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Active Management of Third Stage of Labor & Birth

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Jacqueline Levine, Childbirth Educator/Lactation Consultant, has taken a hard look at the Third Stage of Labor and Birth.
If this stage is “managed” or not may have an impact on your breastfeeding.
Take a look at what this long time professional has to say…..

Prophylactic pit is just  part of that package of “Active Management of Thirds  Stage of Labor” (AMTSL) and there’s  a really great analysis of that concept  and its consequences  in “Optimal Care in Childbirth” Romano and Goer’s  great book.  They contend, and studies agree,  that the medical model of birth…induction and pit to augment labor and other protocols…are modifiable causes of PPH (Post Partum Hemorrhage),  and all woman do not just bleed to death after birthing their babies.   

We know that docs think that medical intervention is always the answer to a problem… never the cause.   I quote from the Goer/Romano book “…research fails to provide ANY evidence that universal application of AMTSL   results in clinically important improvements in maternal outcomes in developed countries, while documenting that it introduces harms”  (p379).     

 In 2010, Cochrane reviewers raised many issues about the trade-offs between the benefits and harms of managing third stage, including worries about prophylactic pit for all women regardless of their risk profile. The key phrase for looking at PPH is, I think, “developed” countries.   99% of deaths due to hemorrhage are in undeveloped and developing countries (says the WHO) , and pit has had  great success in the prevention and treatment of PPH in low-resource countries.

 But here in the US and  in other  high-resource settings, AMTSL “ conferred no benefit other than a small absolute reduction in transfusion rates, but findings show that transfusion rates are not an objective measure”, (Goer/Romano p379), because of the biases found in decisions about  the administration of transfusion and the lack of standardization as to when to treat.   Here, where we have the best medical resources (badly used and badly distributed, no doubt), a pit shot for every woman is overkill, unnecessary for the healthy mother, takes the place of her own highest-ever levels of natural oxytocin, upsets the beneficent cocktail of post birth hormones  the high levels  that nature provides for the most successful and joyous first minutes and hours with her newborn.  

During a c-section,  the mother may lose as much as 1000ml of blood, and that’s not enough to make docs call for a transfusion, but the standard for vaginal birth is only 500ml, and one wonders how they can tell how much blood loss there really is, when much of what a woman loses may be absorbed in the chux pads under and around her.

The Cochrane  says” Women should be given information on the benefits and harms of both methods to support informed choice. Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third-stage management.”

Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev. 2011; 11:CD007412 (ISSN: 1469-493X) Begley CM ; Gyte GM ; Devane D ; McGuire W ; Weeks A
School of Nursing and Midwifery, Trinity College Dublin, 24, D’Olier Street, Dublin, Ireland, Dublin 2.

 

They Get It…Why Can’t We?

 

As some of you may know, I have just returned from an awesome vacation in Belize.S6304091 While visiting a friend in Corozal Town, we passed a park at the water edge called Mother’s Park.
In the center of this park, for all to see, every single day, S6304087in color no less, is a statue of a mother breastfeeding her baby.
PERFECT! JUST PERFECT!

S6304089
As my picture was being taken, this little girl wanted to stand with me. With her mother’s permission, we posed.
In the second picture, she S6304090wanted us to say “cheese”. Who am I to deny such an adorable child?
Our country is so advanced compared S6304088to this small country. How can we be so delinquent in something that is so very natural?

 

What Impact Can IV Fluids Have on Mother, Baby and Breastfeeding?

 A Quick Look.

images (4)Written by guest author, Jacqueline Levine

Having IV fluids is a medical procedure. It’s meant to restore normal body fluid balance when there’s blood loss or dehydration, but the Listening to Mother’s Survey1 reports that 83% of women have IV in labor. Having a routine IV , as so many do, isn’t risk-free.2 An excess of IV fluid can dilute red blood cells and other components of the blood like clotting factors, so that less oxygen gets to the uterus and less to the fetus, increasing the possibility of post partum anemia or hemorrhage3,4.
Too much fluid can overcome normal pressure in blood vessels, and fluid goes where it shouldn’t. The mother’s and/or baby’s lungs can become “wet”5. Large amounts of fluid given quickly (a bolus) can interfere with the activity of the uterus.6 The type of IV fluids given can have unhappy effects as well, such as hyponatremia which can cause seizures, and symptomatic hypoglycemia in the baby7,8,9. Plastic IV lines may “off-gas” phthalates and other chemicals that are harmful. This list is brief. There are lots of studies that show harms from routine use of IV. Even the safety of “normal saline” has come under scrutiny.10 And the effect of IV administration lasts well into the days after the mother is disconnected from her hanging bag of fluids.
Fluid has weight, of course; haven’t you heard that helpful little reminder, “a pint’s a pound the world around”? If a laboring mother gets bag after bag of IV fluids, odds are that her baby will be born with an inflated birth weight. Breastfeeding success is often measured by how quickly the baby regains its birth weight after the normal weight loss in the first week or so. What exactly might that baby’s normal birth weight have been? What does it mean to the motherbaby pair when of them both are full of extra fluids? Water moves everywhere in the mother’s body and aside from ankles and wrists and fingers and toes that can be swollen like sausages, breasts and nipples hold water as well. A swollen breast with taut skin makes latching difficult. This scenario is often the beginning of early nursing troubles10: the transition from colostrum to mature milk may be delayed in a water-swollen breast, and a newborn may not able to achieve a deep latch so he can’t get sufficient food and cannot stimulate the breast well. Supplementation comes next. We know it and the studies show it. There are remedies to those situations…good support for mother and baby… but best-evidence, optimal maternity care is the answer.
Supplementation frequently comes next. We know it and the studies show it. There surely are remedies to the problem of swollen breasts, like Reverse Pressure Softening, and methods to build up milk supply, and ways to support better positioning for a baby who is having latch difficulties..
But the overarching answer is for mothers to be aware of best-evidence, optimal maternity care, and to understand their rights as patients to refuse routine interventions. By avoiding IV fluids except for compelling medical reasons, mothers will be able to avoid the negative consequences of fluid overload to their babies and themselves, and give themselves a chance at better breastfeeding beginnings.

Jacqueline (Jackie) Levine, LCCE, FACCE, CD(DONA), CLC is committed to providing a continuum of care for underserved women at PlannedJackie-Levine Parenthood, on Long Island, NY, where she has provided free Lamaze education, birth and breastfeeding support to all the women in her classes for the last 9 years. She is a guest lecturer on Childbirth in the US at CW Post, has worked for CIMS, contributed to the Lamaze e-newsletter Building Confidence Week-by-Week , all after her 30-year career as a designer in the garment center. Jackie is a recipient of the Lamaze Community Outreach Award, mother of three and Grandmother of five.” Science & Sensibility

 
References:
1-DeClerq E, Sakala C, Corry MP, et al. Listening to Mothers ll: Report of the Second National US Survey of Women’s Childbearing Experiences. New York: Childbirth Connection
2-Wasserfstrum N. Issues in fluid management during labor; general considerations. Clin Obstet Gynecol 1992;35(3):505-13
3-Carvalho JC, Mathias RS, Intravenous Hydration in obstetrics. Intl Anesthesiol Clin 1994:32(2):103-15
4- Carvalho JC, Mathias RS,Senra WG et al. Hemoglobin concentration variation and blood volume expansion during epidural anesthesia for cesarean section. Reg Anesth1991;16(1S):73
5-Gonik B., Cotton DB.,Peripartum colloid osmotic changes; influence of intravenous hydration. American Journal Obstet Gynecol1984;150(1):99-100
6-Cheek, T.G., Samuels, P.,Miller, F., Tobin, M., Gutshe, B.B. Iv load decreases uterine activity in active labor. Journal of Anaesthesia 1996;77:632-635
7-Stratton JF, Stronge J, Boylan PC. Hyponatremia and non-electrolyte solutions in laboring primigravida. Eur J Obstet Gynecol Reprod Biol 1995;59(2):149-151
8-west CR, Harding JE. Maternal water intoxication as a cause of neonatal seizures. J Pediatr Child Health 2004;40(12):709-10
9-Nordstrom L, Arulkumaran S, et al. Continuous maternal glucose infusion during labor; effects on maternal and fetal glucose and lactate levels. Am J Perina. Am J Perinatol;1995;12(5);357-62
10-http://www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Normal-saline-is-not-normal-may-be-harmful/ArticleNewsFeed/Article/detail/776186?ref=25
11-Chantry CJ, Nommsen-Rivers LA, Peerson JM et al. Excess Weight Loss in First-Born Breastfed Newborns Relates to Maternal Intrapartum Fluid Balance. Pediatrics 2010

The Latch On Song

In honor of my friend, who has left us all too soon, and in honor of her passion to promote breastfeeding…

Janna Melsness; CNM, MSN, MPH, RN, BSN

January 28, 1981 – April 5, 2015