“We don’t birth according to the science. We birth according to what we believe.
And we don’t believe the science.”
~ Mother Billie

Hospital-based birth presents some unique safety challenges. Over the years, there have been various efforts to reduce the increased risks. Some of them have been successful, such as hand washing and sanitation to reduce infections, and some of them not at all successful, such as any attempt to reduce unnecessary caesarean sections.

Postpartum haemorrhage is a complication that can happen in any birth setting, although it’s more likely in a hospital (1,2,3,4). Despite the universal application of “active management” as a prevention, the rate of haemorrhage due to uterine atony has been steadily climbing in developed nations (5,6,7,8).

“Active management of the 3rd stage”, is an intervention for the birth of the placenta, the time when women are most likely to lose a significant amount of blood. It involves injecting the mother with a uterotonic (something to make the uterus contract), usually synthetic oxytocin, as soon as the baby is born, and it may include some other steps like early cord clamping or pulling on the umbilical cord depending on the protocol used. This intervention is applied to all birthing women in all hospitals, birth centres, and homes with few exceptions.

You’d think if every mother everywhere gets this injection, then it must be a good thing. Well, that’s the thing about obstetrics. It tends to take an intervention that might be suitable for some clients in certain situations and applies it to everyone. And the results are increasingly worrisome.

To begin – what is a postpartum haemorrhage?

The general definition of postpartum haemorrhage is blood loss of 500mls in the first 24 hours following a vaginal birth, or blood loss of 1000mls following caesarean surgery. A severe postpartum haemorrhage is loss of 1000mls after a vaginal birth (or 1500mls in some locations).

The first question we need to ask is why 500mls was chosen as the threshold for defining a haemorrhage? When no uterotonics are used and postpartum blood loss is measured, the average blood loss in the first hours is actually around 500mls (9,10). Estimating blood loss by looking at it is fairly inaccurate and most observers tend to underestimate blood loss (11,12,13). This means that healthy births that look like they didn’t release much blood have actually released about 500mls in the first hours, which is technically a haemorrhage.

Since 500mls has been selected as the threshold for haemorrhage, the effectiveness of every intervention is based on its ability to reduce the average amount of blood a woman releases in the first hours after birth, because now average is considered pathological.

If we move away from pathologising average amounts of blood, then a new definition of postpartum haemorrhage might be considered. A haemorrhage could be considered as any blood loss that exceeds that mother’s physiological capacity to accommodate it without any accompanying morbidity.

For a mother with adequate iron stores and a healthy blood volume expansion, which is about 1450mls of additional circulating blood, a loss of over 500mls may present no additional challenges. In fact, most women who experience a blood loss of over 500mls receive no clinical intervention or experience any serious consequences (14,15,16). And yet, for a mother who has had a challenging pregnancy or other health concerns, with poor blood volume expansion and exhausted iron stores, a loss of much less might present difficulties and require treatment.

It’s hard to get estimates on the prevalence of postpartum haemorrhages as there are profound differences in reported outcomes from different countries, facilities, and clientele (17). This tells us there are significant differences in how blood loss is measured, the health of the clientele, and what is done to the birthing client that either improves or exacerbates bleeding. And because women are not standardised machines, there is tremendous variability between individuals.

Why does it happen?

About 80% of the time, a postpartum haemorrhage is the result of uterine atony, which is a lack of effective contractions (5,18). Without effective contractions, the blood vessels behind the placenta fail to close and blood continues to flow freely. It can also be caused by physical trauma, for example lacerations in the vagina or cervix from tearing, forceps, or an episiotomy. Uterine rupture can cause a haemorrhage, as can a placental abruption, where the placenta prematurely separates from the uterine wall. Retained placental tissue or blood clotting disorders in the mother can also cause a haemorrhage.

Active management to the rescue!

Active management only addresses uterine atony. It can’t help when the reason for the haemorrhage is physical trauma from tearing or cutting, or address a blood clotting disorder. The World Health Organisation and most medical and midwifery associations recommend giving 100% of women an injection of synthetic oxytocin just after the baby arrives as a means of preventing postpartum haemorrhage (19). Oxytocin is a naturally occurring hormone that causes the uterus to contract. It’s the primary hormone of labour. An injection of 10IU of synthetic oxytocin, either intramuscular or added to an IV, is the recommended intervention. In low resource settings where there is no synthetic oxytocin, which requires stable temperature and a skilled attendant to administer it, then an oral dose of misoprostol is recommended as a preventive.

What about that shot of synthetic oxytocin?

Synthetic oxytocin is a drug that is marketed under the brand names Pitocin, Syntocinon, and a number of lesser-known brands. It’s a clear aqueous solution that contains a chemically identical synthetic version of naturally-occurring oxytocin. Naturally-occurring oxytocin is produced in the brain by the hypothalamus and released both as a neurotransmitter across the brain facilitating feelings of love, bonding, trust, empathy, and compassion, and as a hormone through the posterior pituitary gland into the blood where it acts on smooth muscles in pulses or waves. Synthetic oxytocin is delivered through a syringe into the mother’s muscle (usually the thigh or bum) or through an IV directly into the blood stream. It does not cross the mother’s blood-brain barrier and doesn’t support bonding with the baby.

Looking at Pitocin, we see that it also contains 0.5% Chlorobutanol, a chloroform derivative as a preservative, acetic acid to adjust its pH, and may contain up to 16% of total impurities (20).

When given as an injection, the uterus responds by contracting within 3-5 minutes and lasts for 2-3 hours. When given in an IV, the uterus responds almost immediately and it lasts about an hour. It’s removed from maternal plasma through the liver and kidneys.

Just like any drug, synthetic oxytocin comes with risks, including

Anaphylactic reaction – an allergic reaction where the individual may stop breathing
Uterine hypertonicity, spasm, or tetanic contraction
Uterine rupture
Premature ventricular contractions – feels like heart palpitations or the heart is “skipping a beat”
Pelvic haematoma – a blood clot similar to a deep bruise
Hypertensive episodes – spiking blood pressure
Cardiac arrhythmia – fluctuations in heartbeat
Nausea and vomiting
Headache, loss of memory, confusion
Loss of coordination, fainting
Seizures
Subarachnoid haemorrhage – bleeding beneath the membrane that covers the brain. This can lead to stroke, seizures, brain damage, and death
Fatal afibrinogenemia – an absence of fibrinogen circulating in the blood which is needed for blood clotting. This leads to sudden and uncontrollable haemorrhage until death
Postpartum haemorrhage
Prolonged bleeding in the days and weeks after birth

“The possibility of increased blood loss and afibrinogenemia should be kept in mind when administering the drug.” ~ drugs.com

The preservative Chlorobutanol has a half-life of 10 days and is anti-diuretic, meaning it will interfere with normal elimination for up to 10 days and may contribute to increased breast engorgement. An allergic reaction can cause dermatitis, usually beginning on the face and chest. It is known to cause light headedness, ataxia (loss of coordination, speech, or eye movement), and nightmares.

Does this intervention work?

The most recent Cochrane Review (2019) (17), reveals that this recommendation is based on studies with “very low” to “moderate” level quality. According to the review, using synthetic oxytocin after the birth of the baby

May reduce the risk of blood loss of 500 mL after delivery (low-quality evidence)
May reduce the risk of blood loss of 1000 mL after delivery (low-quality evidence)
Probably reduces the need for additional uterotonics (moderate-level evidence)
May be no difference in the risk of needing a blood transfusion compared to no intervention (low-quality evidence)
May be associated with an increased risk of a third stage greater than 30 minutes (moderate-quality evidence)

An earlier Cochrane Review revealed that it reduces average blood loss by about 80mls (21). This is usually enough to bring the average blood loss below 500mls thereby avoiding a diagnosis of postpartum haemorrhage. When it comes to severe postpartum haemorrhage of over 1000mls blood loss, it only shows a marginal improvement over expectant management (watching and waiting) (17), and it doesn’t lessen the need for blood transfusion (22).

What else does this drug do?

Synthetic oxytocin dramatically increases the incidence of postpartum depression and anxiety in the first year. In women with a history of depression or anxiety, exposure to this drug increases the risk by a whopping 36%, and for women with no history of depression or anxiety, this drug increases the risk by 32% (23).

Synthetic oxytocin is also associated with greater breastfeeding failure and somatisation symptoms (pain with no known organic cause) (24).

Asking the big questions

Is reducing the average amount of blood loss by about 80mls based on an arbitrary threshold of 500mls worth the risks of this intervention? Are there safer ways to reduce the potential for haemorrhage?

Identifying the risks

There are certain factors that increase the potential for haemorrhage. The rising rates of postpartum haemorrhage have been linked to rising rates of induction and augmentation (25). More women with previous caesareans also mean more haemorrhages, possibly because there are more problems with how the placenta inserts itself in the uterus. Twins or polyhydramnios (excessive water) that overly distends the uterus, is a risk factor. As is pre-eclampsia, chorioamnionitis, and obesity (26).

As mentioned before, hospital birth is a significant risk for a haemorrhage of 1000mls or more (1,2,3,4). This isn’t surprising since hospital births include inductions, augmentations, and complicated pregnancies. However, when comparing the same low risk groups, hospital birth is still an independent risk factor. It’s also the place that is most likely to disrupt the physiology of birth with ritual and routine.

And this is where it gets even more interesting. Studies have shown that when comparing active management with physiological management, that jab of synthetic oxytocin can reduce average blood loss by about 80mls. The problem with these studies is that hospital births are not generally places where physiology is understood or supported. Meaning they might be comparing the same management except that one includes a shot and one doesn’t.

For example, early clamping of the umbilical cord became a world-wide intervention based on terrible presumption and continued in light of great research due to entrenched habit and ego. In one study, women who had a “physiological” 3rd stage had greater postpartum haemorrhages over 1000mls compared to actively managed women (27). The authors noted that the more the placenta weighed, the greater the blood loss. And, why did these placentas weigh so much? Because early clamping of the cord was the usual practice. Draining the cord to reduce the blood volume of the placenta reduces haemorrhage (28) and of course that blood belongs in the baby, not a pail on the floor.

In a study where midwives were familiar with the normal birth of the placenta and were less likely to disrupt it, active management doubled haemorrhages over 1000mls (29). In another study where the birth of the placenta was supported with “holistic” care, active management increased the risk of haemorrhage by 7-8-fold (30).

Feeding the mother and the uterus

Labour is an intense activity and requires about 1000 calories of energy per hour. Denying mothers food during labour was an attempt in the 1940’s to prevent her from vomiting under general anesthesia and then breathing in the vomit (31). We know that obstetrics is slow to change, after all, they’ve had 400 years to get women off their backs! Most women are still denied food in a hospital. No one is using the anesthesia of the 1940’s. Forced fasting doesn’t prevent vomiting (32), it only makes the mother more miserable and contributes to a longer labour (33). And longer labours are more likely to be augmented, putting the mother at risk for haemorrhage.

Perhaps a hungry uterus is one that doesn’t contract after the birth of the baby. A study that compared the usual shot of synthetic oxytocin in the mum’s bum to giving her some lovely dates to eat after the birth showed that eating dates was more effective in reducing blood loss than the injection (34). I remember discussing this with some traditional midwives who reported the same great results from giving the mother apricot nectar after the birth. Nourishing mothers is just good care.

What is this holistic care that makes birth so much safer?

Holistic care acknowledges that we are mammals and need the same conditions as any mammal giving birth. Birth is a time of reconnection where mother and baby’s interdependence moves from womb to arms. Both the mother and the baby have been waiting for this moment to gaze into each other’s eyes and to say “I know you”. Supporting this reconnection is key to ensuring the birth of the placenta unfolds safely.

And we return to oxytocin, the kind our brain produces, to ensure this reconnection is joyous and safe. Oxytocin is the hormone of love, bonding, trust, empathy, and the one that contracts the uterus and ejects the milk. Oxytocin is also the hormone of orgasms. Anything that disrupts a good orgasm is what disrupts the bonding and the expulsion of the placenta.

Oxytocin is easily encouraged, but it’s also easily disrupted.

holistic care

The room is warm, dimly lit, a sanctuary encircling the mother with love and support. She is nourished and feels safe and cared for. Her labour has begun spontaneously, no drugs, no stretch-and-sweep, and no “natural” induction. The hormones of birth are primed and mother and baby are prepared for this transition from womb to arms. Their hearts cry out for each other; their very skin crawling in anticipation of each other’s touch. The mother heeds the calls of her labour and sways, groans, rises, and pushes. The baby emerges with its protective coating of vernix and is colonised by its mother’s flora. The mother’s waiting hands draw her baby up to her chest which has already adjusted its temperature to ensure the baby is kept warm through her own bodily heat and skin-to-skin contact. The baby smells divine! Its head is releasing pheromones drawn in with each of the mother’s breaths. This baby’s scent reaches the olfactory bulb in the limbic system where the amygdala creates a permanent memory of this precious child. The hypothalamus receives the message that the newest member of our humanity is earthside and sends a gush of oxytocin to ensure bonding, preparation for breastfeeding, and a message to the uterus to contract to begin expelling the placenta. As mother and baby continue to explore each other, the placenta is released and mother feels the urge to expel it. She moves freely, adjusting, and rising to use gravity to her advantage again as it falls gently into a bowl. The bowl is placed next to her as there’s no rush to sever the connection between the baby and its placenta until baby is secure in its connection to its mother. Then she rests, with her baby nestled between her breasts, beginning its journey to her nipple to receive the long-awaited nectar. Both are wrapped in a blanket to ensure they are warm and cocooned. A cup of warm sweet tea and a snack is brought to her and she admires her courage, her strength, and her baby at her breast. Her uterus contracts as it is nourished and charged by the suckling of the baby. Her bleeding is much like a heavy period for a few days, then lessens, and is generally finished within 2-3 weeks.

usual care

The room is cool and bright, smelling of antiseptic, the shoes of exhausted nurses and midwives, and echoing the cries of others down the hall. The mother is lying on a narrow bed thrashing as the waves hit, unable to get up, run, leave. The belts are wrapped around her belly measuring each wave requiring her to limit her movement to meet their unfeeling demands. She is exposed and hungry with an IV feeding her fluids and keeping an open port in anticipation of an emergency. On her back, her waves are met with instructions to pull back her legs, bow her head, and hold her breath and push to the count of ten as the room fills with strangers, lights point at her vulva, and the appointed one sits between her legs. The resuscitation station has been warmed and primed to receive her newly born baby. The appointed one may choose to cut open her perineum. As the baby emerges, it is received by the appointed one who may also choose to separate the baby from its source of blood and oxygen through careless ritual. The mother is injected with a dangerous drug and the baby is dried. A hat is placed on the baby’s head so the glory of its scent cannot reach the mother’s limbic system to register this new life. The baby may be wrapped up, preventing the benefits of skin-to-skin, including colonising the mother’s flora, regulating its temperature, and preventing postpartum haemorrhage (35). The baby may be placed on its mother’s chest or it may go to the warming station for weighing and injecting. Once on its mother’s chest, strange hands continue to probe, measure, and instruct. In time, there is food. Her bleeding remains heavy for the first 2 weeks and tends to finish by her 6-week postpartum check-up.

But, but … the hat!

Since the placing of hat is a ritual that is often replicated at home, thereby increasing the potential for haemorrhage, let’s talk some more about it.

Newborn babies don’t regulate their body temperature with the same efficiency as adults. They need help in staying warm. However, biology is glorious and rarely needs our routines. The space between the mother’s breasts adjusts its temperature to ensure the baby is kept at the right temperature, even accommodating the different needs of twins (36). This requires skin-to-skin contact. The other regulating factor is the temperature of the room. A warm room keeps the baby warm (37).

It’s believed that because babies have large heads, they are more likely to lose heat through their heads, so putting a hat on it will keep the baby warm. Only it doesn’t. Stockinette hats don’t affect the core temperature of the baby (38,39). Thermal hats do, and they’re an important part of caring for and transporting a vulnerable premature baby. The only thing knitted hats do is prevent the mother from breathing in the baby’s scent and releasing more oxytocin in response. It’s a foolish ritual.

The elements of holistic care:

Wait for spontaneous labour where possible
Freedom of movement throughout labour to avoid a long labour and augmentation
Nourish the mother with food and drink according to her preference
Warmth and privacy
Spontaneous pushing in the mother’s preferred position
No clamping or cutting of the cord until the placenta is birthed
Immediate skin-to-skin
No hat on the baby
Quiet, private, and supported time between mother and baby
Placenta is birthed by maternal effort aided by gravity
Nourishment for the mother soon after the birth
Ongoing comfort, warmth, and autonomy for the mother

Conclusion

Active management appears to be a dubious and somewhat dangerous intervention that was introduced to overcome obstetrics’ lack of understanding of physiology and their pathological need to disrupt it.

When birth is supported with holistic care, it’s up to 7-8 times safer than routine hospital care with the routine jab. Preventing postpartum haemorrhage comes down to understanding and respecting the physiology of birth, the intense need that mothers and babies have for one another, and not getting in the way. And if there’s a problem, then it requires prompt treatment, but not before to cause the problem.

Much love,

Mother Billie

Endnotes

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