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Nurses pushing on stomach after birth - help.

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29K views 228 replies 43 participants last post by  Katie8681 
#1 ·
I'm going to have my 4th baby in April (3rd VBAC). 5 years ago I had my 3rd girl which was an all natural hypnobabies birth at a hospital. After I had her, the nurse literally pushed over and over and over again on my stomach getting more blood to come out each time and citing that it was "necessary" to do so. I felt that she was using as much pressure as she could with both hands on my stomach pumping vigorously and more than a bit EVIL! My thought was that the blood would eventually come out on its own - wouldn't I be bleeding for weeks anyway? It hurt so badly and felt like torture to me. I literally wanted to jump out of the bed and smack her. I'm wondering if this practice is really necessary, why it's done as it wasn't done to such extremes with baby #2 which was also a VBAC and how to prevent it from happening in April. We are going with a midwife this time and a different more natural birth friendly hospital, but I want to be prepared in case it happens again. And again, this was the nurse that was doing it - not the OB. Thanks for any help!
 
#227 ·
Quote:
Originally Posted by holly6737 View Post

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).
 
#228 ·
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.
 
#229 ·
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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