Beyond the Shot: Preventing Postpartum Haemorrhage ~ Wisdom from a Traditional Birth Companion
Postpartum haemorrhage is a complication that can happen in any birth setting, although it’s more likely in a hospital. 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.
“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.
© Billie Harrigan Consulting
“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.
REX/Shutterstock
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.
Early cord clamping - Getty Images
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.
© Billie Harrigan Consulting
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.
BSIP/Getty Images
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.
Image by Engin Akyurt from Pixabay
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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Prichard, J. A., Baldwin, R. M., Dickey, J. C., & Wiggins, K. M. (1962). Blood volume changes in pregnancy and the puerperium. Am J Obstet Gynecol, 84, 1271-1282.
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Drugs.com. Retrieved from https://www.drugs.com/pro/pitocin.html April 10, 2020.
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Kroll‐Desrosiers, A. R., Nephew, B. C., Babb, J. A., Guilarte‐Walker, Y., Moore Simas, T. A., & Deligiannidis, K. M. (2017). Association of peripartum synthetic oxytocin administration and depressive and anxiety disorders within the first postpartum year. Depression and anxiety, 34(2), 137-146.
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The Art of Palpation ~ Wisdom from a Traditional Birth Companion
Palpation is the act of using one’s hands to figure out something on or in a body. In maternity services, the practitioner routinely palpates the pregnant belly to assess the position and size of the foetus.
After the male midwife, which later became the obstetrician, infiltrated birth services and paternalized it into a male-centric, provider-centric practice, they’ve been “discovering” all kinds of things that were just normally known and carried out by midwives for centuries. Among them is the standard way to palpate a pregnant belly.
I tend to see palpation through a different lens. I feel it’s more about building a relationship with the baby than anything else.
Nana playing with/palpating her granddaughter before she was born. ©Billie Harrigan Consulting
Palpation is the act of using one’s hands to figure out something on or in a body. In maternity services, the practitioner routinely palpates the pregnant belly to assess the position and size of the foetus.
After the male midwife, which later became the obstetrician, infiltrated birth services and paternalized it into a male-centric, provider-centric practice, they’ve been “discovering” all kinds of things that were just normally known and carried out by midwives for centuries. Among them is the standard way to palpate a pregnant belly.
German obstetrician-gynaecologist Christian Gerhard Leopold (1846-1911) is credited with the obstetrical manoeuvre used today to palpate pregnant bellies called ‘Leopold’s Manoeuvre’.
Leopold’s Manoeuvre is a series of 4 specific actions. These 4 actions, along with an assessment of the maternal pelvic shape will help the practitioner to determine if complications will occur during delivery and whether a caesarean should be recommended. They think of it much like a crystal ball that somehow predicts the future. In the provider-centric world of maternity services, it’s another way the practitioner replaces the pregnant mother as the expert on her body and her birth and minimises the power of the birth dance where the mother and baby work together through movement to bring the baby earthside.
Manoeuvre one: Fundal Grip
The practitioner walks their hands up the sides of the uterus to the top of the uterus, called the ‘fundus’. Palpating the upper abdomen will determine if the foetus is lying longitudinal (up/down), oblique (on an angle), or transverse (side-to-side). If the baby is longitudinal, palpating the upper abdomen should determine if it’s a bum or a head.
Manoeuvre two: Umbilical Grip
Next is to determine where the foetal back is lying. By placing hands on either side of the mid-abdomen, the practitioner applies deep pressure on alternating sides to determine where the back is and where the extremities are (arms and legs).
Leopold’s Manoeuvres - public domain
Manoeuvre three: Pawlick’s Grip
This is also named after a male obstetrician-gynaecologist, Karel Pawlick (1849-1914). This step determines how much of the foetus is above the pelvic inlet. The practitioner uses their fingers and thumb to grasp the lower abdomen, just above the pubic bone (pubic symphysis) to feel how much of the foetus can be felt above the pubic bone.
Manoeuvre four: Pelvic Grip
The practitioner faces the patient’s feet and tries to locate the foetus’ brow by placing both hands on the lower abdomen and moving the fingers of both hands towards the pubis by sliding the hands over the sides of the patient’s uterus. On the side where there is the greatest resistance to the practitioner’s descending fingers is the baby’s brow. A well-flexed head, meaning the chin is tucked down towards the chest, will be on the opposite side of the foetal back. If the head is extended, that is, looking straight ahead or upwards, the back of the head is felt on the same side where the back was found. If the brow cannot be found, the head is descended into the pelvis.
With the routine overuse of ultrasound, many practitioners are losing the art of palpation. Routine multiple ultrasounds are now taking the place of non-invasive and non-risky palpation to assess foetal size (with varying degrees of accuracy), amniotic fluid volume (with varying degrees of accuracy), and position of the baby (with a great deal of accuracy). It could be that since ultrasound is very accurate at determining position, practitioners are losing confidence in their own skills.
As a Traditional Birth Attendant, I like palpating pregnant bellies. I especially like it as a grandmother (Nana). Nothing delights me more than playing with my own grandchildren inside their mother’s bellies. In fact, Nana has turned her own grandchild from breech to cephalic. It’s a simple skill that tends to make me a more useful grandmother.
In all the texts I scoured that discusses how to do Leopold’s Manoeuvre, not once was the foetus ever considered as a sentient member of the procedure. The mother’s comfort is often considered, but primarily, it’s about the practitioner doing something to the client to gather information.
I tend to see palpation through a different lens. I feel it’s more about building a relationship with the baby than anything else. After all, if I’m going to be invited to the birth, the baby should know who I am and whether I am someone they can trust to care for their mummy and therefore take care of them.
In my relationship with pregnant families, the first part of palpating a pregnant belly is to ask the mother if she would like this. She doesn’t have to submit to this. This is her choice. I’ve had clients with a history of sexual assault where this was a very threatening idea that someone would be touching their belly and never wanted it. Instead, they just told us where the baby was and what their guess was on how big the baby was. As it turns out, maternal guessing is pretty accurate and often beats the guesses of ultrasounds or experienced practitioners (1). Another client liked palpation, but could only do it sitting up with one hand over her breasts and one protecting her groin.
If the mother agrees to palpation, then I always suggest she go relieve her bladder first. There’s nothing worse than someone playing with your belly and a full bladder. It’s a recipe for leaking out a wee drip or a pent-up fart.
I have a nice couch by a sunny window that clients are invited to lie down on with as many pillows behind them as feels comfortable. I tend to sit on the couch with them nestled beside their legs.
Now here comes the most important part of palpation:
I introduce myself to the baby.
I say hello to the baby. I tell them my name and that I’m a friend of their mummy and daddy. I let them know that Nana often has cold hands.
I start very gently and talk to the baby the whole time. There are no pre-determined set of manoeuvres as this is usually led by the baby. I may find their little bum and squeal with delight! I talk about how much they’re growing. I invite them to play with me. Sometimes their little foot will poke out to start a little game with me. I’ll ask them to show me what position they’re in and if they’d be ok with us listening to their heartbeat with a fetoscope. If my hands are going to go lower on the mother’s abdomen to where a head might be nestled, I always ask permission from the mother before touching her anywhere close to her pubic bone. Likewise, if the parents want a measurement of fundal height, it’s the mother that places the end of the measuring tape on the top of her pubic bone. There’s no need for someone else to be rooting around down there. Once mum picks her spot where the tape measure starts, then that also helps to eliminate measuring errors that can come with multiple people measuring her belly and placing the tape differently.
Some babies become quite playful. And some will lie quietly, listening to me, deciding if I am friend or foe. It becomes quite easy to sense the baby’s receptivity. A baby who has taken a journey along with their mother through previous obstetric mistreatment or disrespectful prenatal visits will often lie quietly, perhaps taking in their mother’s reactions. It may take another visit to warm up to me and become more playful. I tell them that by the time they arrive, I hope we’ll be good friends.
Through gentle palpation, the baby and I are getting to know each other. The parents and I are building trust. We’re having fun! And through gentle touch, we discover where the baby is positioned at that particular moment. It’s not predictive of much else. Even persistently breech babies have turned in labour when I’ve been present. Perhaps in the presence of calm and loving family and birth attendant, the babies felt it a simple matter to rotate and come out head first.
Through gentle palpation, we can also get a sense for how much amniotic fluid is in the womb. It’s a chance to talk about hydration and salt. Parents are invited to listen to their baby’s heartbeat with a fetoscope, and depending on the position of the placenta, they may be treated to the sounds of its ‘whooshing’ as blood flows through the maternal side.
A fetoscope is non-invasive and listens to the baby’s heartbeat and the placenta
Through gentle palpation, we can invite the baby to adjust their position to make it easier on mummy. Perhaps a poking foot is feeling like it’s about to break mummy’s rib. Or little one hasn’t started the descent down into the pelvis as it gets closer to term. Having a simple conversation with the little one and explaining how they can help has shown over and over that these precious babies are sentient and love their mothers and want to participate in a loving and safe arrival.
And to conclude the palpation, I thank the baby for allowing me to play with them.
This gentle approach has brought many mothers to tears. For many of them, it’s the first time their body and their baby have been treated with reverence. In fact, I too, have often been brought to tears by the enthusiastic response of these precious babies who quickly understand that I care deeply about them.
Modern maternity services are decidedly centred around the practitioner. The manoeuvres designed to gather information help the practitioner to determine a course of action that lessens the potential for an obstetrically-determined negative outcome. However, truly client-centred and family-centred maternity care includes the baby as a fully sentient member of the family who deserves as much care, caution, respect, and dignity as every other member of the family. And that’s where we see some of the best outcomes!
Much love,
Mother Billie
©Billie Harrigan Consulting
Endnote
1. Ashrafganjooei, T., Naderi, T., Eshrati, B., & Babapoor, N. (2010). Accuracy of ultrasound, clinical and maternal estimates of birth weight in term women. EMHJ-Eastern Mediterranean Health Journal, 16 (3), 313-317, 2010.
The Art of Palpation ~ Wisdom from a Traditional Birth Companion
Palpation is the act of using one’s hands to figure out something on or in a body. In maternity services, the practitioner routinely palpates the pregnant belly to assess the position and size of the foetus.
After the male midwife, which later became the obstetrician, infiltrated birth services and paternalized it into a male-centric, provider-centric practice, they’ve been “discovering” all kinds of things that were just normally known and carried out by midwives for centuries. Among them is the standard way to palpate a pregnant belly.
I tend to see palpation through a different lens. I feel it’s more about building a relationship with the baby than anything else.
Nana playing with/palpating her granddaughter before she was born. ©Billie Harrigan Consulting
Palpation is the act of using one’s hands to figure out something on or in a body. In maternity services, the practitioner routinely palpates the pregnant belly to assess the position and size of the foetus.
After the male midwife, which later became the obstetrician, infiltrated birth services and paternalized it into a male-centric, provider-centric practice, they’ve been “discovering” all kinds of things that were just normally known and carried out by midwives for centuries. Among them is the standard way to palpate a pregnant belly.
German obstetrician-gynaecologist Christian Gerhard Leopold (1846-1911) is credited with the obstetrical manoeuvre used today to palpate pregnant bellies called ‘Leopold’s Manoeuvre’.
Leopold’s Manoeuvre is a series of 4 specific actions. These 4 actions, along with an assessment of the maternal pelvic shape will help the practitioner to determine if complications will occur during delivery and whether a caesarean should be recommended. They think of it much like a crystal ball that somehow predicts the future. In the provider-centric world of maternity services, it’s another way the practitioner replaces the pregnant mother as the expert on her body and her birth and minimises the power of the birth dance where the mother and baby work together through movement to bring the baby earthside.
Manoeuvre one: Fundal Grip
The practitioner walks their hands up the sides of the uterus to the top of the uterus, called the ‘fundus’. Palpating the upper abdomen will determine if the foetus is lying longitudinal (up/down), oblique (on an angle), or transverse (side-to-side). If the baby is longitudinal, palpating the upper abdomen should determine if it’s a bum or a head.
Manoeuvre two: Umbilical Grip
Next is to determine where the foetal back is lying. By placing hands on either side of the mid-abdomen, the practitioner applies deep pressure on alternating sides to determine where the back is and where the extremities are (arms and legs).
Leopold’s Manoeuvres - public domain
Manoeuvre three: Pawlick’s Grip
This is also named after a male obstetrician-gynaecologist, Karel Pawlick (1849-1914). This step determines how much of the foetus is above the pelvic inlet. The practitioner uses their fingers and thumb to grasp the lower abdomen, just above the pubic bone (pubic symphysis) to feel how much of the foetus can be felt above the pubic bone.
Manoeuvre four: Pelvic Grip
The practitioner faces the patient’s feet and tries to locate the foetus’ brow by placing both hands on the lower abdomen and moving the fingers of both hands towards the pubis by sliding the hands over the sides of the patient’s uterus. On the side where there is the greatest resistance to the practitioner’s descending fingers is the baby’s brow. A well-flexed head, meaning the chin is tucked down towards the chest, will be on the opposite side of the foetal back. If the head is extended, that is, looking straight ahead or upwards, the back of the head is felt on the same side where the back was found. If the brow cannot be found, the head is descended into the pelvis.
With the routine overuse of ultrasound, many practitioners are losing the art of palpation. Routine multiple ultrasounds are now taking the place of non-invasive and non-risky palpation to assess foetal size (with varying degrees of accuracy), amniotic fluid volume (with varying degrees of accuracy), and position of the baby (with a great deal of accuracy). It could be that since ultrasound is very accurate at determining position, practitioners are losing confidence in their own skills.
As a Traditional Birth Attendant, I like palpating pregnant bellies. I especially like it as a grandmother (Nana). Nothing delights me more than playing with my own grandchildren inside their mother’s bellies. In fact, Nana has turned her own grandchild from breech to cephalic. It’s a simple skill that tends to make me a more useful grandmother.
In all the texts I scoured that discusses how to do Leopold’s Manoeuvre, not once was the foetus ever considered as a sentient member of the procedure. The mother’s comfort is often considered, but primarily, it’s about the practitioner doing something to the client to gather information.
I tend to see palpation through a different lens. I feel it’s more about building a relationship with the baby than anything else. After all, if I’m going to be invited to the birth, the baby should know who I am and whether I am someone they can trust to care for their mummy and therefore take care of them.
In my relationship with pregnant families, the first part of palpating a pregnant belly is to ask the mother if she would like this. She doesn’t have to submit to this. This is her choice. I’ve had clients with a history of sexual assault where this was a very threatening idea that someone would be touching their belly and never wanted it. Instead, they just told us where the baby was and what their guess was on how big the baby was. As it turns out, maternal guessing is pretty accurate and often beats the guesses of ultrasounds or experienced practitioners (1). Another client liked palpation, but could only do it sitting up with one hand over her breasts and one protecting her groin.
If the mother agrees to palpation, then I always suggest she go relieve her bladder first. There’s nothing worse than someone playing with your belly and a full bladder. It’s a recipe for leaking out a wee drip or a pent-up fart.
I have a nice couch by a sunny window that clients are invited to lie down on with as many pillows behind them as feels comfortable. I tend to sit on the couch with them nestled beside their legs.
Now here comes the most important part of palpation:
I introduce myself to the baby.
I say hello to the baby. I tell them my name and that I’m a friend of their mummy and daddy. I let them know that Nana often has cold hands.
I start very gently and talk to the baby the whole time. There are no pre-determined set of manoeuvres as this is usually led by the baby. I may find their little bum and squeal with delight! I talk about how much they’re growing. I invite them to play with me. Sometimes their little foot will poke out to start a little game with me. I’ll ask them to show me what position they’re in and if they’d be ok with us listening to their heartbeat with a fetoscope. If my hands are going to go lower on the mother’s abdomen to where a head might be nestled, I always ask permission from the mother before touching her anywhere close to her pubic bone. Likewise, if the parents want a measurement of fundal height, it’s the mother that places the end of the measuring tape on the top of her pubic bone. There’s no need for someone else to be rooting around down there. Once mum picks her spot where the tape measure starts, then that also helps to eliminate measuring errors that can come with multiple people measuring her belly and placing the tape differently.
Some babies become quite playful. And some will lie quietly, listening to me, deciding if I am friend or foe. It becomes quite easy to sense the baby’s receptivity. A baby who has taken a journey along with their mother through previous obstetric mistreatment or disrespectful prenatal visits will often lie quietly, perhaps taking in their mother’s reactions. It may take another visit to warm up to me and become more playful. I tell them that by the time they arrive, I hope we’ll be good friends.
Through gentle palpation, the baby and I are getting to know each other. The parents and I are building trust. We’re having fun! And through gentle touch, we discover where the baby is positioned at that particular moment. It’s not predictive of much else. Even persistently breech babies have turned in labour when I’ve been present. Perhaps in the presence of calm and loving family and birth attendant, the babies felt it a simple matter to rotate and come out head first.
Through gentle palpation, we can also get a sense for how much amniotic fluid is in the womb. It’s a chance to talk about hydration and salt. Parents are invited to listen to their baby’s heartbeat with a fetoscope, and depending on the position of the placenta, they may be treated to the sounds of its ‘whooshing’ as blood flows through the maternal side.
A fetoscope is non-invasive and listens to the baby’s heartbeat and the placenta
Through gentle palpation, we can invite the baby to adjust their position to make it easier on mummy. Perhaps a poking foot is feeling like it’s about to break mummy’s rib. Or little one hasn’t started the descent down into the pelvis as it gets closer to term. Having a simple conversation with the little one and explaining how they can help has shown over and over that these precious babies are sentient and love their mothers and want to participate in a loving and safe arrival.
And to conclude the palpation, I thank the baby for allowing me to play with them.
This gentle approach has brought many mothers to tears. For many of them, it’s the first time their body and their baby have been treated with reverence. In fact, I too, have often been brought to tears by the enthusiastic response of these precious babies who quickly understand that I care deeply about them.
Modern maternity services are decidedly centred around the practitioner. The manoeuvres designed to gather information help the practitioner to determine a course of action that lessens the potential for an obstetrically-determined negative outcome. However, truly client-centred and family-centred maternity care includes the baby as a fully sentient member of the family who deserves as much care, caution, respect, and dignity as every other member of the family. And that’s where we see some of the best outcomes!
Much love,
Mother Billie
©Billie Harrigan Consulting
Endnote
1. Ashrafganjooei, T., Naderi, T., Eshrati, B., & Babapoor, N. (2010). Accuracy of ultrasound, clinical and maternal estimates of birth weight in term women. EMHJ-Eastern Mediterranean Health Journal, 16 (3), 313-317, 2010.
Beyond the Shot: Preventing Postpartum Haemorrhage ~ Wisdom from a Traditional Birth Companion
Postpartum haemorrhage is a complication that can happen in any birth setting, although it’s more likely in a hospital. 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.
“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.
© Billie Harrigan Consulting
“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.
REX/Shutterstock
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.
Early cord clamping - Getty Images
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.
© Billie Harrigan Consulting
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.
BSIP/Getty Images
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.
Image by Engin Akyurt from Pixabay
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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Hutton, E. K., Cappelletti, A., Reitsma, A. H., Simioni, J., Horne, J., McGregor, C., & Ahmed, R. J. (2016). Outcomes associated with planned place of birth among women with low-risk pregnancies. Cmaj, 188(5), E80-E90.
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Nordström, L., Fogelstam, K., Fridman, G., Larsson, A., & Rydhstroem, H. (1997). Routine oxytocin in the third stage of labour: a placebo controlled randomised trial. BJOG: An International Journal of Obstetrics & Gynaecology, 104(7), 781-786.
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Prichard, J. A., Baldwin, R. M., Dickey, J. C., & Wiggins, K. M. (1962). Blood volume changes in pregnancy and the puerperium. Am J Obstet Gynecol, 84, 1271-1282.
Bloomfield, T. H., & Gordon, H. (1990). Reaction to blood loss at delivery. Journal of Obstetrics and Gynaecology, 10(sup2), S13-S16.
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Carroli, G., Cuesta, C., Abalos, E., & Gulmezoglu, A. M. (2008). Epidemiology of postpartum haemorrhage: a systematic review. Best practice & research Clinical obstetrics & gynaecology, 22(6), 999-1012.
Selo-Ojeme, D. O. (2002). Primary postpartum haemorrhage. Journal of Obstetrics and Gynaecology, 22(5), 463-469.
Prendiville, W. J., Harding, J. E., Elbourne, D. R., & Stirrat, G. M. (1988). The Bristol third stage trial: active versus physiological management of third stage of labour. Bmj, 297(6659), 1295-1300.
Salati, J. A., Leathersich, S. J., Williams, M. J., Cuthbert, A., & Tolosa, J. E. (2019). Prophylactic oxytocin for the third stage of labour to prevent postpartum haemorrhage. Cochrane Database of Systematic Reviews, (4).
Bateman, B. T., Berman, M. F., Riley, L. E., & Leffert, L. R. (2010). The epidemiology of postpartum hemorrhage in a large, nationwide sample of deliveries. Anesthesia & Analgesia, 110(5), 1368-1373.
World Health Organization. (2012). WHO recommendations for the prevention and treatment of postpartum haemorrhage. World Health Organization.
Drugs.com. Retrieved from https://www.drugs.com/pro/pitocin.html April 10, 2020.
Prendiville, W. J., Elbourne, D., & McDonald, S. J. (2000). Active versus expectant management in the third stage of labour. Cochrane database of systematic reviews, (3).
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Kroll‐Desrosiers, A. R., Nephew, B. C., Babb, J. A., Guilarte‐Walker, Y., Moore Simas, T. A., & Deligiannidis, K. M. (2017). Association of peripartum synthetic oxytocin administration and depressive and anxiety disorders within the first postpartum year. Depression and anxiety, 34(2), 137-146.
Gu, V., Feeley, N., Gold, I., Hayton, B., Robins, S., Mackinnon, A., Samuel, S., Carter, C.S. & Zelkowitz, P. (2016). Intrapartum synthetic oxytocin and its effects on maternal well‐being at 2 months postpartum. Birth, 43(1), 28-35.
Kramer, M. S., Dahhou, M., Vallerand, D., Liston, R., & Joseph, K. S. (2011). Risk factors for postpartum hemorrhage: can we explain the recent temporal increase?. Journal of Obstetrics and Gynaecology Canada, 33(8), 810-819.
Wetta, L. A., Szychowski, J. M., Seals, S., Mancuso, M. S., Biggio, J. R., & Tita, A. T. (2013). Risk factors for uterine atony/postpartum hemorrhage requiring treatment after vaginal delivery. American journal of obstetrics and gynecology, 209(1), 51-e1.
Jangsten, E., Mattsson, L. Å., Lyckestam, I., Hellström, A. L., & Berg, M. (2011). A comparison of active management and expectant management of the third stage of labour: a Swedish randomised controlled trial. BJOG: An International Journal of Obstetrics & Gynaecology, 118(3), 362-369.
Mohamed, A., Bayoumy, H. A., Abou-Gamrah, A. A. S., & El-Shahawy, A. A. S. (2017). Placental cord drainage versus no placental drainage in the management of third stage of labour: Randomized controlled trial. The Egyptian Journal of Hospital Medicine, 68(1), 1042-1048.
Davis, D., Baddock, S., Pairman, S., Hunter, M., Benn, C., Anderson, J., Dixon, L. & Herbison, P. (2016). Risk of severe postpartum hemorrhage in low-risk childbearing women in new zealand: exploring the effect of place of birth and comparing third stage management of labor-Birth (Berkeley, Calif.)-Vol. 39, 2-ISBN: 1523-536X-p. 98-105.
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Mendelson, C. L. (1946). The aspiration of stomach contents into the lungs during obstetric anesthesia. Obstetrical & Gynecological Survey, 1(6), 837-839.
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When not to induce – reason #408 – a placenta with calcium deposits
I received yet another phone call from someone who was trying to sort out the risks of staying pregnant versus the risks of being induced. From what the client could share, it was hard to know if the practitioner wasn’t fully informed on placental calcification at term, or wasn’t fully forthcoming about the non-clinical indications of that particular development in a healthy pregnancy.
To be sure, there are times when the benefits of an induction to rescue a compromised baby far outweigh the short and long-term risks of an induction.
Unfortunately, when trying to make an informed decision, clients often need to learn what their practitioners don’t know or won’t tell them.
“I’m 3 days overdue and my midwife says I need to be induced because my placenta is calcifying and that means it’s dying.”
I received yet another phone call from someone who was trying to sort out the risks of staying pregnant versus the risks of being induced. From what the client could share, it was hard to know if the practitioner wasn’t fully informed on placental calcification at term, or wasn’t fully forthcoming about the non-clinical indications of that particular development in a healthy pregnancy.
To be sure, there are times when the benefits of an induction to rescue a compromised baby far outweigh the short and long-term risks of an induction.
Unfortunately, when trying to make an informed decision, clients often need to learn what their practitioners don’t know or won’t tell them. So let’s take a little tour of the placenta.
© Billie Harrigan Consulting
To begin, the placenta is a fetal organ, meaning it is made from the same sperm and egg that makes the baby. As the baby grows and ages, so does the placenta. Both the baby and the placenta (which comes from the same genetic material) need to reach a certain level of maturity in order to be born healthy. The placenta does not suddenly expire when the pregnancy reaches an arbitrary number of weeks.
When the placenta is not well, the baby is usually not well. When the baby is well, then the placenta is usually well. Sometimes, there are variations in the placenta that are more common in babies at risk and they might also be present in a healthy baby. So not all variations mean something is wrong every time.
The placenta is a marvellous organ that has a maternal side that attaches to the wall of the mother’s uterus, and a fetal side where the umbilical cord arises to transport blood back and forth from the fetus to the placenta.
The umbilical cord usually has 2 arteries (going away from the baby’s heart towards the placenta) and one vein (returning back to the baby’s heart). So while blood that is full of oxygen is usually flowing through our arteries, in the case of the umbilical arteries, it’s going away from the baby to the placenta with waste and then the umbilical vein returns to the heart with oxygen and nutrients that are supplied by the placenta. The surrounding Wharton’s Jelly protects these important vessels inside the cord.
The mother’s blood and the baby’s blood don’t intermingle thanks to the wisdom of the placenta and the uterus working together. However, the baby gets all it’s nutrients from the mother’s blood stream and counts on mum to clean the waste the baby produces. Thanks to something called trophoblasts, which extend from the placenta into an area of the uterus where mum’s blood flows freely, oxygen and carbon dioxide and various nutrients and wastes are exchanged between mum and baby without baby’s blood and mum’s blood touching each other.
Khan Academy – meet the placenta
Due to the wonders of ultrasound, we’re now taking a look at things that were once hidden. And since we love to organise what we see and give things names, the placenta has been given names to indicate where it is in its development, as seen through ultrasounds:
Grade 0: less than 18 weeks gestation
Grade I: 18-29 weeks gestation
Grade II: 30-38 weeks gestation
Grade III: 39 weeks until birth
Each of these “grades” has specific features that help the technician to “date” the placenta.
One of the features of a Grade III placenta is that it often shows circular indentations that have calcium deposits (calcification). This is considered to be a natural part of the aging process in much the same way that our skin develops wrinkles as we age. And just as wrinkles in the skin of a person of any age doesn’t mean that this person is at risk of imminent death, neither does the appearance of calcification in a normal placenta at term mean that it’s about to expire (Harris & Alexander, 2000; Jamal et al., 2017; Nolan, 1998).
So where did this idea come from that calcification on a placenta meant it was dying?
This notion has come from the observation and study of preterm births of compromised fetuses. A compromised fetus that is born early often has a “grade III” placenta with significant calcification.
Image source: http://www.fetalultrasound.com/online/text/3-065.HTM
So while calcification of a placenta at term – around 39-42 weeks is part of the normal appearance of a full-term placenta and has no clinical significance in a healthy pregnancy, the appearance of significant calcification earlier in pregnancy is associated with risks to both the mother and baby. Just like we would be concerned about a very young person with wrinkles – it could be a sign of something significant happening.
Although, most every study has shown that calcification at term is normal and doesn’t mean anything in terms of negative outcomes for mum or baby, over the years, there has been conflicting evidence that early calcification was or wasn’t associated with poorer outcomes. That was because there were too many variables. In some studies, the mothers were smokers, which is associated with more calcification and more preterm births. In other studies, the mothers had hypertension, which can affect the health of the placenta and the baby. The studies were making comparisons on different ultrasound machines with interpretation by different technicians.
In a study of over 1000 pregnancies that controlled for these variables (Chen, Chen, & Lee, 2011), the participants agreed to frequent ultrasounds to monitor the development and progression of their baby’s placenta. The results indicated that when the placenta prematurely developed into a “grade III” with calcification prior to 32 weeks gestation, then,
The mother experienced increased
placental abruption
postpartum haemorrhage
transfer to the ICU
The baby experienced increased
preterm birth
low birth weight
low Apgar scores at 5 minutes (below 7)
neonatal death
However, if the placenta graduated to a “grade III” with calcification after 32 weeks gestation, then there were no increases in adverse outcomes. This was true whether the mother had other risk factors such as diabetes, hypertension, or smoking (Chen, Chen, & Lee, 2012).
Infarcts
Now let’s talk about those signs of “calcification” after the baby is born. Some placentas arrive with granular bumps across the maternal side and some parents are told that it’s a sign that the placenta was aging and starting to lose function. However, that’s not true for healthy full-term pregnancies.
Those granular bumps are not calcium deposits, but rather infarcts, deposits of fibrin, which are bits of scar tissue that have formed over dead cells through the process of infarction. Fibrin appears as small yellowish-white deposits that are the result of interference in the blood supply to the placenta.
Image source: http://wonderfullymadebelliesandbabies.blogspot.com/2012/11/variations-placentas-and-cords.html
Small placental infarctions (bumps of fibrin) are common in healthy full-term pregnancies and have no clinical significance. Only when there’s extensive infarction, meaning 10% or more of the placenta has died and been replaced by scar tissue is there an association with fetal growth restriction, fetal hypoxia, and fetal death, particularly if the infarctions occurred in the second and early third trimester (Mousa & Alfirevic1, 2000).
Infarcts can form at any point in the pregnancy and are associated with (Becroft, Thompson, & Mitchell, 2002; Naeye, 1977; Vinnars, Nasiell, Ghazi, Westgren, & Papadogiannakis, 2011):
maternal hyptertension
smoking
haemoglobin above 120, indicating poor blood volume expansion
maternal under-nutrition
So, in essence, when a mother is healthy and full term, calcification and infarcts are normal features of a healthy placenta – just like your healthy mother has some wrinkles and a few grey hairs.
This is one more bit of misinformation, mis-education, or pure nonsense that needlessly frightens healthy mothers into risky inductions.
Make wise choices, my friends.
Much love,
Mother Billie
References
Becroft, D. M. O., Thompson, J. M. D., & Mitchell, E. A. (2002). The epidemiology of placental infarction at term. Placenta, 23(4), 343-351.
Chen, K. H., Chen, L. R., & Lee, Y. H. (2011). Exploring the relationship between preterm placental calcification and adverse maternal and fetal outcome. Ultrasound in Obstetrics & Gynecology, 37(3), 328-334.
Chen, K. H., Chen, L. R., & Lee, Y. H. (2012). The role of preterm placental calcification in high-risk pregnancy as a predictor of poor uteroplacental blood flow and adverse pregnancy outcome. Ultrasound in medicine & biology, 38(6), 1011-1018.
Harris, R. D., & Alexander, R. D. (2000). Ultrasound of the placenta and umbilical cord. Ultrasonography in obstetrics and gynecology, 4, 597-625.
Jamal, A., Moshfeghi, M., Moshfeghi, S., Mohammadi, N., Zarean, E., & Jahangiri, N. (2017). Is preterm placental calcification related to adverse maternal and foetal outcome?. Journal of Obstetrics and Gynaecology, 37(5), 605-609.
Mousa, H. A., & Alfirevic1, Z. (2000). Do placental lesions reflect thrombophilia state in women with adverse pregnancy outcome?. Human Reproduction, 15(8), 1830-1833.
Naeye, R. L. (1977). Placental infarction leading to fetal or neonatal death. A prospective study. Obstetrics and gynecology, 50(5), 583-588.
Nolan, R. L. (1998). The placenta, membranes, umbilical cord, and amniotic fluid. A practical guide to ultrasound in obstetrics and gynecology, 438-439.
Vinnars, M. T., Nasiell, J., Ghazi, S. A. M., Westgren, M., & Papadogiannakis, N. (2011). The severity of clinical manifestations in preeclampsia correlates with the amount of placental infarction. Acta obstetricia et gynecologica Scandinavica, 90(1), 19-25.