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A
Natural Approach to the Third Stage of Labour
Leaving
Well Alone: A Natural Approach to the Third Stage of Labour
by Sarah Buckley, MD
The medical approach
to pregnancy and birth has become so ingrained in our culture, that we
have forgotten the way of birth of our ancestors: a way that has ensured
our survival as a species for millennia. In the rush to supposedly protect
mothers and babies from misfortune and death, modern western obstetrics
has neglected to pay its dues to the Goddess, to Mother Nature, whose
complex and elegant systems of birth are interfered with on every level
by this new approach, even as we admit our inability to understand or
control these elemental forces.
Medical interference in pregnancy, labour and birth is well documented,
and the negative sequellae are well researched. However, medical management
of the third stage of labour- the time between the baby's birth, and the
emergence of the placenta, to my mind, is more insidious. At the time
when Mother Nature prescribes awe and ecstasy, we have injections, examinations,
and clamping and pulling on the cord. Instead of body heat and skin to
skin contact, we have separation and wrapping. Where time should stand
still for those eternal moments of first contact, as mother and baby fall
deeply in love, we have haste to deliver the placenta and clean up for
the next 'case'.
This 'management' of the third stage, which has been taken even further
in the last ten years, with the popularity of "active management of the
third stage" (see below), has its own risks for mother and baby. While
much of the activity is designed to reduce the risk of maternal bleeding,
or postpartum haemorrhage (PPH), which is most certainly a serious event,
it seems that, as with the active management of labour, the medical approach
to labour and birth actually leads to many of the problems that active
management is designed to address.
Active management also creates specific and potentially life-threatening
problems for mother and baby. In particular, use of active management
leads to a newborn baby being deprived of up to half of his or her expected
blood volume. This extra blood, which is intended to perfuse the newly
functioning lungs and other vital organs, is discarded along with the
placenta when active management is used, with possible sequellae such
as breathing difficulties and anaemia, especially in vulnerable babies.
(For more on this, go here.)
Drugs used in active management have documented risks for the mother,
including death, and we do not know the long-term effects of these drugs,
which are given at a critical stage of brain development, for the baby.
Hormones in the third stage
As a mammalian species- that is, we have mammary glands that produce milk
for our young- we share almost all features of labour and birth with our
fellow mammals. We have in common the complex orchestration of labour
hormones, produced deep within our "mammalian", or middle brain, to aid
us and ultimately ensure the survival of our offspring.
We are helped in birth by three major mammalian hormone systems, all of
which play important roles in the third stage as well. The hormone oxytocin
causes the uterine contractions that signal labour, as well as helping
us to enact our instinctive mothering behaviours. Endorphins, the body's
natural opiates, produce an altered state of consciousness and aid us
in transmuting pain: and the fight or flight hormones adrenaline and noradrenaline
(epinephrine and norepinephrine- also known as catecholamines or CAs )
give us the burst of energy that we need to push our babies out in second
stage.
During the third stage of labour, strong uterine contractions continue
at regular intervals, under the continuing influence of oxytocin. The
uterine muscle fibres shorten, or retract, with each contraction, leading
to a gradual decrease in the size of the uterus, which helps to "shear"
the placenta away from its attachment site. Third stage is complete when
the placenta is delivered.
For the new mother, the third stage is a time of reaping the rewards of
her labour. Mother Nature provides peak levels of oxytocin, the hormone
of love, and endorphins, hormones of pleasure for both mother and baby.
Skin to skin contact and the baby's first attempts to breastfeed further
augment maternal oxytocin levels, strengthening the uterine contractions
that will help the placenta to separate, and the uterus to contract down.
In this way, oxytocin acts to prevent haemorrhage, as well as to establish,
in concert with the other hormones, the close bond that will ensure a
mother's care and protection, and thus her baby's survival.
At this time, the high adrenaline levels of second stage, which have kept
mother and baby wide-eyed and alert at first contact, will be falling,
and a very warm atmosphere is necessary to counteract the cold, shivering
feelings that a woman has as her adrenaline levels drop. If the environment
is not well heated, and/or the mother is worried or distracted, continuing
high levels of adrenaline will counteract oxytocin's beneficial effects
on her uterus, thereby increasing the risk of haemorrhage (Odent, 1992).
For the baby as well, the reduction in fight or flight hormones, which
have also peaked at birth, is critical. If, because of extended separation,
these hormones are not soothed by contact with the mother, the baby can
go into psychological shock which, according to author Joseph Chilton
Pearce, will prevent the activation of specific brain functions that is
nature's blueprint for this time. Pearce believes that the separation
of mother and baby after birth is "the most devastating event of life,
which leaves us emotionally and psychologically crippled" (Pearce 1992).
One might wonder whether the modern epidemic of "stress" - the term was
invented by researchers in the early 20th century- and stress-related
illness in our culture is a further outcome of current third-stage practices.
It is scientifically plausible that our entire Hypothalamic-Pituitary-Adrenal
(HPA) axis, which mediates long-term stress responses and immune function,
as well as short-term fight-or-flight reaction, is permanently mis-set
by the continuing high stress hormone levels that ensue when newborn babies
are routinely separated from their mothers.
Michel Odent, in his review of research on the "primal period" (the time
between conception and the first birthday), concludes that interference
or dysfunction at this time affects the development of our "capacity to
love", which is particularly vulnerable around the time of birth, being
connected hormonally to the oxytocin system. (Odent, 1998) Research by
Jacobsen (1990, 1997)) and Raine (1994), among others, suggests that contemporary
tragedies such as suicide, drug addiction and violent criminality may
be linked to problems in the perinatal period such as exposure to drugs,
birth complications and separation or rejection from the mother.
A crucial role for birth attendants in these times is to ensure that a
woman's mammalian instincts are protected and valued during pregnancy,
birth and afterwards. Ensuring unhurried and uninterrupted contact between
mother and baby after birth, adjusting the temperature to accommodate
a shivering mother, and to allow skin-to-skin contact and breastfeeding,
and not removing the baby for any reason- these are practices that are
sensible, intuitive and safe, and help to synchronise our hormonal systems
with our genetic blueprint, giving maximum success and pleasure for both
partners, in the critical function of child-rearing.
The baby, the cord, and active management
Adaptation to life outside the womb is the major physiological task for
the baby in third stage. In utero, the wondrous placenta fulfills the
functions of lungs, kidney, gut and liver for our babies. Blood flow to
these organs is minimal until the baby takes a first breath, at which
time huge changes begin in the organisation of the circulatory system
Within the baby's body, blood becomes, over several minutes, diverted
away from the umbilical cord and placenta and, as the lungs fill with
air, blood is sucked into the pulmonary (lung) circulation. Mother Nature
ensures a reservoir of blood in the cord and placenta, that provides the
additional blood necessary for these newly-perfused pulmonary and organ
systems.
The transfer of this reservoir of blood from the placenta to the baby
happens in a step-wise progression, with blood entering the baby with
each third-stage contraction, and some blood returning to the placenta
between contractions. Crying slows the intake of blood, which is also
controlled by constriction of the vessels within the cord (Gunther 1957)
- both of which imply that the baby may be able to regulate the transfusion
according to individual need.
Gravity will affect the transfer of blood, with optimal transfer occurring
when the baby remains at or below the level of the uterus until the cessation
of cord pulsation signals that the transfer is complete. This process
of "physiological clamping" typically takes 3 minutes, but may be longer,
or can be complete in only one minute. (Linderkamp 1982)
This elegant and time-tested system, which ensures that an optimum, but
not a standard, amount of blood is transferred, is rendered inoperable
by the current practice of early clamping of the cord- usually within
30 seconds of birth.
Early clamping has been widely adopted in Western obstetrics as part of
the package known as active management of the third stage. This comprises
the use of an oxytocic agent- a drug that, like oxytocin, causes the uterus
to contract strongly- given usually by injection into the mothers thigh
as the baby is born, as well as early cord clamping, and 'controlled cord
traction'- that is, pulling on the cord to deliver the placenta as quickly
as possible.
Haste becomes necessary, because the oxytocic injection will, within a
few minutes, cause very strong uterine contractions that can trap an undelivered
placenta, making an operation and 'manual removal' necessary. Furthermore,
if the cord is not clamped before the oxytocic effect commences, the baby
is at risk of having too much blood suddenly pumped from the placenta
by the over-zealous contractions.
While the aim of active management is to reduce the risk of haemorrhage
for the mother, "its widespread acceptance was not preceded by studies
evaluating the effects of depriving neonates [newborn babies] of a significant
volume of blood". (Piscane 1996)
It is estimated that early clamping deprives the baby of 54 to 160 ml
of blood, (Usher 1963) which represents up to half of a baby's total blood
volume at birth. "Clamping the cord before the infant's first breath results
in blood being sacrificed from other organs to establish pulmonary perfusion.
[blood supply to the lungs]. Fatality may result if the child is already
hypovolemic [low in blood volume]." (Morley 1997)
Where the baby is lifted above the uterus before clamping- for example
during caesarean surgery- blood will drain back to the placenta by gravity,
making these babies especially liable to receive less than their expected
blood volume. The consequence of this may be an increased risk of respiratory
(breathing) distress- several studies have shown this condition, which
is common in caesarean-born babies, to be eliminated when a full placental
transfusion was allowed. (Peltonen 1981, Landau 1953)
The baby whose cord is clamped early also loses the iron contained within
that blood- early clamping has been linked with an extra risk of anaemia
in infancy. (Grajeda 1997,Michaelson 1995)
These sequellae of early clamping were recognised as far back as 1801,
when Erasmus Darwin wrote:
"Another thing very injurious to the child is the tying and
cutting of the navel string too soon; which should always be left
till the child has not only repeatedly breathed but till all pulsation
in the cord ceases. As otherwise the child is much weaker than it
ought to be, a part of the blood being left in the placenta which
ought to have been in the child." (Darwin 1801)
In one study, premature babies experiencing delayed cord clamping-
the delay was only 30 seconds- showed a reduced need for transfusion,
less severe breathing problems, better oxygen levels, and indications
of probable improved long-term outcomes, compared to those whose cords
were clamped immediately. (Kinmond 1993)
Some studies have shown an increased risk of polycythemia (more red
blood cells in the blood) and jaundice when the cord is clamped later.
Polycythemia may be beneficial, in that more red cells means more oxygen
being delivered to the tissues. The risk that polycythemia will cause
the blood to become too thick (hyperviscosity syndrome), which is often
used as an argument against delayed cord clamping, seems to be negligible
in healthy babies. (Morley 1998)
Jaundice is almost certain when a baby gets his or her full quota of
blood, and is caused by the breakdown of the normal excess of blood
to produce bilirubin, the pigment that causes the yellow appearance
of a jaundiced baby. There is, however, no evidence of adverse effects
from this. (Morley 1998). One author has proposed that jaundice, which
is present in almost all human infants to some extent, and which is
often prolonged by breastfeeding, may actually be beneficial because
of the anti-oxidant properties of bilirubin. (Gartner 1998)
Early cord clamping carries the further disadvantage of depriving the
baby of the oxygen-rich placental blood that mother nature provides
to tide the baby over until breathing is well established. In situations
of extreme distress- for example, if the baby takes several minutes
to breathe-this reservoir of oxygenated blood can be life saving, but,
ironically, standard practice is to cut the cord immediately if resuscitation
is needed.
The placental circulation acts, when the cord is intact, as a conduit
for any drug given to the mother, whether during pregnancy, labour or
third stage. Garrison (1999) reports that Narcan, which is sometimes
needed by the baby to counteract the sedating effect of pain-relieving
drugs such as pethidine (demorol), given to the mother in labour, can
be effectively administered via the mother's veins in third stage, waking
up the newborn baby in a matter of seconds.
The recent discovery of the amazing properties of cord blood, in particular
the stem cells contained within it, heightens, for me, the need to ensure
that a newborn baby gets its full quota. These cells are unique to this
stage of development, and will migrate to the baby's bone morrow soon
after birth, transforming themselves into various types of blood-making
cells.
Cord blood harvesting, which is currently being promoted to fill Cord
Blood Banks for future treatment of children with leukaemia, involves
immediate clamping, and up to 100 ml of this extraordinary blood can
be taken from the baby to whom it belongs. Perhaps this is justifiable
where active management is practiced, and the blood would be otherwise
discarded, but, unfortunately, cord blood donation is incompatible with
a physiological (natural) third stage.
Active management and the mother
Active management (oxytocic, early clamping and controlled cord traction)
represents a further development in third stage interference that began
in the mid-seventeenth century, when male attendants began confining
women to bed, and cord clamping was introduced to spare the bed linen.
Pulling on the cord was first recommended by Mauriceau in 1673, who
feared that the uterus might close before the placenta was spontaneously
delivered (Inch 1984). In fact, the recumbent (lying) postures, increasingly
adopted under doctor's care meant that spontaneous delivery of the placenta
was less likely: the upright postures that women and midwives have traditionally
used encourage the placenta to fall out with the help of gravity.
The first oxytocic to be used medically was ergot, derived from a fungal
infection of rye. Ergot was known to be used by 17th and 18th century
European midwives. Its use was limited, however, by its toxicity. It
was refined and revived as ergometrine in the 1930's, and by the late
1940's, some doctors were using it as preventatively, as well as therapeutically,
for postpartum haemorrhage (Inch 1984). Potential side effects from
ergot derivatives include a rise in blood pressure, nausea, vomiting,
headache, palpitations, cerebral haemorrhage, cardiac arrest, convulsion
and even death.
Synthetic oxytocin, which mimics the effects of natural oxytocin on
the uterus, was first marketed in the 1950's, and has largely replaced
ergometrine, although a combination drug, called syntometrine, is still
used, especially for severe haemorrhage. Syntocinon causes an increase
in the strength of contractions, whereas ergometrine causes a large,
'tonic' contraction, which also increases the chance of trapping the
placenta. Ergometrine also interferes with the process of placental
separation, increasing the chance of partial separation. (Sorbe 1978)
Recently active management has been proclaimed "the routine management
of choice for women expecting a single baby by vaginal delivery in a
maternity hospital" (Prendville 1999), mostly because of the results
of the recent Hinchingbrooke trial, comparing active versus "expectant"
(physiological) management.
In this trial (Rogers 1998), which involved only women at low risk of
bleeding, active management was associated with a post partum hemorrhage
(blood loss greater than 500ml) rate of 6.8%, compared with 16.5% for
expectant (non-active) management. Rates of severe PPH (loss > 1000ml)
were low in both groups- 1.7% active and 2.6% expectant.
The authors note further that, from these figures ten women would need
to receive active management to prevent one PPH. They add "Some women
… may rate a small personal risk of PPH of little importance compared
with intervention in an otherwise straightforward labour, whereas others
may wish to take all measures to reduce the risk of PPH."
Reading this paper, one must wonder how it is that almost 1 in 6 women
bled after "physiological" management, and whether one or more components
of western obstetric practices might not be actually increasing the
rate of haemorrhage.
Botha (1968) attended over 26,000 Bantu women over 10 years, and reports
that "a retained placenta was seldom seen…blood transfusion for postpartum
haemorrhage was never necessary." Bantu women deliver both baby and
placenta while squatting, and the cord is not attended to until the
placenta delivers itself by gravity.
There is some evidence that the practice of clamping the cord, which
is not practiced by indigenous cultures, contributes to both PPH and
retained placenta by trapping extra blood (around 100ml, as described
above) within the placenta. This increases placental bulk, which the
uterus cannot contract efficiently against, and which is more difficult
to expel. (Walsh 1968)
Other western practices that may contribute to PPH include the use of
oxytocin for induction and augmentation (speeding up labour) (Brinsden
1978, McKenzie 1979), episiotomy or perineal trauma, forceps delivery,
caesarean and previous caesarean (because of placental problems- see
Hemminki 1996).
Gilbert (1987) notes that PPH rates in her UK hospital more than doubled
from 5% in 1969-70 to 11% in 1983-5, and concludes "The changes in labour
ward practice over the last 20 years have resulted in the re-emergence
of PPH as a significant problem." In particular, she links an increased
risk of bleeding with induction using oxytocin, forceps delivery, long
first and second stages (but not prolonged pushing) and the use of epidurals,
which increase the chance of forceps and of a long second stage.
As noted, western practices do not facilitate the production of a mother's
own oxytocin, neither is attention paid to reducing adrenaline levels
in the minutes after birth, both of which are physiologically likely
to improve uterine contractions and therefore reduce haemorrhage.
Clamping the cord, especially at an early stage, may also cause the
extra blood trapped within the placenta to be forced back through the
placenta into the mother's blood supply with the third stage contractions.
(Doolittle 1966, Lapido 1971) This "feto-maternal transfusion" increases
the chance of future blood group incompatibility problems, which occur
when the current baby's blood enters the mother's blood stream, causing
an immune reaction which can be reactivated and destroy the baby's blood
cells in a subsequent pregnancy, causing anaemia or even death.
The use of oxytocin, which strengthens contractions, either during labour,
or in third stage, has also been linked to an increased risk of feto-maternal
hemorrhage and blood group incompatibility problems. (Beer 1969, Weinstein
1971)
The World Health Organisation, in its 1996 publication Care in Normal
Birth: a practical guide, argue that "In a healthy population (as is
the case in most developed countries), postpartum blood loss up to 1000
ml may be considered as physiological and does not necessitate treatment
other than oxytocics…". In relation to routine oxytocics and controlled
cord traction, WHO cautions that "Recommendation of such a policy would
imply that the benefits of such management would offset and even exceed
the risks, including potentially rare but serious risks that might become
manifest in the future."
Choosing a natural third stage
Choosing to forego preventative oxytocics, to clamp late (if at all),
and to deliver the placenta by our own effort all require forethought,
commitment, and that we choose birth attendants that are comfortable
and experienced with these choices.
A natural third stage is more than this, however- we must ensure respect
for the emotional and hormonal processes of both mother and baby, remembering
how unique this time is. Michel Odent stresses the importance of not
interrupting, even with words, and believes that ideally the new mother
feels unobserved and uninhibited in the first encounter with her baby
(Odent 1992). This level of non-interference is uncommon, even in home
and birth centre settings.
Lotus birth, the subject of this book, gives us a further chance to
"slow the fire drill" after birth, as midwife Gloria Lemay puts it,
and allows our babies the full metaphysical, as well as physical, benefit
of prolonged contact with the placenta. Lotus birth, like a good midwife,
also secludes mother and baby in the early hours and days, ensuring
rest and keeping visitors to a minimum.
Third stage represents a first meeting, creating a powerful imprint
upon the relationship between mother and baby. When both are undrugged
and quiet, fully present and alert, new potentials are invoked, and
we discover more about ourselves, and the sacred origins of our capacity
to love.
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It is reproduced here from the Birthlove site (www.birthlove.com
) with permission from the author Sarah Buckley MD, (sarahjbuckley@yahoo.com)
who wishes you and your babies a wonderful birth.
