topical thursday #2 - postpartum practices (placental procedures)

well since i'm in my postpartum period, seems like a good topic for chldbirth education. one thats often glossed over in live cbe.

i guess there are two componets to the postpartum period: mother care and baby care.

and i guess postpartum actually begins when? after baby is born? before the cord is cut? after? lets just start with the 3rd stage of labor, delivery of the placenta

gloria leamy recently posted an excelent article about the "30 minute third stage" http://www.glorialemay.com/blog/?p=161

heres a different take on third stage mqnagement from the aafp http://www.aafp.org/afp/20060315/1025.html

basically the delivery of the placenta is managed either physiologically or actively. in a physiologic third stage the birth attendant does nothing other than watch for some time. loria suggests 30 minutes. the aafp states that there is a ower incidnce of postpartum hemmorhage in an actively managed third stage though. active management includes "uterotonic medication", early cord clamping and cutting, and controlled cord traction.

this from the article from the aafp:

"A Cochrane systematic review6 identified five randomized controlled
trials (RCTs) comparing active and expectant management that included more than
6,400 women. Compared with expectant management, active management was
associated with: a shorter third stage (mean difference, -9.77 minutes); a
reduced risk of postpartum hemorrhage (number needed to treat [NNT] = 12) and
severe postpartum hemorrhage (NNT = 57); a reduced risk of anemia (NNT = 27); a
decreased need for blood transfusion (NNT = 65); and a decreased need for
additional uterotonic medications (NNT = 7).6 Active management also was
associated with an increased risk of maternal nausea (number needed to harm
[NNH] = 15), vomiting (NNH = 19), and elevated blood pressure (NNH = 99), likely
caused by the use of an intramuscular ergot alkaloid as the uterotonic
medication in four of the five studies in the systematic review. There were no
advantages or disadvantages for the baby with either approach."

BTW: let me explain nnt and nnh. actually heres a wiki on it http://en.wikipedia.org/wiki/Number_needed_to_treat

dr. sara j. buckley weighs in in favor of a physiologic third stage here http://www.birthresourcenetwork.org/the-news/68-leave-well-alone-a-natural-approach-to-the-third-stage-of-labor dr. buckley takes the reduction in blood transfer from the cord to the baby into account in her article.

"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.'10
It is estimated that early clamping deprives the baby of 54 to 160
ml of blood,11 which represents up to half of a baby's total blood volume at
birth. "

and here is a very detailed look at the third stage from childbirth connection

http://www.childbirthconnection.org/pdf.asp?PDFDownload=gecpc3ch33

this is actually taken from the book A Guide to Effective Care in Pregnancy and Childbirth (Oxford University Press, 2000)

In all that i just read it seems to boil down to what the mother wants. the risk of post partum hemmorhage is about 4%. some women would want to do everything to eliminate even that risk whereas others would prefer to have that time of undisturbed bonding as a new family.

in my own case i would have strongly prefered a physiologic third stage. but i can see that active management is an evidence based option as well. it does reduce risk....i just don't feel that the risk is high enought to warrant all the fiddling.

of course there is a third option...... http://en.wikipedia.org/wiki/Lotus_birth