Hi I have been watching from some distance as this thread has been discussed, and think your reflective response today, Maralyn, is very good.
We need to try to understand what is actually happening, rather than necessarily what we were taught to do. The little motto, "In normal birth there should be a valid reason to interfere with the natural process" (WHO Care in Normal Birth 1996) should be a guiding principle. I'm not sure if there is a consensus on what constitutes the gold standard for active management of S3 (eg when the oxytocic is administered, when the cord is clamped, if the blood is drained from the maternal end of the severed cord &c). We had a discussion on this list some time ago about what physiological S3 is, and it seems that there are many variations. Midwives attending homebirths seem to have a great variety of 'management' practices too. (M Odent says "Don't manage third stage"). My practice is to attempt to maintain an unstimulating and calm atmosphere in the room in the minutes immediately after the birth, and trust mother nature (/hormones /physiology) to get on with the marvellous job of completion. I encourage folk to wait until S3 is completed before they make phone calls, and if there are photos, they need to be done quietly. If a woman gave birth in water, we usually wait 5-10 minutes as an initial rest and recovery period, then have a warm supported chair or bed in the same room so that she can give her full attention to the baby. I don't encourage remaining in the water for the birthing of the placenta. Often standing up to get out of the tub gives the woman a feeling of fullness, and she can pop her placenta out. Staying in the same room is important to me, as I think moving to a different space can impede progress. This all may seem pretty prescriptive - it's not fixed in concrete, but it makes sense to me, as a mother and a midwife. I think the first 30 minutes or so are crucial, and I watch the woman and baby without engaging her in eye contact or conversation, and try to make sure they are warm and comfortable. I don't check cord pulsation. Some women are weary, or not able to move immediately into the completion phase. Peaceful quiet seems to allow them to rest, until they are ready to pay a lot of attention to baby, or want to move. Often they say "I'll stand up now, and the placenta will come." Of course it's nice for everyone if this happens in the first hour, but I have not had any problem with waiting longer. Sometimes I think birth of the placenta is like a second birth - as though there needs to be a series of contractions, dilation of the cervix, and an expulsive effort. I used to worry about physiological S3 when I needed to collect cord blood from the babies of Rh negative mothers. But I have found that a very small amount of cord blood taken from the vessels on the fetal side of the placenta is adequate. Women usually report less blood loss in the hours after the birth when they have birthed their placentas naturally. I expect to see between 100-400ml blood loss with the placenta. 'twill have to do for now. Happy birthings. Joy Johnston -----Original Message----- From: [EMAIL PROTECTED] [SMTP:[EMAIL PROTECTED]] Sent: Thursday, March 21, 2002 6:51 AM To: [EMAIL PROTECTED]; [EMAIL PROTECTED] Subject: Re: RE: Finally Thank you all for your responses to my question. I too like to leave the maternal end of the cord unclamped, although as a student I had some midwives ask me to reclamp it as they wanted to know where the blood being lost was coming from. On thinking about the responses I would like to venture that the concern about the baby getting extra blood has been also raised in discussions of physiologic third stage and I think Lois's response is right on the money: it depends on the position of the baby in relation to the mum how much extra blood the baby is getting. Regarding the stronger contractions causing more blood being pumped to the baby, I don't think it works this way for these reasons: 1. The baby's heart is pumping the blood, not the uterus. 2. When you augment or induce a woman in labour and if her uterus experiences hyperstimulation, then the baby may receive less blood not more resulting in fetal distress. 3. The intent of the oxytocic in third stage is to schear the placenta off the uterine wall with the increased contractions constricting the uterine capillaries, if anything perhaps the stronger uterine contractions would restrict the amount of residual placental blood available to the baby. 4. My original concern about the oxytocic crossing the placenta to the baby also seems to be mute if what I just wrote is in someway correct. Bottom line is I still feel like I am guessing about this. The question came up when as a student the mum I was caring for had agreed to having third stage actively managed (she had had a "long labour": tired uterus), but she didn't realise that this meant the cord would be cut immediately after the oxytocic was given (this was our fault as we hadn't covered this with her in the discussion, which brings to mind the flaws of giving informed consent in labour). So, when I was about to clamp the cord she said "Oh, but it hasn't finished pulsing", I said "your right then, we'll just wait for a minute or 2" and the midwife who was supervising me said "Oh! but we've given the pitocin, so we have to cut the cord now". And we did, the mum seemed to be ok with it, she had had a lovely and triumphant birth (I think and hope) apart from that. It was just after reading AndreaQ's lovely story, I felt a pang of guilt and also a lack of knowledge re the consequences of delayed cord clamping after an oxytocic has been administered. Again, thank you to all who responded, I am still pondering. marilyn -- This mailing list is sponsored by ACE Graphics. Visit <http://www.acegraphics.com.au> to subscribe or unsubscribe. -- This mailing list is sponsored by ACE Graphics. Visit <http://www.acegraphics.com.au> to subscribe or unsubscribe.
