RE: Finally - cord cutting and clamping
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
Re: RE: Finally - cord cutting and clamping
Dear Joy... Thanks for your information. How you describe your management of third stage is very similar to what we do in Seattle; basically we are hands off until after the placenta has delivered, and the cord is never cut routinely before it has stopped pulsing. So, that is why when faced with active management of third stage is was pretty much do it as it is described in the protocol. And there seemed to be such an urgency about getting that cord cut as soon as the oxytocic was given. I have a passion for physiology so I want to know what this urgency is all about. At this point I am thinking it is habit. I have read Michel Odent's The Scientification of Love and found it a quick and informative read. I think it is a very interesting question that has been raised regarding the incidence of PPD and administration of oxytocics at any stage during labour. One thing I came across when doing some research on postpartum haemorrhage (and I can't remember the citation, unfortunately) was a small study done (I think in UK) with only about 100 women, where the researchers measured the levels of naturally occurring oxytocin in women postpartum following a spontaneous birth. There was quite a range. They were looking for at least an association with oxytocin concentration and incidence of PPH. They did find one: low levels greater chance of PPH but, if I remember correctly, it wasn't significant. I will try to find it again on Pubmed. I was then reading an article in Scientific American by Roger Smith, where he was looking at the hormonal orchestration of labour. I was struck by the work done on oxytocin receptors in uterine muscle, not only the number of receptors but when they become receptive to oxytocin and what turns them off. As usual it seems the more we find out the more questions arise. Just thinking about it, I am wondering if there could also be a link/association between either lower natural oxytocin production, lower number of oxytocin receptors, induction and/or augmentation of labour, and post partum depression. Of course finding oxytocin receptors on a woman's cells would be an invasive procedure: much of the research for Smith's article had been done on sheep. I am just prattling on. I just find it all incredibly interesting. love, marilyn -- This mailing list is sponsored by ACE Graphics. Visit http://www.acegraphics.com.au to subscribe or unsubscribe.
Re: Finally - cord cutting and clamping
I found the management of 3rd stage my greatest challenge when I became a MIPP. The management of labour was always clear as a midwife I held the space as the journey evolved and the baby was born then I developed all these scenarios for 3rd stage basically wait and see unless time and bleeding interjected I was always relieved when the placenta was delivered . Now I'm an observer of the third stage and intuitvley act /not act depending on whats happening. [ie same as therest of birth. What cured my anxiety? I shared my anxiety re 3s with another MIPP J enny Parret she said you have forgotten the 3rd stage is part of the birth treat it the same as the rest and now I do. My advice , CARE FOR THE WOMAN AND SHE WILL COMPLETE HER BIRTH WHEN SHE IS READY. love Jan - Original Message - From: Johnston [EMAIL PROTECTED] To: [EMAIL PROTECTED] Sent: Thursday, March 21, 2002 8:29 PM Subject: RE: Finally - cord cutting and clamping 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
