Am I right to refuse active management

[minkymama]

Hi all, I need some help with my birth plan and upcoming specialist appt.
I had a homebirth with severe PPH with DD. We transferred to hospital where the PPH was conservatively managed for a few hours - I then had surgery where they found retained placenta. I ALWAYS retain placenta - have had 4 m/c and retained product every time.

I'm due in Sept and will deliver in hospital - we live 40 mins away so I don't feel good about homebirth with my history. Care in my country is midwife-led, but I will see a specialist to document a birth plan for my 3rd stage. The hospital protocol is that all women SHOULD have a managed 3rd stage, and previous PPH's MUST have a managed 3rd stage My midwife will support me in declining this. NZ also has laws around patient choice - I can easily refuse, will prob have some attitude from staff but that's their prob.

MY prob is, some of the reading I've done on active management and it's success in preventing PPH is starting to sound quite persuasive. I can see how it might help if you had previously bled because of atony, no retained product. It would be great not to bleed, but I am TERRIFIED of having an active 3rd stage and then having retained product trapped behind my closed cervix. While my surgery last time was unpleasant, it was easy enough for them to get in there and get the placental fragments out - they just reached in. I chose a local anaethestic and it was ok. I don't want to go through the drama of a general so they can re-dilate my poor cervix.

I'm worried the specialist won't belive me that if i bleed post partum, it will be retained product. I'm worried that they'll just repeat the mantra 'active management is good' without analysing the specifics of my case. I'm worried that I'll cave and agree - doctors have that effect on me.

Eek, what should I do? Am I correct in my reasons for not wanting active management? It would be great to not bleed after, but I feel it's inevitable and I'll have gone through active managment (and lost all the benefits of a phys 3rd stage) for nothing, as the prob is retained product and I'm not sure active management can help with that.

[kltroy]

I did a lot of reading on this topic before my last birth, and basically concluded that the only good reason to avoid active management of the third stage was because I wanted to have a completely "natural" experience. The medical evidence is pretty conclusive that active management does reduce the risk of PPH and if you have a history of retained placenta I would guess that your care provider would be aware of that.

For my birth I did, in fact, not do any active management. I tried to nurse my baby as soon as possible, we delayed cord clamping, etc. After a while I was still losing quite a lot of blood and my doctor did a little fundal massage and had me try to expel the placenta, which came out in a big squishy glop. I certainly came nowhere close to hemorhaging, but I was till pretty light-headed for about 12 hours after the birth (to the point where I couldn't stand long enough to take a shower).

Would I do it that way again? Probably not... I don't feel particularly strongly about active management and, while I'm not convinced it would have changed things much, it might have lessened my blood loss a bit. It would have been nice to feel a little perkier early on. And I don't really think prophylactic pitocin is that big of a deal. You can find some good information about other birth-related practices by checking the Cochrane Review database here:
http://www2.cochrane.org/reviews/en/subtopics/87.html

I guess the issue that I came up with is in trying to figure out what the benefits of a physiologic 3rd stage *are*? You can still delay cord clamping, nurse right away, etc. Perhaps I'm naive on this one? I don't know.. at the end of the day it's always a balance between risks and benefits, so the best thing you can do is get good information to base your decision on.

[loveneverfails]

I chose active management for my most recent birth, and it made an incredible difference in terms of my ability to enjoy those first few moments with my daughter. My feeling was that I was going to need the pitocin, and it was a question of whether I wanted the pitocin before bleeding to anemia or after bleeding to anemia.

I will be choosing active management for all subsequent births. It was extremely unobtrusive and did not distract me from my daughter in the slightest.

[Beccadoula]

Do you have a doula? We're good for helping moms remember their birth plan.

[Defenestrator]

Originally Posted by minkymama

While my surgery last time was unpleasant, it was easy enough for them to get in there and get the placental fragments out - they just reached in. I chose a local anaethestic and it was ok. I don't want to go through the drama of a general so they can re-dilate my poor cervix.

It is my experience that the cervix is still really stretchy after birth and even if it closes down some, it is possible to stretch it without using instruments. I would guess that after a few hours, the cervix would have begun to close. I think that if you had a manual removal of your placenta at 1 hr. postpartum after active management, it would have been similar to your experience of having tissue removed at a few hours postpartum.

I think that active management might not be a bad idea for you. I don't know that it is a good idea for all women, especially with undisturbed births, but with your history and because you are giving birth in a hospital, I think it is something reasonable to consider.

[CherryBomb]

Originally Posted by kltroy

I did a lot of reading on this topic before my last birth, and basically concluded that the only good reason to avoid active management of the third stage was because I wanted to have a completely "natural" experience. The medical evidence is pretty conclusive that active management does reduce the risk of PPH and if you have a history of retained placenta I would guess that your care provider would be aware of that.

I agree with this. Bring up the concern about partial rentention and see what the ob says.

[minkymama]

Thanks, these replies are really helpful - it was never an issue for my homebirth so I've never thought about it before. We don't use doulas so much in New Zealand but my midwife will be with me through the birth, plus my DH and likely my midwife's student, so I feel confident they will help uphold my birth plan (and refusing active management was the only bit that was likely to be fraught, but given the advice here I might opt for the active choice).