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#211 of 229 Old 04-17-2012, 04:37 AM
 
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If your health care provider is picking out individual original research findings that only support their viewpoint and ignoring the recommendations and meta-analyses, then they are not practicing evidence based medicine. You can't just say, "I have found a piece of original research that supports the way I want to practice, and so I practice evidence-based medicine!" No. It doesn't work that way. You have to look at the body of literature as a whole. It may make YOU feel better, but it's not evidence based medicine. The recommendation to practice active management in all births is based on well-developed, large randomized controlled trials. That's the highest quality of evidence you can find. Not ONE RCT, but multiple. Just because your hcp can find one piece of original research that states that there is no significant difference in blood loss between active and expectant management of third stage, it would be foolish to discount all of those other pieces of high quality evidence that state that active management leads to superior outcomes. You have to take the body of literature as a whole. And further, current really is within the past 5 years. Just because a study is the most current (published in April of 2012 versus April of 2011), that doesn't make it more pertinent. Once again, you have to look at more than one study. More than two studies even. This is why homebirthers who cling to Johnsson and Davis like the Bible are so inherently flawed. They cling to this one study and ignore the VAST body of literature out there that contradicts J&D.
 

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“Evidence-based medicine is a systematic process of appraising and using current research findings. It is a step-by-step process that includes: formulating a clear clinical question of patient needs; searching the current literature; evaluating the literature, deciding which studies are valid and useful to the patient; applying the findings to the patient's care; and then evaluating the outcome.http://library.hsc.unt.edu/content/library-glossary (bolded mine).

 

I  have a hcp that follows this definition of evidence based medicine. I feel pretty lucky to have someone who can read the original research (not just meta-analyses and recommendations), understand it and together we can make a decision of care based on me. If my only choice was to be attended by someone like you, I would UC. I am glad I have a choice. I always think about women who don’t and it makes me sad.

 



 


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#212 of 229 Old 04-17-2012, 06:54 AM
 
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I've been thinking about this more, and it seems that it must be very confusing to your hcp's patients who don't know what their hcp's protocols are going to be prior to coming into the office if they are constantly changing based on the whims of the most recent study. For example, the January 2012 Green Journal had an excellent study in it about mono twins and di twins. It was large prospective cohort study with a little over 1K twin pairs (sufficiently powered). The results of this study showed that mono twins should be seriously offered an elective preterm delivery at 37 weeks gestation as the rate of stillbirth dramatically increases after 34-35 weeks. Additionally, the study results demonstrated that it is acceptable to allow di twins to continue past 37 weeks, but only if there is "intensive ultrasonographic fetal surveillance". Otherwise, it appears to be unsafe to allow di twins to go past 37 to 38. The study starts on page 50. I'm sure your hcp has a copy, as she must subscribe to the Green, the Gray, JAMA and the NEJM in order to be up to date on her literature. You can just borrow a copy from her if you'd like to read it.

 

So, in light of this new study, did your hcp change their practice protocols in regards to management of twin births? If she did not, according to your own definition, she must not be following true evidence based practice!

 

As you can see, it is not tenable to change your practice protocols based on the results of one or two most recent studies q monthly. You must take the body of evidence as a whole. You can't pick and choose what studies you want to follow. This is why evidence based practice recommendations and large meta-analyses are important in creating practice guidelines. No provider has the time to read all of the journals that come out every month and no hcp would be so stupid as to change their practice protocols every month based on the new literature. It has to be taken in context. It can not be taken individually. That's not how science works.


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#213 of 229 Old 04-17-2012, 08:47 AM
 
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Holly, can I ask, what exactly are you going to say to a client when she comes to you and says she wants to avoid active management?

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#214 of 229 Old 04-17-2012, 09:12 AM
 
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Holly, can I ask, what exactly are you going to say to a client when she comes to you and says she wants to avoid active management?




Sure. I would explain what active management of the third stage entails. I would explain that active management does not interfere with delayed cord clamping, that you can still delay. Then I will explain that active management of third stage has been shown through numerous high quality trials to reduce the incidence of PPH. However, if she still wants physiological management of third stage, while it is not my preference, I would be comfortable waiting up to 30 minutes for the placenta to come on it's own before consulting with my supervising physician (and so long as her bleeding is within normal limits). If she is bleeding excessively or if her placenta does not deliver spontaneously within 30 minutes, additional measures would need to be taken to deliver the placenta expediently and/or stop the bleeding. Then, in the delivery room, I would again offer active management of third stage and if she still refuses I would just chart that.

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#215 of 229 Old 04-17-2012, 09:24 AM
 
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Maybe I should've also just asked that in the beginning because you seem pretty reasonable here, whereas the rest of the thread you have been coming off as totally extreme, condescending and insulting.

 

Your constant replies only about superior outcomes and EBM seemed to deny any agency to the birthing woman... ("my way or highway"), that is what I think most people were reacting to, and ugh, I don't think it was just me... this thread is 11 pages long. Either this is epic communication fail or you are backtracking.

 

 

 

Originally Posted by Youngfrankenstein View Post

I'm not being snarky here, are you saying that gentle cord traction should be used if the placenta isn't out in X time?  Or are you saying that every single birth should follow with gentle cord traction?
Originally Posted by holly6737 View Post

It's my philosophy that every single birth should follow with gentle cord traction. I follow the WHO guidelines on active management of the third stage. I catch baby. Baby immediately goes to mom. Cord pulses. Cord pulsations slow or cease. Clamp, clamp, cut. Gentle cord traction with brandt-andrews. Deliver placenta. Pit running in IV (or injected IM if woman does not have IV). Fundal massage. Assess for bleeding. If uterus is not firm after delivery of placenta with fundal massage, follow with sweep of lower uterine segment to evacuate any remaining clots and consider other uterotonics such as cytotec, methergine or hemabate.

 

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#216 of 229 Old 04-17-2012, 10:28 AM
 
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"Either this is an epic communication fail or you are backtracking..."

 

 

OR you don't understand how patient/provider relationships work in practice. *I* prefer active management. That's what I prefer to do. When I go into a birth, that is my default. I believe that is evidence-based practice and I believe active management leads to superior outcomes. I also believe there are things that patients can (and should) be fired for. Rhogam is one of those issues for me. When I'm out on my own in practice and if I have the authority to do so, I would fire a patient for not accepting rhogam. I feel that strongly about the shot. Patients don't own me like I don't own them. But, there are fudge areas on some issues. Not everything is "do this or I fire you". I say, "This is what I want." The patient says "This is what *I* want." I say, "Well, I'm willing to go *here* with you, but no further. It's not what I want. It's not what I believe is the best management plan. But this isn't a make or break issue for me." They say, either "Ok, that's fine with me" or "Maybe I should find another practice". It's just like any situation with compromise, whether that be with your children or your spouse. I am the medical provider, I have delivered a lot of babies, I've been to a lot school, I know what I'm talking about. But sometimes patients just want what they want. You have to be able to give a little or you're being completely unreasonable. But if you give too much, then you're out of your comfort zone and that's not fair to you either.

 

Another example. Patient comes in with SROM x 24 hours. Temp 99.1. Vital signs stable. Reactive strip. Term baby. No medical co-morbidities. Cervical exam is 2/50/-2. UCs are rare and mild. Vertex. I want to start pit immediately and get this party started. It's been 24 hours and she's not going to be afebrile forever. The patient wants to do it all naturally and wants to wait for labor to start on it's own. I'm not comfortable with that. I want to get this baby delivered as she's going to get chorio, that baby is going to get flat, the persistent lates are going to start and then you have to go to section. So I say, "How about we give you another 6 hours. You can walk around the unit, but the RN is going to do intermittent monitoring and we're going to need to take your temp q 1 hr. Also, we're going to need to start some IV antibiotics as you're prolonged ROM. Otherwise, you could spike a temp on us and that would mean section for you. We want to avoid that scenario. Then, if labor doesn't start on it's own in 6 hours, we're going to need to start you on some pitocin." Now, that is not my preference. I don't want to wait 6 hours, I want delivery asap. I want pit asap. So I say, "I'm willing to go *here* with you, but no further." I have seen a very high success rate with this strategy.


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#217 of 229 Old 04-17-2012, 10:35 AM
 
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Thank you for this. This is exactly why I get noxious every time I read one of her posts. And just for the record, they really should teach a class (maybe more than one), on ethics, patients rights, and analysis of scientific data. Maybe they already do but it didn't sink in.  If you don't know what kind of data go into a meta-analysis, you don't know what is coming out! I deal with this on the every day basis and it shocks me that someone would not read current literature. Maybe it is because it is easier getting fed like a baby bird. I think this conversation is done. There is really nothing to add here because Holly does not have an open mind for discussion and is changing her story as she goes along. She learned her ways in school and is going to practice just like she thinks is correct. Good luck, Holly. But for sure that is not evidence based practice!
 

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Maybe I should've also just asked that in the beginning because you seem pretty reasonable here, whereas the rest of the thread you have been coming off as totally extreme, condescending and insulting.

 

Your constant replies only about superior outcomes and EBM seemed to deny any agency to the birthing woman... ("my way or highway"), that is what I think most people were reacting to, and ugh, I don't think it was just me... this thread is 11 pages long. Either this is epic communication fail or you are backtracking.

 

 

 

Originally Posted by holly6737 View Post

It's my philosophy that every single birth should follow with gentle cord traction. I follow the WHO guidelines on active management of the third stage. I catch baby. Baby immediately goes to mom. Cord pulses. Cord pulsations slow or cease. Clamp, clamp, cut. Gentle cord traction with brandt-andrews. Deliver placenta. Pit running in IV (or injected IM if woman does not have IV). Fundal massage. Assess for bleeding. If uterus is not firm after delivery of placenta with fundal massage, follow with sweep of lower uterine segment to evacuate any remaining clots and consider other uterotonics such as cytotec, methergine or hemabate.

 


 

 

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#218 of 229 Old 04-17-2012, 10:42 AM
 
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Originally Posted by holly6737 View Post

OR you don't understand how patient/provider relationships work in practice. 


I guess you have never been railroaded by a hcp in any situation, nor believe it to be possible. I've dealt with it several times recently, not birth related, so maybe I am overly sensitive. I think though that you had many times to clarify, had you thought about how your replies were being perceived or taken the time to do something other than throw insults at ucers, cpms, and anyone interested in making their own healthcare decisions.

 

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#219 of 229 Old 04-17-2012, 10:47 AM
 
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I guess you have never been railroaded by a hcp in any situation, nor believe it to be possible. I've dealt with it several times recently, not birth related, so maybe I am overly sensitive. I think though that you had many times to clarify, had you thought about how your replies were being perceived or taken the time to do something other than throw insults at ucers, cpms, and anyone interested in making their own healthcare decisions.

 



I am totally fine with patients making their own healthcare decisions! They just don't have the right to force their healthcare provider to be a part of their plan of care, (or at least they shouldnt' have that right). Make your own healthcare decisions, by all means. All you have to do is find someone to go along with them.


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#220 of 229 Old 04-17-2012, 10:49 AM
 
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Thank you for this. This is exactly why I get noxious every time I read one of her posts. And just for the record, they really should teach a class (maybe more than one), on ethics, patients rights, and analysis of scientific data. Maybe they already do but it didn't sink in.  If you don't know what kind of data go into a meta-analysis, you don't know what is coming out! I deal with this on the every day basis and it shocks me that someone would not read current literature. Maybe it is because it is easier getting fed like a baby bird. I think this conversation is done. There is really nothing to add here because Holly does not have an open mind for discussion and is changing her story as she goes along. She learned her ways in school and is going to practice just like she thinks is correct. Good luck, Holly. But for sure that is not evidence based practice!
 


 

 


You never answered my questions about how your hcp changed their practice protocols to be uniform with the most recent mono-twin, di-twin study or how their staff keeps up with protocols that change q monthly as new literature appears....

 


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#221 of 229 Old 04-17-2012, 11:11 AM
 
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And I really won't even go there! Do you know why? I will have to read the original study, then other studies that one cited. I am not even that familiar with twin births to begin with. This is not what this thread is all about. However, if I was pregnant with twins, I would dig deep into the research and my hcp would do too (and she's already experienced with this), so it would be a great thing finding out what works for me and see what my options are. I am not here to amuse you. Others have asked you to explain some of the findings in the studies you cited yourself, and you didn't spend a minute responding. Why would I spend a couple hours of my life on this? Like I said before, you are here defending your views and you are not open for a real discussion. Back to work now. I will be reading some wonderful original research and thinking about what your patients will be missing out!
 

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You never answered my questions about how your hcp changed their practice protocols to be uniform with the most recent mono-twin, di-twin study or how their staff keeps up with protocols that change q monthly as new literature appears....

 



 

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#222 of 229 Old 04-17-2012, 11:19 AM
 
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Originally Posted by holly6737 View Post

I am totally fine with patients making their own healthcare decisions! They just don't have the right to force their healthcare provider to be a part of their plan of care, (or at least they shouldnt' have that right). Make your own healthcare decisions, by all means. All you have to do is find someone to go along with them.


Ok Holly, I'm gonna let you have the last word. Apparently I am the moron you have been implying I am throughout the whole thread, or at least in the beginning of our exchanges. But, I don't know... if you are trying to communicate and 10+ people are misunderstanding you, maybe you are the one not communicating well. If you had cut out the snide remarks and insults in the beginning maybe we could've had a more helpful conversation.  

 

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#223 of 229 Old 04-17-2012, 12:26 PM
 
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Oh my god you guys, are you still talking to Holly about this? ROTFLMAO.giflol.gifhappytears.gifwild.gifhug2.gifdrink.gif

 

This thread should be dead...as it is very clear what is going on.

 

 

Holly has a view point and attitude about birthing, which runs counter to the intuition and understanding about birth that is shared by the vast majority of women on these boards.

I'm not talking about anything specific, fundal massage or anything...I'm talking about her views at their root as compared to the rest of us. Most of the people on this site are not looking for a provider like Holly, even if there are people on these boards who are cool with the tests and practices she is talking about...most of us would not tolerate a provider with her general attitude about birth.
That's okay. There are a ton of women out there who feel differently from us, who want a hyper-managed pregnancy/birth. I tend to prefer more a provider who is willing to do all the tests I might want...who knows all about them and can tell me all about them...but who respects me and doesn't try to fight me when I say things like "I actually don't feel I need the GD testing...I've never had the testing before, I've never had GD and I am all set" - instead of telling me, basically, that I'm out of luck with her if I don't agree to testing that nothing is indicating I need. But some women want to hear "This is best, I would do it" and they will say "yes" and they will feel safer, happier and more at peace...and isn't that what we want? That is what it means to be a proponent of Birth Choice. We push for all women to be able to choose alternative paths...and respect that many women will want a really mainstream experience and that they are entitled to that desire.

 

So, that's what is happening....you read what she says and you go all looopy in your brains because you can't wrap your head around someone on this site, who is becoming a birth professional, ACTUALLY saying the things she is saying. That's alright...it's not supposed to make sense to you. It's a different language.

 

Holly, your attitude toward birth, birthing women, pregnant women and your perspective on your role as a birth worker make me want to weep bitter tears while I vomit in my lap...but you have every right to become whatever kind of provider you truly think is needed out there in the community. I can tell you really believe all this stuff you are saying..that's cool, I really believe all the stuff I've said, too. Look at us, a bunch of chicks, sittin' around, empowered in our convictions. happytears.gif

The truth is, there are a ton of women out there who are a little less inspired to seek alternative paths, who are seeking a care provider who is going to manage the shit out of their pregnancies/births and who will tell them what to do and be all "I'm a freaking nurse, obey!" - and all of that. I'm not being sarcastic, there are a lot of women who really do want a provider to take charge, who really become overwhelmed, frazzled and scared when they are faced with a lot of choices and question marks...so...go on ahead with your bad self.

Good luck on your tests and in your continued studies. If you are able to pass all your requirements, I'm sure you will have no trouble finding business.
My only wish, is that you will forever remain at outspoken and brash with your beliefs as you have been on this thread....so that women who are looking for what you truly offer can find you and women who are DEFINITELY NOT looking for what you really offer can avoid you and the possibility that they will be left, late in their pregnancy, facing your "my way or the highway" mentality over a decision that they really shouldn't have to compromise on.


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OR you don't understand how patient/provider relationships work in practice.



I'm now convinced you like to be insulting. How you communicate with your patients is not "how patient/provider relationships work in practice". They're how you do things. Coming out with "or you just don't understand how..." about something as variable as patient/provider relationships is pointless and condescendingt. FWIW, the only provider I've ever had who even acknowledged that I had a viewpoint on my own birth was my unlicensed midwife. All those safe, wonderful professionals you're raving about informed me how it was going to be (and changed their tunes on that, as it suited them) and completely ignored everything I said to them. (Okay - my last one didn't, but since I was already signing up for the full elective c-section package, there wasn't a lot for us to disagree about. She did, admittedly, close me with sutures at my request, so I'll give her some credit there. It made a huge difference in my recovery.)

 

Many of us have been on the patient side of the "relationship". We don't see it the same way you do. Maybe you don't understand how patient/provider relationships work in practice. You handle your practice the way it works for you. (I do wonder if you'd disclose that fundal massage can be very painful when talking about active management, though. IME, care providers never even mention the downsides of the course of action they're recommending. I've never once heard it happen in real life.) That doesn't mean that all providers operate that way.


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#225 of 229 Old 04-17-2012, 03:58 PM
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I have no stake in this argument, I am not a scientist, have never given birth, and know nothing about 3rd stage management, and do not have an opinion either way. 

 

With that in mind, Holly, I mean this respectfully. You may be a nice person, and a smart person, and decent HCP, but you come off as very, very rude and condescending. Your attitude is why so many women, understandably, look for other options for pregnancy care. We can all feel the condescension from your posts and that is likely why you are getting a strong reaction. Please consider a change in tone. 

Again, I have no stake in this issue either way.

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#226 of 229 Old 04-17-2012, 04:30 PM
 
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I'm now convinced you like to be insulting. How you communicate with your patients is not "how patient/provider relationships work in practice". They're how you do things. Coming out with "or you just don't understand how..." about something as variable as patient/provider relationships is pointless and condescendingt. FWIW, the only provider I've ever had who even acknowledged that I had a viewpoint on my own birth was my unlicensed midwife. All those safe, wonderful professionals you're raving about informed me how it was going to be (and changed their tunes on that, as it suited them) and completely ignored everything I said to them. (Okay - my last one didn't, but since I was already signing up for the full elective c-section package, there wasn't a lot for us to disagree about. She did, admittedly, close me with sutures at my request, so I'll give her some credit there. It made a huge difference in my recovery.)

 

Many of us have been on the patient side of the "relationship". We don't see it the same way you do. Maybe you don't understand how patient/provider relationships work in practice. You handle your practice the way it works for you. (I do wonder if you'd disclose that fundal massage can be very painful when talking about active management, though. IME, care providers never even mention the downsides of the course of action they're recommending. I've never once heard it happen in real life.) That doesn't mean that all providers operate that way.


Probably 90% of the patients I've seen have (and wanted to have) epidurals. So, to them, it's not painful. When I have a woman without an epidural, I always tell her when I'm about to touch her and what I'm going to do so she knows what's happening. And I'll admit fundal massage isn't as aggressive because yeah, normally she does react and I don't like hurting people.

 


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#227 of 229 Old 04-17-2012, 06:12 PM
 
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Probably 90% of the patients I've seen have (and wanted to have) epidurals. So, to them, it's not painful. When I have a woman without an epidural, I always tell her when I'm about to touch her and what I'm going to do so she knows what's happening. And I'll admit fundal massage isn't as aggressive because yeah, normally she does react and I don't like hurting people.

 



May I gently suggest that you mention this when telling her about your labour management protocol, instead of while she's in the throes of one of the most intense experiences of her life? I'm not trying to be argumentative (this time - sometimes, I probably am), but I, personally, am very frustrated by the number of things that care providers never seem to think to mention until the last possible minute. If someone is telling me that he/she practices active management of the third stage, I want to know if that includes cord traction, pit and/or fundal massage. And, if any of those procedures are/can be painful, I want to know about that, too. I don't want it sprung on me just as he/she is about to start. In a true emergency, there isn't always time to discuss details, but when it's something you do routinely, your patients should know what it really is. And, you know...I don't think most people would hear "fundal massage" and think "this is going to be torture" (to use the term used in the OP).


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#228 of 229 Old 04-17-2012, 06:32 PM
 
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This thread is still going? :p I just wanted to point out that I absolutely did not pick those two studies because they supported my viewpoint. I was exhausted and went with the first two studies that popped up on web of science with my choice of key words. Look..I agree..meta-studies can be useful tools. However, what I love about science is that it is always changing, new things are always discovered, and everything is up for being questioned. To me, if you really want to understand science, you have to understand that basic thing, that everything can be questioned and tested. So honestly, how dare you call yourself evidence based when really you come across as a person who is completely inflexible in your view. I'm not sure exactly how groups like the WHO work, but I imagine they update their recommendations every so often, right? Or are you saying they never change? 

 

I would hope that HCP's are capable of keeping up to date with current literature. You say this is important on one hand, yet at the same time you go on about how it's impossible to keep up with all the new studies coming out. Well, if there are studies coming out that contradict current rec's, I would think those are the most important ones for you to read. 

 

I really don't have time to go through the WHO studies, but a I would be interested in a study done on active management of the 3rd stage on women who live in a first world country and have had natural, uncomplicated births. That's the subset of women that I'm in, and I'm curious if their would be a difference between them and women who had many interventions such as pit, epi, forceps, etc etc. 

 

Holly, do you feel it's dangerous for a woman to wait 30 minutes to see if the placenta is expelled naturally before starting active management or not? I'm not clear on your views now that you've seemed to change them a bit. 


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SimonMommy:

 

In the Kashion article, I would like to point out that the control group was not managed expectantly. Everyone in the group received prophylactic pitocin after the birth of the placenta. It's considered "mixed management". Also the cord traction management occurring "immediately following the uterotonic" sounds very aggressive- no mention of looking for signs of separation? In my opinion it's possible that overly aggressive cord traction could have led to the higher rate of blood loss in the intervention group. The most recent research on cord traction supports that. By the way, the Cochrane review you listed next excluded this study from its analysis "because of the high rate of exclusion after randomization (48%)".

 

From Begley:

 

 

"Active management also showed a significant decrease in primary blood loss greater than 500 mL, and mean maternal blood loss at birth, maternal blood transfusion and therapeutic uterotonics during the third stage or within the first 24 hours, or both and significant increases in maternal diastolic blood pressure, vomiting after birth, after-pains, use of analgesia from birth up to discharge from the labour ward and more women returning to hospital with bleeding (outcome not pre-specified). There was also a decrease in the baby’s birthweight with active management, reflecting the lower blood volume from interference with placental transfusion. In the subgroup of women at low risk of excessive bleeding, there were similar findings, except there was no significant difference identified between groups for severe haemorrhage or maternal Hb less than 9 g/dL (at 24 to 72 hours)...
 
Overall, active management reduced the risk of severe bleeding, but it would be important to investigate if this benefit arose from the uterotonic component of the active management alone. The negative effects of active management appear, in the main, to be due either to 1) the administration of a specific uterotonic (e.g. hypertension due to ergometrine-containing preparations and hypotension due to IV oxytocin boluses (Lewis 2007)) or 2) possibly to controlled cord traction leading to retained shreds of membrane or placenta, thus causing the increased incidence of return to hospital due to bleeding or 3) early cord clamping leading to a 20% reduction in the baby’s blood volume. Different uterotonics will have differing effects, and clinicians will need to assess the optimum one for use in their circumstances. Recent international guidelines have turned to IM oxytocin as a uterotonic that provides effective prophylaxis but without the associated side effects (ICM-FIGO 2003; NICE 2007; WHO 2006). The increased incidence of women in the active management group having to return to hospital due to bleeding is of concern, as such bleeding takes place away from immediate access to medical assistance. This would, again, be of greater significance for women in low-income countries."
 
For some reason, the reviewers considered "severe and very severe hemorrhages" to be a primary outcome while plain-old >500ml hemorrhage is considered secondary. Do you know how hemorrhages are prevented from becoming severe or very severe? Administration of one or more uterotonics, for one. So you've got your first line, pitocin, which has very few adverse effects in terms of management of PPH, and then if that doesn't work you've got cytotec, either buccal or per rectum (per rectum HURTS btw), methergine, hemabate- all of these have very unpleasant adverse effects, but they are considered preferable to uncontrolled hemorrhage/hysterectomy. VIGOROUS fundal massage. This hurts like holy hell but again, better than bleeding out and losing your uterus. Manual removal of the placenta, if it's still in there and not coming with cord traction. This also hurts like holy hell. All of these things hurt like holy hell by themselves, but put together, it's truly awful. It leads to those delightful adverse effects the studies refer to. Labor was nothing compared to management of my postpartum hemorrhage following expectant management; the initial significant pain and then the day of feeling shitty and nauseous as result of PO cytotec given as a result of continued heavy bleeding after the official hemorrhage ended. This thread began with the OP wondering why something that hurt so much was done with no apparent reason, so I wanted to specifically address the alternatives. The other alternative is, of course, a relatively discomfort-free third stage. Most women do not hemorrhage. Some do. As one of the ones who did, with no previous intervention or risk factor, I will tell you that it sucks.
 
Another issue I have with this meta analysis is that what they consider an integral part of "active management" includes immediate to up to 1 min cord clamping and cutting. This is not the recommendation of the WHO: http://apps.who.int/rhl/pregnancy_childbirth/childbirth/3rd_stage/cd004074_abalose_com/en/index.html  Delaying the clamping of the cord for up to 3 minutes (that may not sound like much, but the research on delayed clamping and cutting has found the benefits in effect by that time- see academicobgyn.com for his grand rounds on the topic). 
 
Athalbe: This was a PILOT study, with a tiny n. It looked at one aspect of active managment, cord traction. Both groups received prophylactic pit, perhaps the most effective aspect of active management.
 
That's my take on these studies. 
 
Just to throw it out there, I would still support a woman who wanted a hands-off third stage, with the explanation of what reasons would cause me to want to deviate from that plan. There's no way I would fire a patient for that. 
 
 
 
 
 
 
 

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