Birth

The issues with “active management” of the third stage

I have a few issues with this phrase and the way it is presented to women both in pregnancy and in the moments after birth. Language is incredibly important when it comes to pregnancy and birth, and for too long the negative impacts of the language used in maternity care has been ignored. I believe that “chemically induced third stage” is a more accurate term for what is currently known as an “actively managed third stage”.

The phrase “Active Management” and what it implies

Firstly, the phrase “active management” comes with some serious implications. It suggests that this is the safe, controlled way of birthing your placenta and that waiting for your body to do what it is designed to do is “unmanaged” and therefore dangerous. I went to a birth recently where the midwife described the cervix as a “vice” and told the woman that “sometimes nature just doesn’t do enough to get it out” – this kind of attitude towards women’s bodies is a huge problem in my eyes.

The importance that is put on the length of time passed since the baby was born is immense, but with very little evidence. By calling it a “chemically induced third stage” it is making it clear that this is an intervention that involves medication and is the act of forcing the placenta to be born before the body is ready to do so on its own. It seems appropriate given that it is essentially the same as chemically inducing labour – injecting a woman with an artificial “hormone” to force the uterus to contract.

 

What the body needs for a smooth birth of the placenta

The birth of the placenta needs the same basic things as the birth of the baby. A woman in labour needs to feel safe, unobserved and undisturbed – the same applies to the birth of the placenta given that it uses the same hormones.

If you ever witness an undisturbed birth, and the environment stays the same after the baby is born, you will see a smooth birth of the placenta too. It may not happen fast, but it will happen. If you witness a birth with midwives present, or people around who are looking for danger, on high alert and full of adrenaline, you will see the environment change entirely. The voices that were soft (or better still, silent) for the many hours prior are suddenly at a normal volume, asking questions and stating observations, the lights might even come on and suddenly the birth space is no longer the safe cacoon that it was before.

If midwives are present, the clock is started – they are counting down the seconds until the placenta is born, perhaps not once considering that by asking the woman questions and observing her so closely they are hindering the process. The fear is contagious, even if it is not justified. Despite there being no known “normal” length of time for the placenta to come, the 60-minute limit is applied and so the pressure begins, even though there is no evidence (nor common sense reason) that a woman’s cervix would close itself naturally before birthing the placenta. It does however make sense that this might happen if the woman has induced artificial uterine stimulation due to the use of Syntometrin.



The risk and varying definitions of post-partum haemorrhage

The common British definition of a haemorrhage is 500mls, whereas in Holland the definition is 1000mls. Whenever there is a big difference (in this instance a HUGE difference) in policies and guidance, it makes me question where they are getting their numbers from. What are they basing these thresholds on if they are so vastly different?

We know that when a woman is pregnant her blood volume increases dramatically, so whether this extra blood comes out immediately after birth, or in the weeks or months following, it is likely the same amount in total. The measurement of blood loss also doesn’t tell us much – one woman could lose a lot of blood and feel perfectly fine, another could lose a small amount and feel awful – surely the way the woman feels should determine whether medical attention is needed, not an estimated measurement.

The supposed benefits are based on very low-quality data, all of the studies were undertaken in hospital settings and according to the Cochrane Review;Although the data appeared to show that active management reduced the risk of severe primary PPH greater than 1000 mL at the time of birth, we are uncertain of this finding because of the very low-quality evidence. Active management may reduce the incidence of maternal anaemia (Hb less than 9 g/dL) following birth, but harms such as postnatal hypertension, pain and return to hospital due to bleeding were identified.”.

We know that the risk of having a PPH is significantly lower for women who plan a home birth, even if they transfer into hospital for the birth itself. So why is the same low-quality data that only applies to hospital births being implemented into standard practice at home births too?

Also, as a side note, the maternity system can’t be massively concerned about preventing PPH when they are inducing women at alarming rates, which also increases the risk of having a PPH.



The risk and definition of “retained placenta”

re·tained pla·cen·ta

incomplete separation of the placenta and its failure to be expelled at the usual time after delivery of the child.

So what is the “usual time”? The National Institute for Health and Care Excellence (NICE) recommends that; “the third stage is diagnosed as delayed if it takes longer than 30 minutes to deliver the placenta with active management or 60 minutes if allowed to deliver the placenta physiologically with maternal effort.” 

* Notice the use of the word “allowed” – this is what I’m talking about with the use of language *

However, this doesn’t even begin to encompass the wide range of normal. From listening to women’s stories who birthed with no medical staff present, their third stages lasted varying amounts of time with no ill effects. In one freebirth study published in a midwifery journal, they varied from 30 minutes to 5 hours, and some women anecdotally report going to sleep for several hours before birthing their placenta.

According to an article in ‘Best Practice & Research Clinical Obstetrics & Gynaecology’, in less developed countries, retained placenta affects about 0.1% of deliveries, whereas, in more developed countries, it happens in around 3% of vaginal deliveries. Considering the intervention rates are higher in developed countries, this leaves a lot of questions about what is causing the increase in cases of retained placenta, how they are defining “retained placenta” and whether these stats are referring to women who do not have the injection or include those who do.

There are very clear symptoms of a retained placenta that is causing an issue, but in the standard practice of midwives, they do not wait for any of these symptoms. Instead, like many of the standard practices in maternity care, they simply assume that the body is incapable of performing its natural functions and intervene too soon. 

These are the symptoms of a retained placenta;

  • Constant pain
  • Fever/high temperature
  • Passing large pieces of placental tissue
  • Heavier than expected bleeding
  • Foul-smelling vaginal discharge

* Note that having an extended period of rest between the birth of your baby and your placenta isn’t listed as a symptom, so decisions to intervene should not be based on that without any actual indications of a problem.

 

The risks of Syntometrin

Syntometrin is the injection given for an induced third stage. It is made up of oxytocin and ergometrine maleate. Women are quite often told all of the risks of doing nothing, and only the so-called benefits of having the injection and getting it “all over and done with”. From my experience, the only reason women have accepted the injection (even when they had previously declined), is due to fear and/or to stop the constant pestering. The coercion that I have witnessed during that golden time between the birth of the baby and the placenta is truly awful and eventually takes its toll.

We know that with the injection the placenta tends to come fairly quickly, but at the cost of added discomfort due to fundal pressure and cord traction (having a midwife push on your bump and pull on the cord). But there is rarely any mention of the risks and side-effects of having the injection.

In reading the information provided on Syntometrin, here is what I found on the risks:

  • Ergometrine is known to cross the placenta and its clearance from the foetus is slow. Concentrations of ergometrine achieved in foetus are not known.
  • Ergometrine derivatives are excreted in breast milk but in unknown amounts. It can also suppress lactation.
  • Ergometrine can cause vasoconstriction
  • Caution is required in patients with mild or moderate hypertension, cardiac disorder, or hepatic or renal impairment
  • Oxytocin should be considered as potentially arrhythmogenic
  • Patients should be warned of the possibility of dizziness and hypotension

Some of the reported adverse drug reactions:

  • Anaphylactic/anaphylactoid reactions associated with dyspnoea, hypotension, collapse or shock
  • Headaches
  • Dizziness
  • Myocardial infarction (heart attack)
  • Chest pain
  • Vomiting
  • Nausea
  • Abdominal pain
  • Hypertension

 

“It might just be sitting there”… So what?!

We often hear this from midwives; “It’s likely that your placenta has detached from the uterine wall and is just sitting there on your cervix”. Okay, that makes sense… so what? What is the issue?

In our work as doulas, we trust in birth, we trust in women and their intuitive wisdom. We trust that if a woman feels well, she is well, and if something isn’t right she will know what to do. Women who have had undisturbed births describe feeling contractions and then a sudden urge to move positions due to feeling uncomfortable sitting or lying down, and with this movement, they birth their placenta. These women weren’t timing their third stage or being told when and how to move – just as in their labour, they were listening to the most up-to-date information their body was giving them and acting or waiting, accordingly.

So is a placenta truly retained if it just hasn’t had enough time to come out yet? If it isn’t causing any of the obvious physical symptoms of a genuine issue, does it just need time and patience? Does the presence of someone who is timing this pause have a negative impact on the process? Why are we treating every woman as if a PPH is incredibly likely when that isn’t the case? In the same way that the “failure to progress” label is put on women whose labours aren’t following an arbitrary timeline, intervening can lead to a whole host of other issues, not least that woman feeling like her body failed when the reality is that the maternity system failed to wait.

 

 

Resources:

https://sarahbuckley.com/leaving-well-alone-a-natural-approach-to-the-third-stage-of-labour/

https://www.medicines.org.uk/emc/product/865/smpc

https://www.evidentlycochrane.net/third-stage-of-labour/

https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/1471-2393-12-130

https://www.bellybelly.com.au/birth/how-inductions-increase-the-risk-of-haemorrhage/

https://www.sciencedirect.com/science/article/abs/pii/S1521693408000965

man and women with newborn baby in the bath
Birth, Birth Story, Doulas, Uncategorized

A healing second birth – Part 2

We’re back again with the next part of this inspiring birth story. Here Jess shares her experience of the last weeks and days of her pregnancy and the beginnings of labour!

Jess with her toddler and breastfeeding her newborn babyEden’s birth story Part 2:

Every evening for over a week I’d get these annoying period type cramps. Once I even had a contraction. I’d also get these strange nerve pains that would make my legs feel numb, quite scary when I first experienced them. I’d have to do a low squat & breathe through them. Anyone witnessing me doing this as I walked around Tesco must have thought I was in labour! 🤣 In fact someone once asked me if I was okay!! All these things were uncomfortable & annoying but I took them as normal late pregnancy issues & tried to let go and enjoy our last days as a family of three.

For a few weeks I felt the need to slow down and conserve energy. We had help from family so I was able to spend time connecting with baby, resting, meditating, writing, nesting & batch cooking. Looking back I think these quiet times helped lay the foundations for the birth we were to have. Some dear friends put on a mother blessing for me & I made a birth altar in my bedroom with the affirmation art they made for me & other things I cherished.

I also met with my doulas, Greater Manchester Doulas, a few times and generally talked about how things had been. They were my true antenatal care, they listened with no agenda & made me feel valued. The main thing that kept coming up for me was not knowing the midwife who would attend my home birth. Everything I’d researched about the smoothest & safest way to birth was for the mother to be undisturbed so she can tune into her own body. So the idea of having someone there who knew nothing about me & who I’d never met before seemed bizarre and scary. I hadn’t had good experiences with my midwife team so had no faith that they would respect or even consider the importance of the energy or atmosphere they’d bring. So I decided we’d contact them late on in labour & ask them to stay in another room unless needed. I dared not tell any of the midwives this was our plan as I couldn’t face the barrage of questions and scare mongering that would have been bestowed on me so late in pregnancy. (Continued in comments)

Jess sat with her toddler breastfeeding her newbornInstead I wrote a birth plan and Ben and my doulas agreed to speak with them when the time arrived.

As the days rolled by and the baby got lower and heavier in my pelvis and the cramping and nerve pains continued, I began to get cabin fever. The day of Eden’s birth I was so grumpy and restless, like when you have an itch that you can’t quite scratch. Looking back this must have been a result of a hormonal surge in my body preparing for labour. I spent the day on my own and slept a lot. I had the urge to make a really nutritious and carb heavy lunch which is unusual as we tend to eat our main meal in the evening. The restlessness grew stronger as the day went on. I text a few friends and made a plan to meet up the next day with Luca in tow. I had no idea how I’d physically manage to wobble around a park with a toddler at nearly 42 weeks pregnant, but that feeling of needing change was intense! Later that evening Ben persuaded me to go for a walk with Luca and our dog Tilly. Walking any distance would set off the nerve pains so I wasn’t always up for them. It was a beautiful sunny evening and after our return, still feeling fed up, I decided there was only one thing for it…. a glass of wine! Well, this certainly got the baby moving! He started somersaults and pushing right down into my pelvis and generally having a dance party!! 🤣

Luca’s bedtime came round and I lay with him and fed him to sleep while Ben went to get us both food. While I lay there I began to realise the period cramps that I often experienced in the evenings were coming and going in more of a pattern than before. Not wanting to get excited I didn’t allow myself to think this could be the start. At this point in my pregnancy I was genuinely considering the idea that I might be pregnant FOREVER!! 😆 Luca went to sleep easily and we ate takeaway and chatted. Ben suggested watching TV but I didn’t fancy it. I felt an energy in me stirring, a really subtle shift of consciousnesses where half was busy somewhere else, perhaps preparing and paving the way for the journey I was about to take, while the other half was here, in the now. I knew I wouldn’t be able to concentrate on much. I was in the ‘doing’ phase of labour: also the ‘denial’ phase where it’s actually obvious things have started but you pretend to yourself it hasn’t!!

newborn baby breastfeedingWhen Ben asked how I was I told him the cramps where coming and going but not to get his hopes up as they would probably fade away. I could talk quite easily through them. It was about 9pm and the surges were probably every 20 minutes (although I wasn’t timing them and had no intention to start doing so either; I wanted to just stay in the moment). I suggested we got an early night incase things stepped up but by the time we’d sorted the dishwasher etc it was 10pm before we went upstairs. I told Ben to sleep in Luca’s room as I wanted him to get as much sleep as possible and not worry about disturbing him. At this point I was also really craving to be by myself.

To be continued…

Part 3 coming soon! In the meantime follow Jess and her wild adventures through motherhood on Instagram @these_adventures_of_ours

man and women with newborn baby in the bath
Birth, Birth Story, Doulas, Uncategorized

A healing second birth – Part 1

Our recent Wonder Woman was the lovely Jess, wild mother to Luca and Eden. We are lucky enough to be able to share her journey, from a traumatic first birth to the beautiful, healing home birth she had with her littlest one Eden.

Eden’s birth story Part 1:

During Eden’s pregnancy I knew I needed to work through many fears and unanswered questions from my first birth experience if I was going to birth in a way that felt positive and empowering this time round.

Woman with her toddler and a scan pictureI’d wanted a water birth with minimal intervention with my first born, but in the end he was pulled from me with no time for any pain relief. I lay on my back, pain like I’d never known, under bright lights with lots of people watching, I felt helpless and powerless. I tore awfully and had to leave my tiny newborn and go straight to theatre for 3 hours afterwards. Yes I know others have traumatic births and yes I did have a healthy baby, but I’m not ashamed to say it broke me. I felt horrendous. Cheated. Angry. Grief stricken. Violated. Unheard. Except I wasn’t supposed to feel this way. I was supposed to feel lucky, relieved and ecstatic that my baby was safely here and grateful to the doctors that had helped me. People told me how fortunate it was that I hadn’t had the home birth I’d been thinking about having. “Imagine if the doctors weren’t there to help”, they would say. At the time I kind of agreed with them, but I also had this niggling feeling that things could have been different somehow if someone had truly believed in me and if I had truly believed in myself, but I didn’t quite understand what that meant. My body felt like it’d been run over by a train. My mind raced with thoughts of inadequacy; I’d needed medical intervention to get pregnant (IVF) and now medical help to birth my own baby! How the hell was I now expected to trust myself to know how to mother?!

I know that some people reading this may feel triggered by what I’m saying. You may feel annoyed towards me for feeling this way because you had it worse or you wish you had the privilege of birthing a child or you feel differently – maybe you did feel completely supported by your doctors or that you’d never dream of birthing outside of hospital because you see it as a risk. Know that I respect you and I would never judge a woman by her decisions or feelings. I understand these are my own personal feelings and everyone is different. I would say that if any of my birth story does bring up a strong emotional reaction for you, that it might be worthwhile talking it through with someone. Feel free to PM me. Although I’m not trained I can signpost you in the right direction for support.

Anyway it was a long road of acceptance after Luca’s birth. Talking about it with people who understood helped so much. Also breastfeeding, being able to do something with my body to nurture him helped so much.

toddler holding a babyWhen I fell pregnant again, naturally this time, I knew I could never birth like that again. I thought about an elective c-section but it didn’t fit right. So I talked some more, I rehashed Luca’s birth again. I re-examined every part of it, including the lead up to it. More uncomfortably I looked at the responsibility I held in the events that took place. I studied undisturbed birth and accepted some truths about birth in it’s essence. I sat with lots of fears and what ifs. It took a long while to weed out what I truly needed to birth in power. In the end I came to accept my highest need was to be surrounded by those that knew me and trusted me and trusted birth as a process. I’m not sure if I ever fully voiced it out loud but I came to realise that in my current circumstances I felt most in alignment and empowered when I thought about birthing on my own,
and as it turns out that’s exactly what ended up happening!

To be continued…

Stay tuned for the next part of Jess’ amazing birth story! In the meantime you can find her on Instagram @these_adventures_of_ours.