a nuchal cord are becoming commonly understood in medicine and midwifery. A policy of keeping a nuchal cord intact has been found to improve outcomes for babies (Parr et al. 2014).

For a baby with a tight nuchal cord the worst thing you can do is clamp and cut!

Risks associated with pulling and looping a loose nuchal cord

A far more common practice is pulling and looping a loose nuchal cord. Most care providers do this and I was taught to do this when I trained. However, handling the cord stimulates the umbilical arteries to vasoconstrict, reducing blood flow. Loosening the cord will usually involve some traction which can risk tearing the cord and subsequent bleeding (from the baby), or partial detachment of the placenta. As a student midwife I snapped a cord while looping it over the baby’s head. Luckily my mentor clamped the ends quickly but not before I got blood sprayed in my eyes! I later discovered that babies can be born with the cord around their neck. They either birth through the loop, or they come out with it still wrapped.

Checking for a nuchal cord

So, if you are not going to cut or loop a nuchal cord what’s the point in digging about to see if it is there? Checking for a cord interferes with the physiological process of birth. It also reinforces the notion that this is a birth complication that endangers the baby, rather than a common situation (Reed 2007). Telling the woman to stop pushing and putting your fingers into her vagina can be disempowering and painful. There are also consent issues – how many care providers gain consent before this procedure?

Suggestions

  • Talk to parents before birth about the possibility and normalcy of a nuchal cord (a third of all babies have a nuchal cord at birth)
  • During birth DO NOTHING.
  • IF the cord is preventing the baby descending once the head is born (extremely rare) use the ‘somersault technique’ (Schorn & Blanco 1991) – see below.
  • Once the baby is born, unwrap the cord (the mother/family can do this).
  • If the baby is compromised at birth encourage the parents to talk to their baby and touch him whilst the placental circulation re-establishes the normal blood volume and oxygen for the baby. If the baby requires resuscitation do it with the cord intact.

The baby in the photo at the top of this post was born at home into water. His cord was tightly around his neck twice. The midwife is in the process of unwinding the cord whilst bringing him to the surface and into his mother’s arms. He took around 30 seconds to start breathing whilst his placental circulation re-established his blood volume and oxygenated him. His father gently blew on his face and he took his first gasp – resuscitated by his placenta and his father.

Here is an amazing film of a baby with a multiple nuchal cord beautifully managed by his mother:

You can also watch a mother unwrap a nuchal cord during a water birth here.

The somersault manoeuvre 

I have only had to use this twice in hundreds of births.

There is a movie of this technique available (although also it refers to checking and looping).

Further information / resources

Posted in baby, birth, intervention, midwifery practice | Tagged , , , | 332 Comments

Vaginal examinations: a symptom of a cervical-centric birth culture

Updated: January 2019

This post is about routine vaginal examinations (VE) during physiological birth ie. an uncomplicated birth without any medical intervention. The VE is a useful assessment in some circumstances, but it’s routine use in an attempt to determine labour progress is questionable. As birth knowledge evolves, and research challenges the current cervical-centric approach to labour progress, there is an opportunity to shift practice. I’m hoping this post will inspire readers to reconsider their beliefs and practices regarding cervixes and VEs.

History: the rise of the cervix

How did we get fixated on what one small area of the body is doing during the complex and multidimensional birth process? An article by Dahlen et al. (2013) discusses the history of VEs. It seems that midwives (and others) have been performing this intervention throughout recorded history. However, for most of this time VEs were carried out in response to suspected pathology eg. an obstructed labour or an unusual presentation. The VE provided an assessment of a complication and informed the response. Midwifery text books warned against unnecessary VEs: “Too much vaginal meddling is bad too: the best thing is to wait patiently, alert to all cues” – French midwife Madame du Coudray [1563-1636] (cited in Dahlen et al. 2013).

The development of medicine was influenced by the notion that the body could be understood like a machine, with distinct parts that could be studied and understood separately. The birthing woman was ‘broken’ into physical parts – uterus, cervix, baby – and a systematic, linear understanding of progress created (McCourt 2010). This is still evident in modern textbooks. The woman has disappeared in favour of diagrams depicting her ‘parts’ (and the fetal skull) alongside precise measurements. This simplified and incorrect understanding has underpinned education about birth, and practice during birth. In the 1970s, based on this reductionist and linear approach, the partogram became established within medicalised maternity systems. The aim of the partogram was/is to measure and control labour progress by plotting cervical dilatation onto a graph, along with descent of the baby’s head. If the cervix does not open along the prescribed timeframe (1cm per hour or 0.5cm per hour depending on the hospital), labour will be augmented ie. speeded up with an ARM or synthetic oxytocin.

Now: new understandings and contradictions

In recent years, new knowledge about birth physiology and research has challenged the cervical-centric approach to labour progress assessment. A previous article/post discusses the research regarding labour patterns and partograms. In summary, the research shows that women’s labour patterns do not fit the timeframes prescribed by partograms. A Cochrane Review (2017) on the use of partograms in normal labour concluded that: “On the basis of the findings of this review, we cannot be certain of the effects of routine use of the partograph as part of standard labour management and care, or which design, if any, are most effective. Further trial evidence is required to establish the efficacy of partograph use per se and its optimum design.” The findings of a large study by Oladapo et al (2018) also challenged the accuracy of partograms concluding that: “Averaged labour curves may not truly reflect the variability associated with labour progression, and their use for decision-making in labour management should be de-emphasized.”

Partograms and VEs go hand in hand – filling out a partogram requires regular vaginal examinations to ‘plot’ along the graph. However, there is no evidence that routine VEs in labour improve outcomes for mothers or babies. A Cochrane Review (2013) concluded that: “We identified no convincing evidence to support, or reject, the use of routine vaginal examinations in labour…” (Downe et al. 2013). Another recent study (Ferrazzi et al. 2015) found that cervical dilatation during spontaneous natural labour is non-linear and unpredictable.

Without adequate evidence for the use of the partogram, or routine VEs there is increasing debate in academic circles about the way forward. Unfortunately we are so cervical-centric that the proposed solutions still involve cervical measurements, and therefore VEs. For example, Zhang et al. (2015) in their article ‘statistical aspects of modeling the labor curve’ state: “…any labor curve is illustrative and may not be instructive in managing labor because of variations in individual labor pattern and large errors in measuring cervical dilation. With the tools commonly available, it may be more productive to establish a new partogram that takes the physiology of labor and contemporary obstetric population into account.” At the ICM Conference in Prague (2014) and at the University of California it was proposed that the partogram (ie. the clock) should be started at ‘6cm dilated’ rather than the current ‘3-4cm’ to avoid unnecessary intervention.

There is also reluctance to change hospital policies, underpinned by a need to maintain cultural norms. The Cochrane review on the use of partograms on the one hand states that they cannot be recommended for use during ‘standard labour care’, and on the other hand states: “Given the fact that the partogram is currently in widespread use and generally accepted, it appears reasonable, until stronger evidence is available, that partogram use should be locally determined.” Once again, an intervention implemented without evidence requires ‘strong’ evidence before it is removed. The reality is that we are unlikely to get what is considered ‘strong evidence’ (ie. randomised controlled trials) due to research ethics and the culture of maternity systems. Guidelines for care in labour continue to advocate ‘4 hourly VEs’ and reference each other rather than any actual research to support this (NICE, Queensland Health). Interesting whilst Queensland Health guidelines recommend 4 hourly VEs, their parent information leaflet states: “While a VE can provide information about how a woman has progressed so far in labour, it cannot predict how much longer you will be in labour…”  and that there are “…other factors such as the strength, duration and length of contractions as well as a woman’s behaviour and wellbeing that can indicate progress in labour”. Which begs the question ‘why bother doing a VE’?

The cervical-centric discourse is so embedded that it is evident everywhere. Despite telling women to ‘trust themselves’ and ‘listen to their body’, midwives define women’s labours in centimetres “She’s not in labour, she’s only 2cm dilated”. We do this despite having many experiences of cervixes misleading us ie. being only 2cm and suddenly a baby appears, or being 9cm and no baby for hours. Women’s birth stories are often peppered with cervical measurements “I was 8cm by the time I got to the hospital”. Even women choosing birth outside of the mainstream maternity system are not immune to the cervical-centric discourse. Regardless of previous knowledge and beliefs, once in labour women often revert to cultural norms (Machin & Scamell 1997). Women want to know their labour is progressing and there is a deep subconscious belief that the cervix can provide the answer. Most of the VEs I have carried out in recent years have been at the insistence of labouring women – women who know that their cervix is not a good indicator of ‘where they are at’ but still need that number. One woman even said “I know it doesn’t mean anything but I want you to do it”. Of course, her cervix was still fat and obvious (I didn’t estimate dilatation)… her baby was born within an hour.

Vaginal examinations: not just a benign procedure

In order to gain consent for a VE, women need information about the lack of evidence supporting VEs, and about the potential consequences of VEs. I’ve started a list below and welcome any additions you can think of:

  • VEs are invasive and often painful: There is limited research into women’s experiences of VEs (surprise, surprise). Most women report being ‘satisfied’ with their VE experience, some find it painful, for a few VE is associated with PTSD (Dahlen et al. 2013). I’d be interested in your comments about experiences of VEs.
  • The findings can be misleading: What the cervix is doing at the moment of a VE does not indicate what the cervix is going to do in the future. Therefore, the findings cannot effectively inform decisions about pain medication or other interventions (although this is often the rationale given for performing them).
  • The measurements are subjective and inconsistent between practitioners: The accuracy between practitioners is less than 50% (Buchmann & Libhaber 2007).
  • A VE disregards the woman’s knowledge and reinforces the ‘external expert’: Often the findings do not match the woman’s experience and the result can be disempowering, for example in  early labour.
  • A VE can result in accident rupturing of the membranes: It is not uncommon to accidentally break the amniotic sac whilst carrying out a VE – this alters the birth process and increases risk for the baby.
  • VEs can increase the chance of developing an infection (Dahlen et al. 2013).

Other ways of knowing

birth4

Amanda Greavette: http://amandagreavette.com

The truth is that women’s bodies are complex, unique and immeasurable. Birth is a multidimensional experience that cannot be accurately defined by anyone outside of the experience. We – those of us who give birth and/or attend birth – know this. Midwives already assess labour based on other (less invasive) ways of knowing. In my PhD findings midwives’ birth stories were filled with descriptions of mothers’ behaviour. One participant said: “It’s like a performance… at this stage of this performance what is it saying? And… it’s not what she’s saying, it’s what she’s not saying. And it’s what she’s displaying, the way she’s moving, what her body is doing in a physiological sense.” Other studies have also described this approach to labour assessment. Dixon et al. (2014) mapped their research about the emotional journey of labour with findings from previous studies, and integrated this with physiology. Duff (2005) studied women’s behaviour during labour and created an alternative ‘partogram’ based on her findings. There are also physical changes that occur to women’s bodies during labour that can be seen and indicate labour progress (eg. the shift of the Rhombus of Michaelis and the purple line). It is not within the scope of this post to discuss these behaviours in depth (perhaps a separate post?). I am just trying to point out that the cervix is not the only indicator of labour progress. Yes, women’s behaviours are individual and may not fit any expected patterns, therefore relying on these methods may be misleading in some cases. But VE’s are also inaccurate and misleading (see above)!

Suggestions for midwives

  • Be mindful of language and how we communicate about labour to each other and women. Stop talking about centimetres and start talking about behaviours and other signs of progress.
  • During pregnancy: provide women with honest information about VE’s, their limitations and the potential consequences; and the alternatives. This should also include information about policies in their chosen birth setting, and their right to decline policy recommendations.
  • Care in labour is influenced by the setting. For example, a hospital may have a policy of ‘4 hourly VE’s’ – and as an employee you are obliged to follow policy. However, your obligation is to offer a VE, not to carry it out. To do a VE without consent is assault and battery and a breach of professional standards. If you provide the woman with adequate information (see above), and make it clear that this is an ‘offer’ based on policy (not your own needs), and that from all external signs she is progressing well… some women will decline your offer. You can document her decision and carry on having fulfilled your duty to the woman, and to the hospital.
  • If you are in a setting where VEs are not routine (eg. homebirth) and the woman asks for a VE (which they do)… try and work out what she really wants. Does she want reassurance that all is well and she is progressing, or does she really want to know what her cervix is doing. If it is the latter, encourage her to feel her own cervix. If she insists -do a VE with consent.
  • When communicating the findings of a VE include other changes – “the baby has descended, rotated, flexed” – and positives about the cervix – “it is stretchy, soft, opening up nicely”. If she needs a number, give her one, but demonstrate that this is not important to you. Do not use the findings to dictate her behaviour eg. pushing or not pushing.

Summary

Routine vaginal examinations during physiological birth are a symptom of a cervical-centric birth culture. There is enough evidence to support a shift away from this common intervention towards a more woman-centred approach to labour progress assessment. We need to value the ‘other ways of knowing’ that are already established, and reinforce the woman as the expert in her own birth experience.

Posted in birth, midwifery practice | Tagged , , | 104 Comments

Induction: a step by step guide

Updated: August 2019

This post has been inspired by conversations I’ve had with women about their experiences of induction. Induction of labour is increasingly common, yet women often seem to be very mis-informed about what it involves, or what was done to them during induction and why. For example, one woman was told by her obstetrician that induction would involve him using a pessary to ‘gently nudge her into labour.’ Women need to be given adequate information in order to make birth choices; and practitioners need to give adequate information in order to meet legal requirements. I have written about the risks of induction in a previous post so will not repeat myself here. Instead, this post aims to provide some basic information about the process of induction – what is done and why. I would really appreciate input from readers about their experiences of induction – what was done, how it felt etc. I am hoping this post will be a resource for women who are considering induction, or are unsure about what happened during their induction.

In my old 1997 version of the ‘Midwives’ Dictionary’ induction is ‘causing [labour] to occur’ ie. someone causes a labour to occur rather than allowing the baby/body to initiate labour. The dictionary goes on to say ‘this may be carried out when the life or health of the mother or fetus is in danger if the pregnancy continues.’ Of course this statement is open to interpretation and most inductions are carried out because of a variation to pregnancy (eg. postdates) rather than a complication (eg. pre-eclampsia). Regardless of the reason for induction, the process is fairly standard.

Making the decision

The decision to undergo an induction of labour is the woman’s – you can read more about roles and responsibilities in the mother-midwife (or other care provider) relationship in this post.

The National Institute of Health Care Excellence (UK) provide guidance for health professionals about what information they should share with women when offering induction:

  • The reasons for induction being offered
  • Where, when and how induction could be carried out
  • The arrangements for support and pain relief (recognising that women are likely to find induced labour more painful than spontaneous labour)
  • The alternative options if the woman chooses not to have induction of labour
  • The risks and bene fits of induction of labour in specific circumstances and the risks and bene fits of the proposed induction methods
  • That induction may not be successful and what the woman’s options would be.

There are a few things you need to be clear about before choosing to be induced:

  • That the risks involved continuing the pregnancy are greater than the risks involved in induction (risk is a very personal concept – see a quick word about risk).
  • You are committed to getting this baby out. Once you start you cannot back out, and a c-section is recommended for a ‘failed induction’.
  • You are not having a physiological birth. You have intervened and this intervention creates risks that require further monitoring and intervention. There is no ‘natural’ induced birth – vaginal birth maybe, empowering perhaps, but not physiological.

The Induction Process

There are 3 steps to the induction process. You may skip some of the steps along the way, but you should be prepared to buy into the whole package when you embark on induction.

In a physiological birth the baby and placenta signal to the mother’s body that baby is mature and ready to be born – this starts the complex cascade of physical changes that results in the labour process.

Note: If your waters have broken naturally the term ‘augmentation‘ rather than induction is used to describe getting labour started. This is because it is assumed that your body has started the labour process itself. You can read more about this situation here.

Step 1: Preparing the Cervix

During pregnancy the cervix is closed, firm and tucked into the back of your vagina. This means that you can have contractions without the cervix opening. In order for the cervix to respond to contractions it needs to make a number of complex physiological changes. Relaxin and oestrogen initiate these structural changes, and prostaglandin, leucocytes, macrophages, hyaluronic acid and glycoaminoglycans are all involved in softening the cervix ready for labour. You don’t need to remember all of this scientific stuff – all you need to know is that it is a complex process, and prostaglandins are only one piece of the puzzle. However, prostaglandins alone are the focus of the induction process. All of the interventions aimed at preparing the cervix for labour (ripening) either stimulate the body to produce prostaglandins, or introduce synthetic prostaglandins. Prostaglandins are part of the body’s inflammatory response.

Some practitioners offer a membrane sweep during pregnancy to avoid a ‘post-dates’ pregnancy. The procedure involves a vaginal examination where the practitioner places a finger into the opening of the cervix and ‘sweeps’ it around the inside of the lower part of the uterus. The aim is to separate the membranes of the amniotic sac from the lower uterus – this releases prostaglandins. A Cochrane Review into membrane sweeping concluded that: “Routine use of sweeping of membranes from 38 weeks of pregnancy onwards does not seem to produce clinically important benefits. When used as a means for induction of labour, the reduction in the use of more formal methods of induction needs to be balanced against women’s discomfort and other adverse effects.”

When you are being induced your cervix will be assessed by vaginal examination. If your cervix has already changed and is soft and open enough to get an amnihook in you can skip straight to step 2.  If your cervix is still firm and closed, attempts will be made to change it so that step 2 is possible. This is usually done by putting artificial prostaglandins (prostin E2 or cervidil) on the cervix in the form of a gel, pessary or sticky tape.  Artificial prostaglandins can cause hyperstimulation of the uterus resulting in fetal distress, therefore your baby’s heart rate will be monitored by a CTG after the prostaglandin is administered. You may also experience ‘prostin pains’ which are sharp strong pains sometimes accompanied by contractions. If there are concerns about giving you prostaglandin (eg. previous c-section) your obstetrician may suggest ways of trying to get your own cervix to release natural prostaglandin by ‘irritating it’ (this is the theory behind membrane sweeps). This is done by inserting a balloon catheter into the cervix and filling it with water ie. you basically have a water balloon sitting in your cervix.

Successfully completing step 1 may take a few attempts with re-insertion of prostaglandins. This can take hours or days because you must wait hours before re-assessment and re-insertion. You may respond to the prostaglandin by going into labour therefore skipping the following steps. However, you are still having an induced labour and will usually be treated as ‘high risk’.

Step 2: Breaking the Waters

I realise that this step is not always part of US inductions but I  have never experienced this approach, so will stick to what I know… Once your cervix has softened and is open enough to get an amnihook in, your waters will be broken. This allows induced contractions to be more effective; the baby’s head to press harder on the cervix; and may trigger contractions avoiding step 3. I was also taught that it reduces the risk of an amniotic embolism (amniotic fluid getting into the blood system) which is a rare risk associated with induction. There are risks associated with artificially breaking the waters. Once your waters have been broken you can wait a few hours to see if labour starts, or go straight to step 3.

Step 3: Making Contractions

You now have a cervix ready to respond to contractions and no amniotic water in the way – next you need contractions. In a natural physiological labour oxytocin is released from the brain and enters the blood stream – it has two main functions:

  1. It works on the uterus to regulate contractions
  2. It works in the brain to contribute to the altered state of consciousness associated with labour and promotes bonding feelings and behaviour

In an induced labour, artificial oxytocin (pitocin/syntocinon) is given via a cannula directly into the blood stream. It is unable to cross the blood brain barrier therefore only works on the uterus to regulate contractions. I have written about the risks associated with artificial oxytocin here along with references. Basically, it can be pretty nasty stuff which is why your baby will be monitored closely using a CTG. Women usually describe artificially stimulated contractions as being different and more painful than natural contractions. Having supported women during inductions I am also convinced there is more pain associated with induced contractions. During an induced labour contraction pattern and intensity increases quickly compared to most natural labours. Women are not able to slowly build up their natural endorphins and oxytocin to reduce their perception of pain. In addition the circumstances and environment that often surrounds induction (intervention, equipment, etc.) can result in anxiety, increasing the perception of pain.

Once your baby is born you will need to continue using artificial oxytocin to birth the placenta. A physiological placental birth is not safe because you are not producing your own natural oxytocin at the level required to contract the uterus strongly and prevent bleeding. Basically medicine has taken over and must finish the job.

In Summary

Inducing labour involves making your body/baby do something it is not yet ready to do. Before agreeing to be induced, be prepared for the entire package ie. all the steps. You may be lucky enough to skip one step, but once you start the induction process you are committed to doing whatever it takes to get the baby out… because by agreeing to induce you are saying that you or your baby are in danger if the pregnancy continues. An induced labour is not a physiological labour and you and your baby will be treated as ‘high risk’ – because you are.

You can read more about induction in my book Why Induction Matters

Why_Induction_Matters_-_Pinter___Martin_Publishers

Posted in birth, intervention | Tagged , , , , , , | 165 Comments

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

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

What’s the big deal?

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

The physiology of placental birth

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

Before the baby is born

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

Separation of the placenta

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

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

After separation

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

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

A mother birthing and catching her own placenta

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

Pathology – when it doesn’t work

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

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

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

Most PPHs occur after the placenta is out. PPH can and does occur after a c-section too.

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

Active management of placental birth

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

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

  • Timing of injecting syntocinon: Originally syntocinon was given with the birth of the baby’s anterior shoulder. Nowadays it seems to be given after the birth of the baby. There is no research determining the best time. Syntocinon takes around 3 mins to work when given IM (into muscle) – so in theory to mimic physiology it probably should be given soon after the baby arrives. However, there is no evidence to support early administration of syntocinon. In fact, the research suggests that giving the oxytocic before or after the birth of the placenta makes no difference to the risk of PPH (Soltani et al. 2010 – Cochrane Review).
  • Timing of clamping and cutting the cord: The risks of premature cord clamping are now well known, and a Cochrane review recommends delaying cord clamping. Most midwives I know (regardless of where they work) wait until the cord has stopped pulsing before clamping. This may have implications if the cord is not clamped before the syntocinon works. There are concerns (no research) about the impact of this bolus of syntocinon passing through the placenta to the baby and interfering with the baby’s oxytocin system. There is also a theory that the strong contraction will shunt excess blood from the placenta to baby. Some midwives wait until after the cord has stopped pulsing before giving syntocinon to avoid this. Giving the oxytocic after the birth of the placenta would eliminate the chance of either of the above concerns occurring.
  • Whether to ‘drain’ the placenta: If the cord has been prematurely clamped, some of the baby’s blood is trapped in the placenta – this makes the placenta bigger and more bulky, and in theory/experience more difficult to get out. There is no research to support this… but many midwives will leave the placenta end of the cord unclamped and drain the trapped blood prior to attempting to deliver the placenta. Personally, this is my preference as I notice it is much easer to get an empty placenta out. Something I learned while collecting cord blood. Of course it is even better if all that blood is in the baby to whom it belongs.
  • Whether or not controlled cord traction (CCT) is used and when: It is standard practice to pull the placenta out after syntocinon has been injected, and the umbilical cord has been cut. Some midwives wait until they have seen signs of placental separation before pulling (trickle of blood and lengthening of the cord). I think this part of active management causes the most problems. If you pull on a placenta that has not yet separated you can partially detach it = some blood vessels are ‘torn and open’ but the uterus cannot contract because the placenta is in the way. Or, you can detach it before the syntocinon is working i.e. no contractions to stop the bleeding. Or worse case, and very rare scenario you can pull the uterus out (inverted uterus)! You can also, more commonly snap the umbilical cord – which often freaks everyone out. But a snapped cord is not a big drama. It just means the mother will have to get up and push her placenta out… Which brings me around to the idea of not pulling at all. A study by Gülmezoglu et al. (2012) found that the ‘omission of controlled cord traction’ did not increase the risk of severe haemorrhage (they only looked at severe). And another study found that CCT made no difference to the PPH rate and concluded (Deneux-Tharaux et al. 2013). So, women should have the option of getting upright and pushing, or having someone pull their placenta out for them. Or even perhaps pulling their own placenta out?

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

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

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

The physiological vs active management of the ‘third stage’ has been going on since I was a student midwife (I did a literature review on it as an assessment). Today I am doing it the easy way and relying Cochrane to review the studies for me (Begley, et al. 2015Westhoff, Cotter & Tolosa 2013). In summary, the reviews note that there is a ‘lack of high quality evidence’ but conclude that active management reduces the risk of haemorrhage in an ‘all risk’ population birthing in hospital. They also raise concerns about side effects – increased blood pressure, afterpains and vomiting (probably due to the use of syntometrine in some studies); reduced birthweight for baby (probably due to reduced blood volume following premature clamping); more women returning to hospital with bleeding (?). In regards to the last side effect – anecdotally midwives report greater blood loss on the post natal ward after the syntocinon or syntometrine has worn off but this is not measured in studies.

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

As previously described, the baby plays an important role in assisting with the birth of the placenta.Therefore undisturbed interactions between mother and baby are important in avoiding a PPH. A recent study looked at the impact of removing babies from their mother after birth and found that: “women who did not have skin to skin and breast feeding were almost twice as likely to have a PPH compared to women…” who did have this contact with their baby (Saxton et al. 2015). The authors conclude: “…this study suggests that skin to skin contact and breastfeeding immediately after birth may be effective in reducing PPH rates for women at any level of risk of PPH.”

Back to my initial title statement

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

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

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

However, in Australia (AIHW 2014) less than a quarter of women go into spontaneous labour and continue to labour without augmentation. Out of that % how many labour without an epidural or other medication? Out of that % how many are birthing in the conditions described above? I pose the questions because these stats are not presented.

An interesting study by Nove et al. (2012) compared PPH rates between planned hospital birth vs planned homebirth. They adjusted for co-founders such as risk factors associated with PPH. The study found lower rates of PPH for women planning homebirth, even if transferred to hospital during labour or afterwards. The authors conclude: “Women and their partners should be advised that the risk of PPH is higher among births planned to take place in hospital compared to births planned to take place at home, but that further research is needed to understand (a) whether the same pattern applies to the more life-threatening categories of PPH, and (b) why hospital birth is associated with increased odds of PPH. If it is due to the way in which labour is managed in hospital, changes should be made to practices which compromise the safety of labouring women.”

Summary

Active management of the placenta will reduced the chance of a PPH in a setting that does not support physiology and in which routine intervention is the norm. There are further options within active management that can be negotiated (see above). Physiological placental birth is an option, and possible if you manage to avoid induction, augmentation, an epidural or complications – but be aware of how difficult it may be, and don’t beat yourself up if it doesn’t happen.

Further reading/resources

International Confederation of Midwives statement: Role of the midwife in physiological third stage of labour

Can I have a natural placental birth after induction? – Sara Wickham

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

Placental birth: a history – PhD thesis Stojanovic 2012

On Birth and Bleeding – Science & Sensibility

30 Minute Third Stage – Gloria Lemay

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