# Nurses pushing on stomach after birth - help.



## Carrissa (Jul 21, 2006)

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!


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## iowaorganic (May 19, 2007)

Yeah- they did that to me too each time in the hospital. And now that I think of it- my hb midwife (baby #4) did NOT do this one bit! I would ask your midwife why and if they do that where you will be delivering. Could it be to get the placenta to detach quicker? I don't know- I know that I had to deliver the placenta at the hospital right after the baby way born- and when I was at home the placenta didn't come for about 30 minutes or longer- which was awesome to have a nice break. I don't know if that is the reason- just my guess.


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## Spring Lily (Sep 26, 2006)

I gave birth in the hospital and they did this a little after my vaginal birth, but after my c-section it was really bad. It had nothing to do with the placenta, this is in recovery, later. I was told that it had to do with checking on the blood clots, because if they are a certain size that would be a safety issue. I assume it was worse after the c/s because I'd just had a major surgery in that area!

I'd talk to your MW about it and call the charge nurse in your hospitals L&D dept. That's who would be able to explain the reasoning for that and discuss your choices with you. If it is about clots, perhaps there are other things they can do. I understand your fear, because it was pretty horrible my last time. For some reason it wasn't too big of a deal with my vaginal birth, but it was over really fast that time. Good luck in coming up with a plan you feel more comfortable with!


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## Alenushka (Jul 27, 2002)

Fundal checks and fundal massage.

http://community.babycenter.com/post/a4182425/why_do_they_massage_belly_after_birth

This is what &D nurse wrote above

"I'm a postpartum nurse and the one doing the fundal checks. Labor and delivery nurses do fundal massage in the first hour or so after the birth to ensure that the uterus clamps down like it should to slow the bleeding. This can be uncomfortable. This helps to dispel clots and placental/amniotic fragments and such as well. During this time, you may also receive pitocin through an IV, an injection in your leg, or a suppository if your bleeding is heavier than they would like. We also do fundal massage if your bleeding is too heavy, if your uterus is lax, or if you pass large clots for the same reasons. Once you are stable and there are so signs of heavy bleeding or clots, we generally only do fundal checks 2-3 times in 24 hours to catch potential bleeding complications before they start. These fundal checks and massage are much easier than the alternatives if you are bleeding! You could opt out, I suppose, but it would make it very difficult to do our jobs of making sure that you are safe, healthy, and able to care for yourself and your baby. The uterus does shrink back on its own, but sometimes needs encouragement and that is what we are there for!! "


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## mom2qts (Sep 3, 2011)

As unpleasant as this is I was told by my midwife that this is something she does somewhat regularly to prevent excessive bleeding. They aren't just pushing blood out they are helping the uterus clamp down after the fact to stop too heavy of bleeding. I had it done after my first 3 pgs and hated it but never thought much more about it. Then came number 4. He was an unexpected UC delivery, he just came so fast no time for the midwife to arrive. Before he was completley out I already knew something wasn't normal cause with each push lots of blood would come out. Then once I delivered him I just kept bleeding very heavily. We ended up calling the paramedics who were idiotically obsessed with the fact that the baby's cord hadn't been cut and acted like it was life and death if that that wasn't done immediatly. So even though I mentioned the heavy bleeding they didn't pay much attention until we got into the ambulance where I started hemmoraging and thats the last thing I remember for some time. Long story short after i retold the events to my miwife she had told me that if she had been there she would have "massaged" the uterus and it most likely would have stopped it from getting to full blown hemmorage. I don't know your situation but maybe the nurse didn't like the amount of bleeding she was seeing and wanted to be proactive before things got out of control? Just a thought.


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## SilverMoon010 (Jul 15, 2009)

I just gave birth (hospital) on 2/1 and I can feel your pain...literally! I don't remember them doing that with my first 4 years ago but they probably did. It DOES feel like pure torture and I also wanted to smack the nurse. If only pushing really hard once wasn't enough, she kept doing it over and over again to get all of the blood and urine out. I never knew why she had to do that so thanks for asking this question! I am learning a lot as to why they need to do it. I just think using the term "massage" is a little misleading, however


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## mom2qts (Sep 3, 2011)

I couldn't agree more! I think I laughed out loud when my midwife said it. You can call it anything you want but its still miserable!


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## JPiper (Apr 9, 2011)

I don't know what made me start reading this thread but ooch! It brings back some squishy and unpleasant memories.... Good luck!


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## katt (Nov 29, 2001)

I had some bleeding, enough that my mw told my dh to feed me iron rich foods for dinner and a while (thus broccoli beef, yum). I think there was even thought of transfer, but no one mentioned anything to me.

My MW never did any fundal 'massage' (if you can call it that)

I figure if I start bleeding too much I'll take a bite of my placenta. That should stop things pretty well.


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## dovemama (Dec 12, 2011)

Quote:


> Originally Posted by *JPiper*
> 
> I don't know what made me start reading this thread but ooch! It brings back some squishy and unpleasant memories.... Good luck!


Yikes, me too. I am not ready for those pains again!


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## angelpie545 (Feb 23, 2005)

My first two births were with my midwives, and I can't quite remember if I have fundal massage after their births. I had some pretty bad bleeding with my first, nearly passed out and had to have an IV, so I'm rather certain that's what they did. It was almost 12 years ago (my baby is so big! lol) so I can't recall exactly. #2 is kind of a blur as well. I know with my son in the hosptial they definitely did it, but I had an epi so I didn't feel much. I do remember that it was very uncomfortable and doing a lot of the massaging myself. I didn't bleed excessively that time, though.


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## srmomof2 (Feb 23, 2012)

One of the midwifes I had for my last baby prepared us in class for it- it is called fundal massage, but she would joke and say it is "more like fundal punching." Maybe the nurse or midwife you had probably should have warned you first what they were doing. A little "I'm going to massage your uterus to make sure it clamps down and slows bleeding. It will be uncomfortable." would go a long way in warning you about what needs to be done.


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## LiLStar (Jul 7, 2006)

I've never had excessive bleeding, but I can totally understand that if there IS excessive bleeding, or the uterus doesn't seem to be shrinking or contracting the way it needs to, or suspected retained placenta, or whatever *abnormal* thing is happening, that unpleasant measures might need to be taken which, though unpleasant, are better than, say, bleeding out and dying. That said, never, in 3 births (1 c-section, 2 hbac) has anyone ever done more than very gently feel for the location of my fundus to verify that it was firm and shrinking. It has never been painful or even uncomfortable. Since everything was normal, nothing else was done.. as it should be.. if its not broken, don't fix it.


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## ExperientialMom (Feb 14, 2012)

I'm only in my first pregnancy, so I can't offer any advice or direct experiences. My friend (a true trooper in the delivery room!) mentioned that the nurses "pushed" on her stomach afterward, but she didn't present it as a big deal. Thank you for your insight; I'll be sure to mention to the nurses in the beginning stages of delivery that I'd appreciate a heads up and/or gentle massage rather than hard pushing. I can see that massages are necessary (or helpful), but I'm sure there are different ways to do it.


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## cappuccinosmom (Dec 28, 2003)

This was done to me with my last 3 births. And though I was in a hospital, it was midwive who were caring for me. The one that started it, I bled very badly, so from now on they do it preventatively.

Yes, it hurts. This last time they did it very mildly to start with, but because of the amount of blood and size of the clots, they got more vigorous. It was seriously as bad as labor. But I would rather that than bleed out. And because I knew what the midwives were doing, and the reasoning behind it, I was OK with what was going on.


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## Carrissa (Jul 21, 2006)

The thing with it was that she never said I had excessive bleeding or that it was too much blood to be comfortable with. I wasn't even lightheaded and yet, she was like a nazi about it. It was not a massage - punching was a more accurate term!


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## kitson (Mar 6, 2012)

My grandma was a nurse before and she did this, but I don't know why.


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## womenswisdom (Jan 5, 2008)

When the placenta detaches from the uterine wall, the blood vessels that have been supplying it for the past 9 months are still open. They are interwoven with the muscle fibers of your uterus, so if your uterus contracts down, you will not bleed too much. If the uterus does not contract down well, the blood vessels will continue to bleed freely. When a nurse or midwife checks your uterus after birth, they are feeling for the tone of the uterus - firm or boggy. If it does not feel firm, the first thing they need to do is to cause it to contract, which is what fundal massage does. If your uterus is boggy, it's going to hurt more than a uterus that is clamping down nicely - unfortunately, if you need it, it's going to hurt. Sometimes, more vigorous massage is necessary to expel clots that can block the cervical opening and cause concealed bleeding. Also, anything in the uterus can prevent it from contracting effectively, so the clots need to come out. So that's the deal with the fundal massage.


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## Buzzbuzz (Aug 27, 2011)

Isn't that one of the advantages of an epidural -- that fundal massage, if needed, isn't painful?


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## Zenmama1 (Aug 10, 2011)

I don't recall having this done to me. But my OB did gently massage my belly as she pulled my placenta out. Maybe she didn't need to be rough because I breastfed immediately?? Since BF makes the uterus contract I wouldn't think it would be necessary to do a rough massage.


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## Slmommy (Jan 22, 2012)

I have read delivering the placenta in a vertical position will aid in the uterus clamping down as the weight from your organs above helps. Of course that is not always an option in some settings or with epidural.


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## Buzzbuzz (Aug 27, 2011)

Depends on the nature of the epidural...


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## Slmommy (Jan 22, 2012)

I thought walking epidurals were not allowed in all hospitals?


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## phathui5 (Jan 8, 2002)

Quote:


> Originally Posted by *Buzzbuzz*
> 
> Isn't that one of the advantages of an epidural -- that fundal massage, if needed, isn't painful?


No, since it's something that's done postpartum.


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## Buzzbuzz (Aug 27, 2011)

Actually, isn't it usually done almost immediately post-partum? A friend says she had it performed while the epidural remained in place (also remained in place for a short while after delivery to deal with afterpains).


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## branditopolis (Mar 14, 2011)

I don't know how I stumbled upon this thread but...

This didn't happen to me. I was hemmoraging because I take blood thinners but no one massaged me, they just kept checking and changing my pads. Could they have not done it because it might release too much blood?


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## Lizbiz (Jun 15, 2008)

I've had two homebirths and have never had this done. And no one ever pulled my placenta out either; I just pushed it out all on my own. Afterward, I almost immediately started nursing my baby, and we just checked periodically to make sure the uterus was clamping down ok.

My dad is a doc and has delivered a few 1000 babies  - and he has told me of a few times where he's had to do fundal massage in order to convince a lax uterus to contract appropriately. But he's never mentioned that being standard protocol - he did it only when there actually was an issue, not as a preventative measure. The uterus, when left to its own devices, generally gets things right. But if you are pulling on the placenta to get it out, I can see that you may need to do this, since it's not being given time to do its own thing.

Reading the nurse's explanation - it seems like just one more thing they think they MUST do to ensure your safety. Really, it seems to me that simply checking that the uterus is clamping down periodically and educating the mother on what normal bleeding looks like (which is what my midwife did) should be sufficient to ward off issues.


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## holly6737 (Dec 21, 2006)

Fundal massage is standard protocol, and should be done in all births. It's a part of the "active management of third stage" which is encouraged by the WHO. It prevents uterine atony and PPH. It is an imperative part of the birthing process, unless you want to lose an uncommon amount of blood. It can hurt, but it's very important. Nurses and midwives don't push on your belly to hurt you, they push on your belly to control postpartum bleeding.


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## Slmommy (Jan 22, 2012)

Quote:


> Originally Posted by *holly6737*
> 
> Fundal massage is standard protocol, and *should be done in all births*. It's a part of the "active management of third stage" which is encouraged by the WHO. It prevents uterine atony and PPH. *It is an imperative part of the birthing process, unless you want to lose an uncommon amount of blood.* It can hurt, but it's very important. Nurses and midwives don't push on your belly to hurt you, they push on your belly to control postpartum bleeding.


I saw an ob/gyn about 12 hours after my UC, and he commented about how nicely my fundus had contracted down. He also didn't seem to think I was losing or had lost an uncommon amount of blood. I delivered baby and the placenta in upright positions, nursed my baby, and took sheperd's purse after. No fundal massage.









Personally, this type of healthcare - an exam/procedure is indicated or necessary sometimes for someone in some circumstance = everyone must do in every case all the time, is the kind of care I am seeking to avoid.


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## justKate (Jun 10, 2008)

Quote:



> Originally Posted by *slmommy*
> 
> I thought walking epidurals were not allowed in all hospitals?


At my hospital, I was told that it was ultimately up to the anesthesiologist.


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## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *slmommy*
> 
> I saw an ob/gyn about 12 hours after my UC, and he commented about how nicely my fundus had contracted down. He also didn't seem to think I was losing or had lost an uncommon amount of blood. I delivered baby and the placenta in upright positions, nursed my baby, and took sheperd's purse after. No fundal massage.
> 
> ...


It's fine with me if you don't want to do fundal massage. I'm not sure how you would do it on yourself anyway since you UC. The fact is, though, that the World Health Organization recommends fundal massage after delivery of the placenta and they are a very evidence-based organization. You can choose to not follow the evidence-based recommendation if you'd like. It's your uterus.


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## Slmommy (Jan 22, 2012)

eh, I'm not arguing against the importance of fundal massage in some situations, I just don't see why it would always be necessary following every delivery. And if I did not need it, I would not want it. If I had a hcp for next birth, I would like someone who could make that call based on my situation at the time, guess that is just me.

WHO recommends a lot of things that American maternity care does not always follow... from what I remember, c/s rate should be under 15%?, more mws, cautions against routine use of arom, episiotomy, oxytocin... it's been a while since I've looked into it.


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## BroodyWoodsgal (Jan 30, 2008)

Quote:


> Originally Posted by *slmommy*
> 
> I saw an ob/gyn about 12 hours after my UC, and he commented about how nicely my fundus had contracted down. He also didn't seem to think I was losing or had lost an uncommon amount of blood. I delivered baby and the placenta in upright positions, nursed my baby, and took sheperd's purse after. No fundal massage.
> 
> ...


Yeah, the bolded. I will not sit here and say that fundal massage is always unnecessary...but I'd also like to suggest that many it's not necessary every single time. This idea that it is totally necessary every time, for every woman, is nothing more than another way in which the medical model seeks to assert that, if left alone, the body will surely fuck up and kill you at some point during/directly after your birth. It's nonsense. If you need it...you should have it, it could save your life. If you don't need it and don't want it, you shouldn't be subjected to it because it damn well hurts like hell. It's not like it's black or white...you can just check the uterus and see if it needs help and give the help it needs...ONLY if it needs it. Doesn't that seem reasonable?

I've had two intense, but peaceful, 90 minute out of hospital births here and no fundal massage either time. I know that my MW did touch my uterus to try and determine if it was having trouble clamping down (and, being at home and far from a hospital, I don't mind being checked to make sure I'm not bleeding "uncommonly")...but that was NOT immediately post partum and my uterus was doing a fine job, so there was no massage of any kind to "help it" clamp down.

Furthermore, were in my home OR at a hospital and someone came along and started doing something to me that hurt me very much and I didn't know the reason why..they would be stopped immediately and told to back the F off and explain to me what was going on. Nobody just walks up to me and starts doing anything to me that feels anything like torture without fully explaining themselves and if I don't understand or I think it is unnecessary, I'm not going to allow them to do it. What are they going to do? Strap me down and assault my fundus? That's ridiculous. Completely ridiculous.

OP, I have heard many women say that they are not in any way fearing birthing pain or any other aspect of their birthing time...EXCEPT the massage after the fact. I know it's brutal...I'm sorry it happened to you! Maybe they can just check you out this time and see if you actually need it?


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## BroodyWoodsgal (Jan 30, 2008)

Quote:


> Originally Posted by *holly6737*
> 
> It's fine with me if you don't want to do fundal massage. I'm not sure how you would do it on yourself anyway since you UC. The fact is, though, that the World Health Organization recommends fundal massage after delivery of the placenta and they are a very evidence-based organization. *You can choose to not follow the evidence-based recommendation if you'd like. It's your uterus*.


My, what a nasty tone you've taken.

















As far as the WHO is concerned...yeah, I think some of what they say makes a lot of sense...and that a lot of what they say makes *some* sense...and that some of the things they say/recommend are complete and shameless bullshit and make no sense at all. "Evidence" comes from research...shitty research makes for shitty evidence...so, there is such a thing as a WHO recommendation based on shitty evidence...therefore, "shitty recommendation" - I'm not saying that the recommendation that fundal massage be AVAILABLE to all mothers who have given birth is shitty. The bottom line is, there is no one organization on earth that you can look to for the "ultimate truth" every time. The fact that the WHO "said so" means about jack to me until I see the research behind it. Have YOU personally seen the research that provided the evidence upon which this WHO recommendation is based?

The simple FACT of the matter is, not every woman needs it every time. Can't you agree to that? A competent birth worker/woman can check the uterus, observe the bleeding, inspect the placenta and make a more than reasonable guess as to whether or not it is needed.

I do not object to unnecessary fundal massage just for the sake of being contrary...I actually prefer, based on research/evidence/experience, to allow my body to function unhindered when it is doing it's work well. I do not believe that nurse-nosy and her torture hands knows how to clamp down my uterus better than my uterus, until my uterus is not doing it right.


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## fruitfulmomma (Jun 8, 2002)

active management of third stage also includes pit and pulling on the cord to yank the placenta out. should both of those procedures be part of every birth as well???


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## katelove (Apr 28, 2009)

[quote name="holly6737"

It's fine with me if you don't want to do fundal massage. I'm not sure how you would do it on yourself anyway since you UC[/quote]

Actually it's easy to do on yourself. I have worked in places where women are shown how to check their own fundus and massage if necessary.


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## BroodyWoodsgal (Jan 30, 2008)

Quote:


> Originally Posted by *fruitfulmomma*
> 
> active management of third stage also includes pit and pulling on the cord to yank the placenta out. should both of those procedures be part of every birth as well???


Exactly.


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## Katie8681 (Dec 29, 2010)

For those who were saying they felt fine and things seemed normal when all of a sudden the intense fundal massage was done: I had a PPH and it was a serious bleed. Baby was at my breast after my non-augmented, non-medicated, spontaneous placenta birth, and suddenly I felt a gush and said so. It honestly didn't feel like much. I certainly didn't feel lightheaded or anything, since becoming symptomatic often only happens once a PP mother has lost a _great deal_ of blood. My midwife and my husband told me later I had been absolutely gushing bright red blood. I totally trusted my midwife and nurses to do what was necessary, and asked the questions later. I would encourage people to ask their care providers afterwards what the heck happened. Some nurses/midwives/docs are too rough, it's true.


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## JollyGG (Oct 1, 2008)

It sounds like your 1st was a c-section (if your second was a VBAC) and this is simply much more painful after a c-section and most nurses are a lot more aggressive with it after a c-section. When I asked about it after mine I was told that it's not unusual for the uterus to fail to contract down as it would in a vaginal delivery and it needs a little help. I suppose this makes sense in a scheduled c-section where there were no contractions to begin with. But wow does it hurt.


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## Marissamom (Dec 17, 2009)

with my second I just wasn't stopping bleeding, slow hemorrhage, my MW had me sit on the toilette, pee, and she pushed on my fundus, and I passes a fist-sized clot that had been keeping my uterus from contracting fully. but she only needed to do it once, and all was well. if they're doing it again and again then either they're doing too much, or your uterus isn't contracting like it should be.


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## farrah skye (Dec 8, 2004)

thanks for explaining. I'm another mom who came across this. i cant rememeber if i had this done after my 1st two. There was U psuhing but not like ur saying. my 3rd was a c section.


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## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *fruitfulmomma*
> 
> active management of third stage also includes pit and pulling on the cord to yank the placenta out. should both of those procedures be part of every birth as well???


It doesn't advocate pulling on the cord to yank the placenta out. It advocates gentle cord traction with Brandt maneuver to deliver the placenta in a timely fashion.

Yes, I believe both of those should be a part of every birth as well, especially something like a UC. When you UC, you're essentially giving birth as if you are in a third world country so you need to do everything you possibly can to avoid excessive bleeding. A shot of IM pit and gentle cord traction with fundal massage after the delivery of the placenta can all help you avoid PPH, which very well could cause you to bleed excessively and affect your milk supply.


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## fruitfulmomma (Jun 8, 2002)

Because women in America who uc have to walk for hours to access emergency care and are malnutritioned. And who is going to admin the pit???

So, again where are your studies showing interferance is nessacery at *every* single birth?


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## Slmommy (Jan 22, 2012)

Why would a woman who had a successful UC, (baby born ok), be in more need of active management for 3rd stage? I mean, everything worked right up to that point for baby to be born, no medications/interventions... and yeah, you can go to hospital if pph...? If I had problems birthing placenta, the last, last thing I would ever do is pull on cord. I would have gone to hospital. If there were chunks missing or I was bleeding heavily, I would've gone to hospital.

I understand WHO is making world recommendations, but I am getting really sick of the comparisons between complications/outcomes for women who hb/uc to women giving birth in war torn, famine stricken nations with no or little medical access. There are far, far too many other variables to make those things comparable. Education, resources, prenatal care, access to medical care, nutrition, clean water, hygenic birthing supplies, not to mention in a lot of worst birthing nations there are issues of FGM, abuse, teenage pregnancy, etc.

For what it's worth, I did have my UC in what considered a "3rd world country" - one with a 90% c/s rate for women with private insurance, which of course was a major motivator in having baby at home.


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## fruitfulmomma (Jun 8, 2002)

I read this just a little after I posted this morning.... http://www.huffingtonpost.com/robin-lim-cpm/birth-on-the-edge_b_1412505.html

Robin Lim (CPM working in Bali) states "Fortunately, we are able to give each expectant mother prenatal vitamins, due to the generosity of our friends at New Chapter (vitamins) in Vermont. Even so, it's an uphill battle against malnourishment and the impact of one of its main culprits "New Rice," a strain of high-yield white rice that has replaced the nutritious red rice that was once the staple food of this region. *It's now a leading factor in the alarming rate of women hemorrhaging after childbirth.*" (emphasis mine)

Why should women who are healthy and showing *no* signs of pph be treated in the same manor, with interventions that are not without their own risks, as women who are impoverished and malnourished???


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## Katie8681 (Dec 29, 2010)

I wouldn't recommend the cord traction part to a UCer. IMHO it's too likely to lead to partial separation of the placenta---> hemorrhage. It's not always obvious when the placenta has completely separated. With a UC, if the placenta isn't coming by itself, it's time to go to a skilled care provider with tools at hand to manage a hemorrhage.


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## BroodyWoodsgal (Jan 30, 2008)

Quote:


> Originally Posted by *holly6737*
> 
> It doesn't advocate pulling on the cord to yank the placenta out. It advocates gentle cord traction with Brandt maneuver to deliver the placenta in a timely fashion.
> 
> Yes, I believe both of those should be a part of every birth as well, especially something like a UC. When you UC, you're essentially giving birth as if you are in a third world country so you need to do everything you possibly can to avoid excessive bleeding. A shot of IM pit and gentle cord traction with fundal massage after the delivery of the placenta can all help you avoid PPH, which very well could cause you to bleed excessively and affect your milk supply.


"Gentle cord traction to deliver placenta in a timely fashion" should be a part of every birth??? Especially a UC???? Are you joking me? I would slap somebodys face if they yanked on my cord after delivery. That's insane. The placenta will deliver itself in most cases when left alone and advising women in a UC situation to pull on the cord after a normal delivery is just crazy.

"When you UC, you're essentially giving birth as if you are in a third world country" - ummm, what the hell do YOU think it is, that separates the way we are living, from the way people in third world situations are living?? Because I can promise you, it's not the absence of a flat screen TV and some fritos to munch on. We're talking about possibly severe, generations long malnourishment, possible underlying untreated disease, possibly filthy conditions, possible outbreaks of pretty crazy illness around the pregnant mother...and that's just a beginning list. On what planet are you living, that you think a woman having a UC is in any way, shape or form giving birth as if she were in a third world scenario?? That's just obscene, insulting and completely naive.


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## BroodyWoodsgal (Jan 30, 2008)

Quote:


> Originally Posted by *fruitfulmomma*
> 
> I read this just a little after I posted this morning.... http://www.huffingtonpost.com/robin-lim-cpm/birth-on-the-edge_b_1412505.html
> 
> ...


Right!?


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## Marissamom (Dec 17, 2009)

there are studies showing that active management of 3rd stage has better outcome, but there are serious questions about how well done those studies are. and for what it's worth, I had one hospital birth with active management, one home-birth without. I bled considerably less, both right away and long term, without active management.


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## BroodyWoodsgal (Jan 30, 2008)

Quote:


> Originally Posted by *Marissamom*
> 
> there are studies showing that active management of 3rd stage has better outcome, but there are serious questions about how well done those studies are. and for what it's worth, I had one hospital birth with active management, one home-birth without. I bled considerably less, both right away and long term, without active management.


The thing which seriously skews the statistics for me, re: active management in the third stage of labor, is the fact that the first two stages are SOOO over "managed" in so many births these days. What percentage of women receive some type of labor augmentation now-a-days in the form of pitocin or whatever else? Isn't it like 80-85% or something? I'm sorry but, in my mind, there is a complete and undeniable difference between the needs in the third stage of a woman who has had a normal delivery and the needs of a woman who has had her labor pushed along and physiologically altered by powerful drugs.

I do not believe that a uterus which labors in its own time, in a comfortable and natural manner, will need much help in most cases. A "one size fits all" approach fails every time. For some it's too much, for others not enough...but then the medical model is just famous for that, isn't it? Drives me bananas.


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## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *BroodyWoodsgal*
> 
> "Gentle cord traction to deliver placenta in a timely fashion" should be a part of every birth??? Especially a UC???? Are you joking me? I would slap somebodys face if they yanked on my cord after delivery. That's insane. The placenta will deliver itself in most cases when left alone and advising women in a UC situation to pull on the cord after a normal delivery is just crazy.
> 
> "When you UC, you're essentially giving birth as if you are in a third world country" - ummm, what the hell do YOU think it is, that separates the way we are living, from the way people in third world situations are living?? Because I can promise you, it's not the absence of a flat screen TV and some fritos to munch on. We're talking about possibly severe, generations long malnourishment, possible underlying untreated disease, possibly filthy conditions, possible outbreaks of pretty crazy illness around the pregnant mother...and that's just a beginning list. On what planet are you living, that you think a woman having a UC is in any way, shape or form giving birth as if she were in a third world scenario?? That's just obscene, insulting and completely naive.


Yes, I believe gentle cord traction to deliver the placenta in a timely fashion should be a part of every birth. No, I do not think it should be a part of a UC birth as I don't think anyone should ever UC. Without training on how to appropriately apply gentle cord traction, you're liable to just rip the cord right off the placenta and then end up with needing a manual extraction, which no doubt you would try to do on yourself and that would just be a disaster. So, in my perfect world, no one would UC and everyone would get gentle cord traction. I believe in evidence based practice. I have been trained in evidence based practice. The evidence clearly states that active management of third stage leads to superior outcomes. To reference, I will refer you to the WHO (as was stated previously), as well as the International Confederation of Midwives (http://www.internationalmidwives.org/Whatwedo/Programmes/POPPHI/PostPartumHaemorrhage/tabid/339/Default.aspx).


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## Slmommy (Jan 22, 2012)

Well OP, I guess that answers your question... no fundal massage is not always necessary, (and cord traction, pitocin, etc.), and yes, some obgyn/mw/nurses will do it anyways, as they are "trained in evidence based practice" - which may include evidence that you do not agree with or has nothing to do with your personal medical/birth/health situation.

I suggest you ask your hcp about their views of 3rd stage management.


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## BroodyWoodsgal (Jan 30, 2008)

Quote:


> Originally Posted by *holly6737*
> 
> Yes, I believe gentle cord traction to deliver the placenta in a timely fashion should be a part of every birth. No, I do not think it should be a part of a UC birth as I don't think anyone should ever UC. Without training on how to appropriately apply gentle cord traction, *you're liable to just rip the cord right off the placenta and then end up with needing a manual extraction, which no doubt you would try to do on yourself and that would just be a disaster.* So, in my perfect world, no one would UC and everyone would get gentle cord traction. I believe in evidence based practice. I have been trained in evidence based practice. The evidence clearly states that active management of third stage leads to superior outcomes. To reference, I will refer you to the WHO (as was stated previously), as well as the International Confederation of Midwives (http://www.internationalmidwives.org/Whatwedo/Programmes/POPPHI/PostPartumHaemorrhage/tabid/339/Default.aspx).


Oh...now I understand. I totally understand. I'm a woman without a "MD" behind my name...so I'm an effing idiot when it comes to birth and shouldn't believe that I have what it takes to do it myself, despite the fact that many, many women have very wonderful, completely safe UCs all the time. Those women are all just "lucky". Preparation, research and individual skill/knowledge base have nothing to do with their success.  End of story!

Clearly there is nothing I could say to you and nothing you could say to me, that would put the two of us seeing "eye to eye" when it comes to birth. Just to make you aware, the bolded was incredibly frustrating and insulting to read. I don't know if you meant it to be or not..so, whatever. For the sake of saying it: UC birthers are not anywhere close to the idiotic monkeys asses you, apparently, believe them to be. Your dearly loved Medical Community and their "Evidence Based Practice" do/say/believe idiotic things all over the place. There is no one magical way to birthing success.


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## Slmommy (Jan 22, 2012)

Quote:



> Originally Posted by *BroodyWoodsgal*
> 
> Clearly there is nothing I could say to you and nothing you could say to me, that would put the two of us seeing "eye to eye" when it comes to birth. Just to make you aware, the bolded was incredibly frustrating and insulting to read. I don't know if you meant it to be or not..so, whatever. For the sake of saying it: UC birthers are not anywhere close to the idiotic monkeys asses you, apparently, believe them to be. Your dearly loved Medical Community and their "Evidence Based Practice" do/say/believe idiotic things all over the place. There is no one magical way to birthing success.


For me, this thread just reaffirms uc as viable option... and stresses how important it is to know exactly who/what you are getting when choosing a hcp. If I am going to pay hcp for pregnancy/birth, I want them to make decisions about care for ME and I want them to have the expertise to know when something is actually needed or not, (not assume my uterus is going to fail at everything, all the time!)

Kinda reminds me of when you have internet troubles and call for help - talking to a real, attentive person, or getting one of the people reading off the screen - did you do a, please try b... now do c --- when x, y, z is the real issue!!

As far as all the "evidence based" backhanded insults being slung around mdc, here is an interesting article written by Union of Concern Scientists about how a lot of the times your evidence is corrupted - http://www.ucsusa.org/assets/documents/scientific_integrity/how-corporations-corrupt-science.pdf

It has nothing really to do with birth specifically but does address a whole range of health, medical, environmental concerns and how "science" is easily manipulated or discarded... very often there is plenty of evidence for either side of an issue. If you want to make all of your decisions based off of possibly biased/corrupted/irrelevant statistics or studies, that's your business.

Lest anyone confuse anything, I will state one more time, I DO understand that fundal massage is very necessary sometimes. But I fail to see why it should be done if not needed, and how hard it would really be for an experienced hcp to make that call.


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## fruitfulmomma (Jun 8, 2002)

Tha line is propably the single most offensive thing I have read on all my years at mdc and I am not a uc'er. (Ironically enogh, due to my particular circumstances, I chose Ob care in part this time because of my concerns about increased risk in grand multiparity of pph, even though I've never had it and don't expect to. I still expect my ob to treat me as a person with individual needs and not a machine.)


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## BroodyWoodsgal (Jan 30, 2008)

Quote:


> Originally Posted by *slmommy*
> 
> Quote:
> 
> ...


This is what I'm talking about. People cling to the "evidence" and "research" that comes out of some of these mega-huge institutions and I swear, most have NO idea how "paid for" and corrupted a lot of this "science" is. Even when it's not for super evil reasons, or because some corporation/industry is making sure trials and research come come out in "easily marketable" ways...the research we are fed often times cannot be taken at face value just because of how sloppy a lot of the science is. It's just sloppy and nonsensical and we must always be on guard against that sort of thing.


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## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *BroodyWoodsgal*
> 
> This is what I'm talking about. People cling to the "evidence" and "research" that comes out of some of these mega-huge institutions and I swear, most have NO idea how "paid for" and corrupted a lot of this "science" is. Even when it's not for super evil reasons, or because some corporation/industry is making sure trials and research come come out in "easily marketable" ways...the research we are fed often times cannot be taken at face value just because of how sloppy a lot of the science is. It's just sloppy and nonsensical and we must always be on guard against that sort of thing.


I'm interested to know who profits financially from the recommendation that fundal massage and gentle cord traction be a part of every birth. What motivation do the WHO, the ACNM, and the ICM have to recommend fundal massage if it is not worthwhile?


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## Youngfrankenstein (Jun 3, 2009)

Quote:


> Originally Posted by *holly6737*
> 
> Yes, I believe gentle cord traction to deliver the placenta in a timely fashion should be a part of every birth.


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?


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## LiLStar (Jul 7, 2006)

The above quote is speaking more about research that is simply sloppily done than research where someone profits based on the results. In the US, guidelines like that protect dr's from liability. The only risk is hurting the mom, which to them is perfectly acceptable. If they just do "everything they can" every time, their butt is covered. Some of us don't want to be treated like that. We'd rather be watched for signs of problems and be treated if they come up. I will not oppose fundal massage if there's signs that things are less than perfect. And I'm sure if my midwife thought something was up, she'd do it above my protests because its better than bleeding out. Also, with the in case of home birth midwives not routinely doing fundal massage, home births are just plain different from hospital births. For example, induced and augmented labors are associated with a higher risk of PPH and these days, though it varies hospital to hospital, almost everyone gets pit during labor even if they weren't induced. (http://www.ncbi.nlm.nih.gov/pubmed/309347 http://www.ncbi.nlm.nih.gov/pubmed/1984230) Obviously, home births are not induced or augmented. This site: http://pediatrics.med.nyu.edu/conditions-we-treat/conditions/postpartum-hemorrhage lists uterine atony the most common cause of PPH. A uterus that is firm and contracting well is not atonic. So in a spontaneous, non augmented birth with a uterus that is firm and contracting well with palpation and normal bleeding.. why on earth would anyone think its a good idea to start "massaging" the uterus "just because"? Observe the flow carefully and check the uterus regularly? YES!


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## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *LiLStar*
> 
> The above quote is speaking more about research that is simply sloppily done than research where someone profits based on the results. In the US, guidelines like that protect dr's from liability. The only risk is hurting the mom, which to them is perfectly acceptable. If they just do "everything they can" every time, their butt is covered. Some of us don't want to be treated like that. We'd rather be watched for signs of problems and be treated if they come up. I will not oppose fundal massage if there's signs that things are less than perfect. And I'm sure if my midwife thought something was up, she'd do it above my protests because its better than bleeding out. Also, with the in case of home birth midwives not routinely doing fundal massage, home births are just plain different from hospital births. For example, induced and augmented labors are associated with a higher risk of PPH and these days, though it varies hospital to hospital, almost everyone gets pit during labor even if they weren't induced. (http://www.ncbi.nlm.nih.gov/pubmed/309347 http://www.ncbi.nlm.nih.gov/pubmed/1984230) Obviously, home births are not induced or augmented. This site: http://pediatrics.med.nyu.edu/conditions-we-treat/conditions/postpartum-hemorrhage lists uterine atony the most common cause of PPH. A uterus that is firm and contracting well is not atonic. So in a spontaneous, non augmented birth with a uterus that is firm and contracting well with palpation and normal bleeding.. why on earth would anyone think its a good idea to start "massaging" the uterus "just because"? Observe the flow carefully and check the uterus regularly? YES!


If you read the first link you posted (the first ncbi link), you will see what I am talking about. The # 1 risk factor for PPH was prolonged third stage. That was the # 1 risk factor. In fact, prolonged third stage increased your risk of PPH 4-5x as much as augmented labor. I have heard many homebirth midwives say, "I have waited longer on placentas than I have on babies!" So who is really putting women at an increased risk for PPH? Hospital based CNMs who augment labor with pitocin? Or homebirth midwives who cause their clients to have prolonged third stage? The evidence shows that it's the homebirth midwives who cause their clients to have prolonged third stage, by an odds ratio of 7.56 to 1.66. This is why active management of the third stage is so very important. Get the placenta out in a timely manner = prevention of PPH.

We all know (or we all should know, if you are delivering babies) that atony causes 70% of PPHs. Per the AAFP, you go Tone, Trauma, Tissue, Thrombin when evaluating PPH. Tone is atony. Just to say, "Oh, it's atony" isn't enough when it comes to prevention. You have to ask yourself, "What CAUSES atony?" in order to determine how you should PREVENT atony. The cause of atony is a tired uterus. So, prolonged first stage, prolonged second stage, prolonged third stage, macrosomia, twins, multipara, augmented labor, etc. Yes, augmented labor is in there, but it's only after other causes such as prolonged third stage (as per the NCBI link you posted). It's clearly not the number one reason for atony.


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## LiLStar (Jul 7, 2006)

I was talking about fundal massage, not cord traction. I agree that there may be times when cord traction is indicated. The point is having the knowledge to know when that is. It is not unusual for a placenta to come spontaneously within a normal window of time!


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## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *Youngfrankenstein*
> 
> 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?


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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## fruitfulmomma (Jun 8, 2002)

Yep, she is saying *every* single birth that takes place no matter what the circumstances absolutely *must* have a medically managed, active third stage complete with drugs, traction, and massage. No room at all for treating each birth individually and waiting to see how mom handles third stage on her own.

Thankfully, this attitude does not yet seem to have spread completly through the medical community.


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## fruitfulmomma (Jun 8, 2002)

Google 'who active management of third stage of labour' and you should get a bulletin from them with details on their study...

7 countries, none of them western, and various methods of 'management' are reported, including multiple different drugs. Scroll down to the discussion section where you will find this gem... 'Poetentially harmful practices which can increase postpartm hemorage or other 3rd stage complications are observed in up to 94% of deliveries.'

They also state that their study suggests that there is a lack of sufficient watch over the women when it is needed most.


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## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *fruitfulmomma*
> 
> Yep, she is saying *every* single birth that takes place no matter what the circumstances absolutely *must* have a medically managed, active third stage complete with drugs, traction, and massage. No room at all for treating each birth individually and waiting to see how mom handles third stage on her own.
> 
> Thankfully, this attitude does not yet seem to have spread completly through the medical community.


Should it be considered "medically managed" if the ACNM and the International Confederation of Midwives endorse it?


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## fruitfulmomma (Jun 8, 2002)

Huh??? Why would it matter who endorses it. Giving a woman medication to manage her birth makes it medically managed. Your aren't seriously suggesting that it isn't???


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## holly6737 (Dec 21, 2006)

What I am saying is that it's within the midwifery model of care as the ACNM and the ICM endorse the practice.


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## Katie8681 (Dec 29, 2010)

Quote:


> Originally Posted by *fruitfulmomma*
> 
> Google 'who active management of third stage of labour' and you should get a bulletin from them with details on their study...
> 
> ...


http://www.sciencedirect.com/science/article/pii/S0140673697094099 :done in the UK

http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.1991.tb10364.x/full done in the Netherlands, and it's a randomized, double blinded, placebo controlled study

http://ukpmc.ac.uk/abstract/MED/22071837 A 2011 Cochrane review. 6 of the 7 studies they used were in "high income" countries

I'm sure I could keep going. Use google scholar. It's not a small body of research supporting these recommendations.

The evidence is pretty clear that using a uteronic (IM or IV pitocin is the recommended one to start with; methergine and cytotec are associated with more side effects like vomiting and lowgrade fever), quick delivery of the placenta, and fundal massage following the placenta done on everyone, even low risk women, significantly reduces the rate of PPH. Immediate clamping of the cord does not seem to be terribly important- for example it was not part of the Netherlands study protocol and their results were consistent with the others.


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## fruitfulmomma (Jun 8, 2002)

And??? That does not change the fact that it is medical management. If some midwife group started endorsing inductions at 40 weeks for all women that won't change induction from medical management to natural birth.

For those of you who have made it through this far and are interested in choices this looks like a good site... www.thirdstageoflabour.org.


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## Slmommy (Jan 22, 2012)

Quote:


> Originally Posted by *Katie8681*
> 
> http://www.sciencedirect.com/science/article/pii/S0140673697094099 :done in the UK
> 
> ...


I've only had chance to look at one, ttp://ukpmc.ac.uk/abstract/MED/22071837/reload=0;jsessionid=79lEXsgjeLs7bSbrzT11.4, but this already jumped at me.

Quote:


> CONCLUSIONS: Although there is a lack of high quality evidence, active management of the third stage reduced the risk of haemorrhage greater than 1000 mL at the time of birth in a population of women at mixed risk of excessive bleeding, but adverse effects were identified. *Women should be given information on the benefits and harms of both methods to support informed choice.* Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third-stage management.


ETA: the one in the Netherlands -

Quote:


> To compare the effect on post partum bloodloss of the postpartum prophylactic administration of oxytocin or sulprostone in low risk women having an *expectant management of the third stage*


 = (no cord traction)

....and the first link:

Quote:


> *Interpretation*
> 
> Active management of the third stage reduces the risk of PPH, whatever the woman's posture, even when midwives are familiar with both approaches. *We recommend that clinical guidelines in hospital settings advocate active management (with oxytocin alone). However, decisions about individual care should take into account the weights placed by pregnant women and their caregivers on blood loss compared with an intervention-free third stage.*


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## Slmommy (Jan 22, 2012)

Even this http://www.ncbi.nlm.nih.gov/pubmed/10908457 which seems to support active management...

*Active versus expectant management in the third stage of labour.*

Quote:


> Routine 'active management' is superior to 'expectant management' in terms of blood loss, post partum haemorrhage and other serious complications of the third stage of labour. Active management is, however, associated with an increased risk of unpleasant side effects (eg nausea and vomiting), and hypertension, where ergometrine is used. Active management should be the routine management of choice for women expecting to deliver a baby by vaginal delivery in a maternity hospital. *The implications are less clear for other settings including domiciliary practice (in developing and industrialised countries).*


Most of these studies are dealing with hospital births, and I didn't read the specifics of how most of those births went down, if they were provided in the abstracts, I did not see...

*.... and most still advocate for giving the birthing woman informed decision making and personalized care!!!*


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## Katie8681 (Dec 29, 2010)

Quote:


> Originally Posted by *slmommy*
> 
> Even this http://www.ncbi.nlm.nih.gov/pubmed/10908457 which seems to support active management...
> 
> ...


Well, DUH, they advocate for informed decision making and personalized care. If it's more important to you to have a pristine all-natural 3rd stage than to avoid a hemorrhage, then by all means refuse active management! That's your right. But don't lie to yourself about what the research is telling you. You're missing the forest for the trees. Maybe if you tried digging past the abstracts, you'd learn more.

ETA: Placebo controlled studies are going to be nearly impossible to do on this topic now because it wouldn't be ethical to not give a morbidity-decreasing treatment. There are several but most of them were done in the '80s and '90s.


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## Katie8681 (Dec 29, 2010)

And I repeat that UCers should not run out and get pit and prepare to give themselves injections and mess with the birth of the placenta. That would be crazy.


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## Slmommy (Jan 22, 2012)

Quote:


> Originally Posted by *Katie8681*
> 
> And I repeat that UCers should not run out and get pit and prepare to give themselves injections and mess with the birth of the placenta. That would be crazy.


I totally agree, as a ucer.


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## Slmommy (Jan 22, 2012)

Quote:


> Originally Posted by *Katie8681*
> 
> Well, DUH, they advocate for informed decision making and personalized care. If it's more important to you to have a pristine all-natural 3rd stage than to avoid a hemorrhage, then by all means refuse active management! That's your right. But don't lie to yourself about what the research is telling you. You're missing the forest for the trees. Maybe if you tried digging past the abstracts, you'd learn more.


Do you wanna foot the bill for purchasing the whole article for me to be able to read past the abstracts?

I suppose I did have a "pristine all-natural 3rd stage" AND avoided hemorrhage. Must be one in a million, as apparently all women are incapable of decision making and unworthy of personalized care with fundamentally flawed uteri which will always kill them. oh yeah, and as Holly suggested, as a ucer, I am liable to be stupid enough to try ripping my own placenta out or attempting my own manual extraction... all while she stated before that a ucer would be incapable of fundal massage...

The research you cited is telling me nothing... I never intend on having a hospital or medicalized birth, so most of the research is not relevant. One of the ones you posted is totally irrelevant as it involved expectant management and pit, not expectant vs. active management. Did you read past the abstracts? Or even the abstracts?

And, I didn't see 100% pph rates for the expectant management women in the other studies... (... and if a hb or uc turned transfer, yes, my expectations would change, well heck, I'm pretty sure I would just be c/s walking through the door in a country with 90% c/s rate for all women with private insurance).

I'm not against fundal massage, pit, helping placenta, WHEN actually necessary, I am against it, for myself, when not indicated, JUST because some paper somewhere says there may be a percental difference in situations that do not apply to me, maybe, sometimes, kinda, and causes other issues too.


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## Katie8681 (Dec 29, 2010)

Here's the thing: there are risk factors and then there's the luck of the draw. Being low risk does not mean it can't happen to you. Being high risk does not mean it must happen to you. For what it's worth, I'm not a fan of immediate cord clamping or routine cord traction. A large, multi center study just came out in the Lancet in March showing no difference in rates of PPH between women who had active management with or without cord traction, and the "with" group had a case of uterine inversion. But a skilled provider, a shot of pit, and fundal massage after the placenta... it's good sense. You know what gets in the way of loving up a new baby? Recovering from major blood loss. It sucks. I know, personally.


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## jmarroq (Jul 2, 2008)

They did not do this to me. I had 2 c-sections due to breech babies and abruption. My first c-section I was very bruised all over my abdomen for some reason. I had some minor complications and an incredibly rough recovery. I couldn't move without pain for months. I remember my mom telling me that the nurses pushed on her abdomen after her two still births (6 month old fetuses) and she almost punched them out it was so painful!


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## Youngfrankenstein (Jun 3, 2009)

I am shocked to be reading any of this. Frankly, you lost me at Cytotec for all. Yeah, that's evidence-based...


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## Slmommy (Jan 22, 2012)

Quote:



> Originally Posted by *Katie8681*
> 
> Here's the thing: there are risk factors and then there's the luck of the draw. Being low risk does not mean it can't happen to you. Being high risk does not mean it must happen to you.


Thanks I realize this. As someone who had a uc birth, I was extremely aware of that fact, since any complication was going to fall onto my shoulders to act = go to hospital. Last I knew, ucers were allowed to receive medical care if transfer... unless some of you would like to suggest decision to uc should disqualify one from ever receiving medical assistance at any point.

I am getting so sick of seeing this characterization around here that any woman who has *certain ideas* or wants about her pregnancy/birth (which someone disagrees with - uc/hb/cpm apparently now not active management 3rd stage) is a stupid, selfish, uppity, wanna-be-hippie-birth-goddess who at all times will make terrible choices. Yes, I understand birth does not always go how we want... but as to why unnecessary procedures should be done, or why our medical decisions should be invalid, I'm at a loss. I also don't know why, but I guess accept, that some people want automatic robot healthcare and not a hcp who is going to evaluate and treat you as an individual instead of a statistic.

I'm also sick of this attitude around here that someone is so stupid or selfish for going against "evidence based" whatever, (yes I am speaking in general terms for many subjects as it is not just this thread or board). Who the heck makes all their decisions solely based on "scientific evidence" (possibly biased, corrupted, irrelevant, poorly conducted, etc.) in a vaccum without weighing personal experience, observation, gut feelings, advice and anecdotes of peers, family, friends, professionals, and other forms of information? oh yeah and other "scientific evidence" which states or implies the opposite of said position.

All of the studies you posted Katie, were, as far as I can tell, (you can still purchase the entire article for me if you would like so I can "learn more" as you pointed out I so obviously need to do), not really relevant to my birthing situation or even perhaps comparable as to what my situation reaching 3rd stage would be. Most suggested women still have choice about management of 3rd stage. One was even expectant management with pit and measured blood loss and did not give numbers about pph. Even if I bleed a bit more without a shot of pit, perhaps I am in health condition to do so without having any major issues, and still manage to avoid immediate cord clamping, cord traction, medication and fundal massage - (get more cord blood to my baby, avoid unnecessary additional pain, and possibly decrease risk of uterine inversion per your last lancet ref?) Honestly, I would be an idiot to make my birthing decisions solely based off of that "evidence" you provided.

I hope women reading this can see how important it is to find out these issues when choosing a hcp. You are paying them, find a hcp whose philosophy/practice more closely aligns with your own. I'll also state for the record, one more time, if I had retained placenta, major blood loss, pph during UC, guess what, I would've gone to the hospital.

I am going to be without internet for the next few days, so







probably for the best... this thread is making me


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## Slmommy (Jan 22, 2012)

Quote:



> Originally Posted by *Youngfrankenstein*
> 
> I am shocked to be reading any of this. Frankly, you lost me at Cytotec for all. Yeah, that's evidence-based...


Apparently WHO finds it fine for 3rd stage management.

Quote:



> Misoprostol is also used to prevent and treat post-partum hemorrhage, but it *has more side effects and is less effective than **oxytocin* for this purpose.[21] However, it is inexpensive and thermostable (thus does not require refrigeration like oxytocin) making it a cost effective and valuable drug to use in the developing world.[22]
> http://en.wikipedia.org/wiki/Misoprostol#Post-partum_hemorrhage


But one of Katie's posted studies states:

Quote:


> *We recommend* that clinical guidelines in hospital settings advocate active management *(with oxytocin alone)*. However, decisions about individual care should take into account the weights placed by pregnant women and their caregivers on blood loss compared with an intervention-free third stage.
> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(97)09409-9/fulltext


But hey, we should all always have cytotec because it is evidence based! even if it is also evidence based to create more problems too! Expecting our hcp to use oxytocin or perhaps monitor us through intervention-free 3rd stage and use their expertise to act should major blood loss/pph arise, would just make us stupid, selfish, ignoring evidence based medicine and asking too much.

(and just because cytotec may be a godsend for some woman with pph in a developing nation with crappy living conditions and limited medical resources, does not make me selfish or stupid for trying to avoid cytotec use in my births)


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## fruitfulmomma (Jun 8, 2002)

Eh, at least WHO is honest about why they recommend it right? Never mind that it is not FDA approved for such use nor that the manufacturer has stated very clealry that it should never be used in such a manner, that it was never tested for such purpose but that there are clear risks, and that they have no idea what the long term effect is, but hey it's cheap, so we're totally cool.


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## BroodyWoodsgal (Jan 30, 2008)

OKay...re: cytotect: I don't know whether to puke in my lap or punch myself in the face. Are you people on heroin? That doesn't even make SENSE...yeah, that's exactly what we need, more mothers taking cytotec. Ahhhhh!!! Where is a pulling your hair out while you smash your face into a brick wall over and over again smiley when you need one?? Same goes for pitocin after every birth...are you people crazy?? That's CRAZYYYYY talk..I mean, REALLY!

Holly: I was not saying the WHO has anything to gain by tricking mothers. I was merely speaking to the shitty state of research these days.

As for everything else. Gulp. Well, okay guys..I guess you just see birth in a completely different light than I do.







Cytotec and cord traction for all, I guess.









I think now I've *officially* seen it all on MDC.


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## stik (Dec 3, 2003)

I had a hospital birth with no intervention in the third stage, which surprised me. The CNM who delivered my older dd used traction on the placenta, and administered pitocin, and I recall quite a bit of fundal massage. The OB who delivered my younger dd didn't touch the cord until it stopped pulsing, waited for the placenta, and we proceeded without pitocin or fundal massage.

Given a treatment location at a US hospital, I would definitely decline cytotec in favor of pit, but I would only accept either if I was bleeding excessively or if delivery of the placenta was taking an unusually long time. WHO recommendations are not always the best options to apply in care settings in the developed world. I can see how cytotec is a great option for active management of the third stage for a midwife who is biking around rural Southeast Asia, but I think the risk/benefit analysis on waiting for the placenta and using pitocin are different in hospitals in the US.


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## thegoodearth (Jun 6, 2011)

Quote:


> Originally Posted by *BroodyWoodsgal*
> 
> 
> 
> ...


This made me laugh! Especially with the little avatars. Thanks Broody - you brightened my day.


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## holly6737 (Dec 21, 2006)

I guess I'm missing where in the thread anyone advocated for "Cytotec for all"? I never said that. I don't think the other poster did either. Cytotec takes longer to work than Pitocin, so Pitocin should always be your first line drug if it's available. I don't give Cytotec unless there is excessive bleeding. You can do 200 sublingual or 800-1000 per rectum. I prefer the 1000 per rectum, which will produce a good amount of cramping but will so a great job at stopping the bleeding. Methergine and hemabate are really third line drugs. They have contraindications that the other drugs don't have and hemabate, especially, can have some nasty side effects (massive uncontrollable diarrhea for hemabate).

The issue is that Cytotec is cheap and has very little contraindications/side effects, so in a third world country it's easier to store, carry and administer compared to an IM injection of pitocin. So the WHO says that in those situations it's okay to use Cytotec routinely instead of pitocin. But we have pit readily available here so there's no need to go to Cytotec as your first line. Pit works better anyway.

Quote:


> Originally Posted by *BroodyWoodsgal*
> 
> OKay...re: cytotect: I don't know whether to puke in my lap or punch myself in the face. Are you people on heroin? That doesn't even make SENSE...yeah, that's exactly what we need, more mothers taking cytotec. Ahhhhh!!! Where is a pulling your hair out while you smash your face into a brick wall over and over again smiley when you need one?? Same goes for pitocin after every birth...are you people crazy?? That's CRAZYYYYY talk..I mean, REALLY!
> 
> ...


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## BroodyWoodsgal (Jan 30, 2008)

First of all, I think there are a lot of people who would beg to disagree with your assertion that cytotec has very little side effects. A ton of those people would be women who almost died, women missing a uterus who may or may not have been done having kids and families missing a mother/daughter/sister/aunt. Second, okay...so you prefer pit. You still said you prefer it for every birth.

THAT. IS. CRAZY.









I don't care what "evidence" you have to point to...it's just freaking nuts. Every birth absolutely DOES. NOT. NEED the type of "care" you've described and CERTAINLY doesn't need pitocin. Frankly, of the women who do end up benefiting from such an over-"managed" third stage, I can only BEGIN to guess at what percentage of them have had their births completely screwed up (physiologically speaking) from the word go, by drug and intervention happy "care providers" (like you?). Yeah, it stands to reason that an overtaxed, drugged half to death uterus is going to have a hard time performing its function in the third stage. I'm not saying that the only women who ever experience PPH are women who have had intervention heavy births....obviously that's not the case. But in a time when the GIGANTIC majority of women giving birth are doing so with some form of synthetic hormone severely augmenting their "progress" and putting the uterus through a completely atypical birth experience, I have to wonder really hard at the sanity in saying that the fact that so many women "need" such active management in the third stage points to broken birth. I think it speaks more to broken birth management. You can disagree...in fact I know you do. But when I look at the numbers around this issue, that's what stands out at me.

I can't see where you have posted exactly what kind of birth professional you are...but I'm guessing from some of what you have said that you are some sort of midwife or OB. I've got to be honest, that scares me a little. I'm just imagining a new mom sitting in front of you, asking you questions about how you operate....and having the pants scared off of her as you tell her all about how you are going to pump her full of powerful drugs to save her from the wretched death-in-a-box that is birth. A birth professional with a perspective on the process which makes you feel most comfortable with EVERY mother receiving the care you've described as "optimal" in the third stage makes me shiver...like, with an *actual* cold chill up my spine.

My research, core values and personal experience with birth (both my own two *awesome* out of hospital births and others I've witnessed/attended as a lay person only) have led me to a perspective that is so far away from yours, we may as well be on different planets. So...you know, who am I to say you're wrong. But man, I really REALLY feel like you are wrong on this.

I'm not saying that there is not a potential for death, injury or drama in every birth......but there is also potential for natures perfect work to be done. And really, when left alone...the properly nourished, supported mama really does have a better chance of meeting success than she does danger in birth. I've had two 90 minute births that started with my waters breaking and then thirty hours of absolutely *nothing*, before active labor sprung upon me and got the whole job done in one and a half hours. My mother before me had all four of her babies in the *exact* same way.

A birth worker with your perspective would never have given me those 30 hours my body, apparently, needed. I can only imagine what would have happened to me in your hands. Makes me sick, when I think of the perfection my body displayed during my births, to think that had I been in your care....you would have been telling me that something was wrong, that something was broken...as you pumped me full of some shit and told me "Don't worry, we doctors are gods and can make everything happen just as we think it should" - it's a disgrace, really. It's a mockery.


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## holly6737 (Dec 21, 2006)

Well, the only way to really know that I'm wrong is by conducting a study on active management of third stage versus expectant management of third stage. Only they already DID that (multiple times), and they determined that active management of third stage led to superior outcomes. The "evidence" that you so abhor is the ONLY way to determining what works and what doesn't. Anecdotes, intuition, etc. they aren't at all quantitative. N=1 is meaningless. You can say to me, "I had an UBA8C and I didn't rupture!" and that does nothing to tell me that UBA8C is safe. You need a sample size with sufficient power. You must have evidence to back up your claims or your claims are nothing. That's the basis of science. And if we're not applying science to our management plans, you just live in a world full of magical thinking. I don't believe in magic. I believe in science. And Science. Works. If Science is KoolAid, then I drink at the fountain. If science is wrong, I don't want to be right. All hail evidence based practice.



> Originally Posted by *BroodyWoodsgal*
> 
> First of all, I think there are a lot of people who would beg to disagree with your assertion that cytotec has very little side effects. A ton of those people would be women who almost died, women missing a uterus who may or may not have been done having kids and families missing a mother/daughter/sister/aunt. Second, okay...so you prefer pit. You still said you prefer it for every birth.
> 
> ...


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## BroodyWoodsgal (Jan 30, 2008)

OKay Holly....and I'm telling you, that science can take what "they" call birth and poke it and test it and draw all kinds of conclusions...but the "birth" that science is testing, is not the birth I had in my kitchen...it's not the birth I'm about to have under my trees on my back porch. The research you think is so freaking rad, is based MOSTLY on the experiences of:

1. Malnourished women living in third world scenarios, and

2. Women with physiologically completely atypical births

So...okay. Whatever. Cling to that science. Lap it up. I'm not sitting over here "thinking magically" - I'm looking at the science and I'm saying "That science sucks".

As for drinking the kool-aide...well, all I can say about that is that I love science too....but you should be sure not to let science become a religion for you.


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## mirandamiranda (Jun 13, 2011)

I'd like to point out that the Cochrane review (I looked at
http://summaries.cochrane.org/CD007412/delivering-the-placenta-with-active-expectant-or-mixed-management-in-the-third-stage-of-labour )
does not in fact state that active management leads to superior outcomes. It looks to me that the reason they recommend informed choice is because:

The risk of PPH and anemia was not decreased for low risk women, although it was for the larger group of all women;

Active management led to increased risk for a number of other outcomes, including "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".

Where risks are complicated and conflicting it is clear that women should be able to assess them for themselves. If they are at low risk for bleeding and want to avoid the negative effects of active management, then it seems like a reasonable decision. Equally, if they want to stick with mixed management and avoid, say, early cord clamping or other procedures that may be questionable or more problematic, then that would make sense too. Or, of course, if bleeding is a big concern or risk for them they may opt for active management. The point is that not every case, nor every set of risks, is the same.

On a separate note, I would also like to express my concern at the frequent referrals to certain (unspecified) countries as "third world" or "non-western" with the implication that they are war-torn, famine-stricken, and generally terrible and uncivilized. While of course there are plenty of places with dreadful problems for all sorts of reasons, I do not think it is helpful to just write off half the world and lump it together in contrast to our supposed first world paradise. I'm sure I don't need to tell anyone here that there are plenty of women in the USA, for example, who are malnourished and lacking education, resources and access to health care.

It could perhaps be more useful to talk about specific factors that may influence risk factors such as income or education levels, and avoid sweeping statements about how terrible everything is for women in the 'third world". It feels a bit imperialist.


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## fruitfulmomma (Jun 8, 2002)

Appreciate your thoughts Miranda, just a quick response sine this is getting way off topic but references to women in other countries were not made in a we are better than them sort of way but to point out that you can not take a study from a country where the birthing culture and health infrastructure is vastly different than our own and apply to everyone across the board with no account of the differences whichmay includes things like war, famine, malnourishment, lack of clean water, lack of prenatal care, no access to emergency care, etc... When I stated that the ountries in a study were not western it was because they were places I am not really familiar with in regards to their birth culture, again only only pointing out that cultural differences are indeed relevant when deciding if a study applies to me or not. The same sort of issues would apply if we were to try to take a study done in one very high risk US hospital and apply it equally to all low-risk home birthing mothers. I am also certain that if you went and studied some hospitals here that you would find many that were practicing in ways that put women at higher risk for pph, though the bulletin I referenced to did not specify what practices they had observed. We have several friends who have or are practicing middwifery in other countries and the problems the women face in birthing, wwhile not the same in every single one, do have at least some of the elements listed above, things I have never encountered and in all likelyhood never will.

To Holly and (was it?) Katie, I appreciate the conversation even if we vastly disagree on the issues. My background is in the homebirthing community as a mother and sincerly your ideas are completely outside the midwifery model of care that I am familiar with. This discussions has gonea little too far and gotten pretty heated so I am bowing out but plan to follow up the issue with some of the women (and men) who I am more familiar with in homebirth and maternity care to get their opinions. I think we all, obs included, agree that whatever practices are done mustb be in the best interest of mom and baby and that reducing pph and maternal mortality is necessary.


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## BroodyWoodsgal (Jan 30, 2008)

Quote:


> Originally Posted by *mirandamiranda*
> 
> <snip>
> On a separate note, I would also like to express my concern at the frequent referrals to certain (unspecified) countries as "third world" or "non-western" with the implication that they are war-torn, famine-stricken, and generally terrible and uncivilized. While of course there are plenty of places with dreadful problems for all sorts of reasons, I do not think it is helpful to just write off half the world and lump it together in contrast to our supposed first world paradise. I'm sure I don't need to tell anyone here that there are plenty of women in the USA, for example, who are malnourished and lacking education, resources and access to health care.
> It could perhaps be more useful to talk about specific factors that may influence risk factors such as income or education levels, and avoid sweeping statements about how terrible everything is for women in the 'third world". It feels a bit imperialist.


I agree entirely with this statement, Miranda...however, some of the research that was referenced DID in fact contain studies conducted by groups which were operating *specifically* with women in famine stricken, war torn areas...which is why I made the remarks I did. I don't think anyone was equating "third world" (I don't even really like using that term) with "impoverished, uneducated and war weary". It's an unfortunate habit of many, myself included, to "short hand" people living in desperate situations as living in the "third world".

And it IS true that many, many women giving birth in our country are extremely malnourished. Even if actual starvation/famine situations are not so wide spread as in some places in the world....there is such a thing as having "plenty" to eat...and at the same time, eating SO poorly, that your body has next to nothing of what it actually needs to operate on a healthy, nourished level.

We do have people in our country who are actually hungry, with not enough to eat.....but our more wide spread nutritional challenge involves people who fill their bellies all day with such incredibly nutritionally lacking "food stuffs" that they are malnourished despite having "plenty" to eat. This type of nutritional deficit creates a lot of risk for a pregnant woman and shouldn't be ignored.


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## Slmommy (Jan 22, 2012)

Quote:

Originally Posted by *mirandamiranda* 

On a separate note, I would also like to express my concern at the frequent referrals to certain (unspecified) countries as "third world" or "non-western" with the implication that they are war-torn, famine-stricken, and generally terrible and uncivilized. While of course there are plenty of places with dreadful problems for all sorts of reasons, I do not think it is helpful to just write off half the world and lump it together in contrast to our supposed first world paradise. I'm sure I don't need to tell anyone here that there are plenty of women in the USA, for example, who are malnourished and lacking education, resources and access to health care.


> It could perhaps be more useful to talk about specific factors that may influence risk factors such as income or education levels, and avoid sweeping statements about how terrible everything is for women in the 'third world". It feels a bit imperialist.


My rantings on this end were more in reaction to another thread here not too long ago where pps were likening Somalia and Afghanistan as showing what "true natural birth" outcomes would be. I live and birthed in a developing nation.

Broodywoodsgal, I pretty much agree with everything you have said. Perhaps I'm going to crawl over to the UC boards and stay there. This whole thread ...


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## BroodyWoodsgal (Jan 30, 2008)

Quote:


> Originally Posted by *slmommy*
> 
> Quote:
> 
> ...


I'm coming from this exact place(bolded)....I can think of two or three heated, recent threads where birth outcomes in *specifically* war torn, famine suffering, "third world" areas have been pointed to as the example of "what happens" when women birth "naturally"....yeah, because humans would be crowding the earth right now if , before the age of modern medicine, one in eight women could be expected to die at some point in their life from childbirth related complications (as is the case in Afghanistan).

That sentiment drives me up a wall.


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## LiLStar (Jul 7, 2006)

Quote:


> Originally Posted by *BroodyWoodsgal*
> 
> I'm coming from this exact place(bolded)....I can think of two or three heated, recent threads where birth outcomes in *specifically* war torn, famine suffering, "third world" areas have been pointed to as the example of "what happens" when women birth "naturally"....yeah, because humans would be crowding the earth right now if , before the age of modern medicine, one in eight women could be expected to die at some point in their life from childbirth related complications (as is the case in Afghanistan).
> 
> That sentiment drives me up a wall.


Yes! If theres unreassuring FHTs, I can go to the hospital. (And I have a midwife who can check them) symptoms of infection, hospital and antibiotics. Unexplained (in labor) or excessive(pp) bleeding, we can go to the hospital. excessive meconium, hospital. And even if I get exhausted and choose to go to the hospital for an epidural and a nap, I can. If my baby doesn't look well after the birth or is having trouble breathing, we can call an ambulance and in the meantime my midwife, with neonatal resuscitation certification, can administer oxygen and/or suction the airway if necessary. My MW can wash her hands with clean water and soap before examining me or my baby, and she can also use a new, clean pair of gloves before every exam. Nothing third world about any of that!


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## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *LiLStar*
> 
> Yes! If theres unreassuring FHTs, I can go to the hospital. (And I have a midwife who can check them) symptoms of infection, hospital and antibiotics. Unexplained (in labor) or excessive(pp) bleeding, we can go to the hospital. excessive meconium, hospital. And even if I get exhausted and choose to go to the hospital for an epidural and a nap, I can. If my baby doesn't look well after the birth or is having trouble breathing, we can call an ambulance and in the meantime my midwife, with neonatal resuscitation certification, can administer oxygen and/or suction the airway if necessary. My MW can wash her hands with clean water and soap before examining me or my baby, and she can also use a new, clean pair of gloves before every exam. Nothing third world about any of that!


Unless you are doing complete shadow care with an actual midwifery office that has actual hospital privileges, there's no such thing as "just go to the hospital". I've personally dealt with trainwreck transfers and there is no such thing as simply "going to the hospital" with these kind of transfers. We first have to get you in a room. Then, like it or not, we have no choice but to completely discount anything you or your midwife says as you have no medical training and therefore we can't trust your assessments or historical account of what happened. So we have to start from square one and do our assessment, put your babe on monitor, draw your labs, do our cervical check, get you to sign admission paperwork, etc. Then, if we determine there is a problem, we have to prep an OR for you. Then we ahve to get a team available. This may take anywhere from 30 minutes to an hour. Some homebirth midwives like to perpetuate this myth that "the hospital is just five minutes away", as if she can call on her way there and the team will prep an OR for you while you are in route and you can just be whisked back there no questions asked. It doesn't work that way. Unlike many lay midwives, we have licenses to protect and we have rules and standard protocols that we must follow. That's why we have such superior outcomes. Anytime you transfer to the hospital from a homebirth (unless you are homebirthing with a CNM practice who has a good relationship with the hospital and a working back-up relationship with a physician group), it's a nightmare for everyone involved and it always takes a lot, lot, lot longer than you expect. ETA: And no, I'm not anti-homebirth. I had a homebirth myself, so I do support homebirth with a CNM who has a working relationship with a back-up physician.


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## Storm Bride (Mar 2, 2005)

I was a "trainwreck transfer" in 2009. My admission to the hospital went more quickly than my admission in labour with ds1. When I had ds1, I had pre-registered with the hospital and had been in contact with my doctor's office while in early labour (at home). The assessment during my transfer was very quick...just as quick, if not quicker than when I went in with ds1.

As for having to discount anything the pregnant woman or midwife says, because we/they have no medical training...this is exactly why I avoid doctors now. Giving a historical account of what happened during one's own labour doesn't require medical training. Some details might, but a whole lot of them don't require any special training at all. I've never gone in to the hospital for a baby, in any circumstances, without being asked questions about my labour/pregnancy/whatever is applicable. They seemed to trust me on most things...although I've found very few medpros who can wrap their brains around the idea that I might actually know date of my last period...or the date of the only sex I'd had in over six months, for that matter. I guess figuring those things out also requires special medical training? (And, to this day, I sometimes run into "experts" who say that what happened in my first labour can't happen, yet they expect me to trust their "expertise".)

ETA: Anyway...yeah - I did just go to the hospital. It ended up being a trainwreck, partly because the medpros at the hospital were more interested in their "high standards" than in actually listening to anything I had to say.


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## holly6737 (Dec 21, 2006)

You're also in Canada. It's a different system.


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## Storm Bride (Mar 2, 2005)

Quote:


> Originally Posted by *holly6737*
> 
> You're also in Canada. It's a different system.


What about our system could possibly affect whether you have to discount everything the woman and/or her midwife say?

And, for the record, stating that you have licenses you must protect in the same breath as "that's why we have superior outcomes" is very confusing. I hear all the time that unlicensed/illegal midwives are dangerous, because they have to look out for themselves before their clients...and then I hear how this decision was made by a doctor, because he/she doesn't want to be sued for malpractice, or that a licensed midwife has to do things a certain way, because she has her license to protect. Acting to protect one's insurance coverage or license is no more noble than acting to keep out of jail.


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## LiLStar (Jul 7, 2006)

Actually, I CAN "just go to the hospital" my whole point is home birth, be it UC, CPM, or CNM with OB back up, in the country I live in, is *absolutely nothing like birthing in a third world country*. I can be on hospital property within 10 minutes. Mothers in less privileged areas of the world do not have those kinds of amenities when birthing. If we transferred due to nonreassuring heart tone, yes, I can see that it could take some time to receive treatment. I promise though, that if I walk in (actually, ambulance is much more likely in this scenario) with a prolapsed cord between my legs they aren't going to piddle around waiting for me to fill out paperwork and do lab work, they're going to prep the OR immediately!. Anything less would be glaring malpractice. And I have transferred from a home birth before, with an illegal lay midwife. it was the non progressing labor with maternal exhaustion variety of transfer. around 6pm, we called to let them know we were on our way, then yes, I *just walked into the hospital* They took me straight to a room. There was no emergency, but they put on monitors, placed IV, drew labs, etc then did paperwork and I got the epidural as soon as I was able to. Nothing train wreck about that. The only bad thing about it is that it wasn't what I wanted for my birth. (eventual cesarean)

I get that you disagree with home birth except for with a CNM who has back up. Thats not even the point I was making. All I was trying to say is, homebirth, even UC, is nothing like being in a 3rd world country where 1 in 8 women die in childbirth. Because at any point, we can go to the hospital. Those women can't. I dont even think it was you who said that anyway. I dont know who did. a pp referenced an older discussion.


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## Storm Bride (Mar 2, 2005)

Quote:


> Originally Posted by *LiLStar*
> 
> Actually, I CAN "just go to the hospital" my whole point is home birth, be it UC, CPM, or CNM with OB back up, in the country I live in, is *absolutely nothing like birthing in a third world country*. I can be on hospital property within 10 minutes. Mothers in less privileged areas of the world do not have those kinds of amenities when birthing.


Yes, this - exactly.


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## Storm Bride (Mar 2, 2005)

I do have a question for you, Holly. How would you handle it if a labouring woman came into your hospital from out of town? Say she's visiting her parents or something, and went into labour well ahead of when she expected to. Would you discount what she said about her labour, because she has no medical training, or does that only apply to homebirth ttransfers?


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## Slmommy (Jan 22, 2012)

Quote:



> Originally Posted by *Katie8681*
> 
> Well, DUH, they advocate for informed decision making and personalized care. If it's more important to you to have a pristine all-natural 3rd stage than to avoid a hemorrhage, then by all means refuse active management! That's your right. But don't lie to yourself about what the research is telling you. You're missing the forest for the trees. Maybe if you tried digging past the abstracts, you'd learn more.


I have been thinking about this comment for a while now... WHO, or any other major health org/hcp org makes recommendations for huge groups of people, many different people, and sometimes they have certain interests. ACOG hates hb, wonder why? I could care less quite frankly, I am only concerned about my health and my DD's because, well that's the only health I really have any control over. WHO can make recs for the forest, I can only deal with the tree. I am not here stating that ALL women should uc or hb or never have active management for 3rd stage or go ahead and wait 5 hours to deliver placenta, or try to avoid fundal massage even while bleeding out...

I really didn't think that trying to avoid immediate cord clamping, cord traction, pitocin/cytotec, and fundal massage was deemed such a foolhardy decision on mdc where the interest seems, or used to, run towards natural birth... but I am seeing so many threads being over-run by "evidence based" this and that, pretty much bullying the mainstream position and insinuating that the alternative option is sooo incredibly fool-hardy, (natural birth, hb, uc)... here, the "choice" (assuming your hcp gives you one) of intervention free 3rd stage of labor.... really??

...and as to your DUH about informed consent and personalized care... it sounded like you were very much arguing against that, or well just insinuating whoever wants to deliver placenta naturally is an idiot.

Holly can provide whatever philosophy of care she wants as a hcp. It's def NOT what I would ever go for, but probably plenty of women want that. This thread completely demonstrates how important it is to know that about our hcps... you should know what you are getting, and if your hcp is unwilling to provide you with the type of care you are interested in... find another.


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## BroodyWoodsgal (Jan 30, 2008)

Quote:


> Originally Posted by *holly6737*
> 
> Unless you are doing complete shadow care with an actual midwifery office that has actual hospital privileges, there's no such thing as "just go to the hospital". I've personally dealt with trainwreck transfers and there is no such thing as simply "going to the hospital" with these kind of transfers. We first have to get you in a room. Then, like it or not, we have no choice but to completely discount anything you or your midwife says as you have no medical training and therefore we can't trust your assessments or historical account of what happened. So we have to start from square one and do our assessment, put your babe on monitor, draw your labs, do our cervical check, get you to sign admission paperwork, etc. Then, if we determine there is a problem, we have to prep an OR for you. Then we ahve to get a team available. This may take anywhere from 30 minutes to an hour. Some homebirth midwives like to perpetuate this myth that "the hospital is just five minutes away", as if she can call on her way there and the team will prep an OR for you while you are in route and you can just be whisked back there no questions asked. It doesn't work that way. Unlike many lay midwives, we have licenses to protect and we have rules and standard protocols that we must follow. That's why we have such superior outcomes. Anytime you transfer to the hospital from a homebirth (unless you are homebirthing with a CNM practice who has a good relationship with the hospital and a working back-up relationship with a physician group), it's a nightmare for everyone involved and it always takes a lot, lot, lot longer than you expect. ETA: And no, I'm not anti-homebirth. I had a homebirth myself, so I do support homebirth with a CNM who has a working relationship with a back-up physician.


The fact that you are currently training to be a birth worker makes me sick to my stomach. Every single time I see a post from you on a thread lately, you're saying something that makes my face turn red and get hot with anger and/or disbelief. I can't believe some of what comes out of your mouth...the arrogance, the cockiness...

Quote:


> "unlike lay midwives, we have licenses to protect and we have rues and standard protocols that we much follow"


I can just see you rolling your eyes as you type this. You must feel so effing special to be getting your super special shiny badge in nursing school...apparently your "super cool status" as a CNM (in training) gives you the right to think you know a damn thing about the competency and motives of an entire profession. There are some "lay" midwives out there who know more about birth and the pregnant body than you will ever know in your entire freaking career as a "professional" in birth. What a jolly little jab that was..."unlike lay midwives, we have actual effing standards" - wow. That is some priceless arrogance there. I can see you think all "lay midwives" are basically trash, in so far as their ability to give good care is concerned. What the hell do you think these professionals are doing? Picking their noses and drinking moonshine? Just because the hospital has a fancy binder marked "protocol" on the front of it, doesn't mean "lay" midwives are operating less legitimately.

Quote:


> That's why we have such superior outcomes


You cannot imagine what this makes me want to say to you. I could fill page after page with text describing my thoughts on this sentiment. I'm not going to waste my time doing that, though...I'm just going to say: It sucks. Your attitude sucks. The way you view birth is crazy to me. Listening to your words, I feel like I'm reading a textbook on Obstetrics 101. You seem to have such a narrow, mainstream medicine view and it kills me.

Quote:


> Then, like it or not, we have no choice but to completely discount anything you or your midwife says as you have no medical training and therefore we can't trust your assessments or historical account of what happened.


This quote makes me practically blind with hormonal rage. Are you freaking kidding me? CNMs with your (apparent) mentality are the reason I would be MORE CAUTIOUS working with a nurse-midwife than I would be going into a relationship with a "lay" midwife. I can't tell you how many times, when I was interviewing MWs the first time around, I went into a meeting thinking "cool, nurse midwife, this will be great" - and waked out of said meeting blown away at how very, very far away from a traditional midwife the person was. We have enough OBs in the world, we don't need a bunch of "OB lite"s running around tricking women into thinking they are getting care with someone who views their labor as normal and natural, only to have bullshit like "good job on your med-free, completely normal birth...now, for now reason, we're going to give you pitocin and yank on your effing cord" dropped on them at their birth.

Sorry "Trainwreck Transfers" are such a pain in your ass...I can only IMAGINE how awesome these "stupid transferring women" are going to be treated by you, when you have the opportunity to sneer at their stupidity to their faces. What a joke.

I really hope that after you are "certified awesome" by your training program/school/whatever....that you are humbled a bit by your first months/years/whatever on the job and aren't always so arrogant and narrow minded...because seriously, the way your attitude is right now, I can't imagine how unfortunate it would be to have you "help me" if I DID transfer into your care after a homebirth gone sideways....and that's just not freaking fair.

I seriously, SERIOUSLY cannot believe that last quote there...that is unbelievable. Yeah, cause I'm a fucking moron and don't know anything, because I didn't go to nursing school and learn all about how wild and treacherous birth is. But you, you who went to nursing school...land of "Then, after EVERY birth, you give a shot of pitocin and pull the placenta out...." - yeah, you guys are a++ certified and know everything anyone ever needed to know about birth. That makes me ill. You certify yourselves...do you understand that? People with your view are in charge....so people with your view, certify people like YOU, after you submit yourselves to being indoctrinated with this moronic, ridiculous perspective.

Professionals with your viewpoint are the very reason why I would rather go UC, in the event that my MW couldn't help me at home, than submit myself to "traditional modern care" in a hospital setting.


----------



## BroodyWoodsgal (Jan 30, 2008)

and honestly, I don't even care if that post comes across as harsh. Holly, the attitude you seem to have toward birth and birthing women in various scenarios...the snarky, back handed comments about types of birthworkers who choose different paths than the CNM path....it all perfectly embodies everything that I personally feel is wrong with the way modern medicine treats birthing women and underscores why the model of care you uphold as so superior is seen by so many as completely lacking and completely clownish.


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## fruitfulmomma (Jun 8, 2002)

This whole thread is a trainwreck...Funny how one of the most outspoken proponants of homebirth and midwifery care, and against the practice of cytotec in birthing women, Marsden Wagner, was head of WHOWomen and Children for 15 years, but I guess he is just another untrained idiot putting women's lives in danger. I'd choose a birth with the uneducated Ina May with her 40+ years of sitting with women any day over the textbook educated arrogance displayed here. You want to see truly superior outcomes??? Who cleans up *your* messes?


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## Slmommy (Jan 22, 2012)

Originally Posted by *fruitfulmomma* 

This whole thread is a trainwreck...Funny how one of the most outspoken proponants of homebirth and midwifery care, and against the practice of cytotec in birthing women, Marsden Wagner, was head of WHOWomen and Children for 15 years, but I guess he is just another untrained idiot putting women's lives in danger.

http://www.midwiferytoday.com/articles/technologyinbirth.asp Great article written by Marsden Wagner and appropriate for this thread. Sub in "procedure/drugs" for "technology" in this paragraph, (which I believe is still appropriate), and this speaks to the discussion here of active management interventions vs. expectant, and the choice that that should be.

Quote:


> When considering whether a given technology is appropriate for you, it is important that you understand the difference between facts and value judgments. The probability (chance) that using the technology will make things better (efficacy) and the probability (chance) that using the technology will make things worse (risk) are facts that can be scientifically measured. But benefit and safety are value judgments about the acceptability of those chances. To be appropriate, both the benefit and the safety of technology must be judged by those on whom it is used. *Scientists can measure the efficacy and risks, midwives and doctors can inform the woman of the data on these two chances (better or worse) but the person taking the chances (the patient) is the only one who can legitimately decide whether one chance outweighs the other.* It is thus inappropriate and dangerous for a doctor or midwife to tell a patient that something is "safe" when it is not the doctor or midwife taking the chances. Instead, the role of the doctor and midwife is limited to suggesting possible interventions and explaining the chances that the intervention will make you better or worse.


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## Storm Bride (Mar 2, 2005)

Quote:


> Originally Posted by *slmommy*
> 
> *Scientists can measure the efficacy and risks, midwives and doctors can inform the woman of the data on these two chances (better or worse) but the person taking the chances (the patient) is the only one who can legitimately decide whether one chance outweighs the other.*


Yes. Yes. Yes. I hadn't seen this quote before, but it sums up everything that drives me nuts about dealing with medpros. It's been particularly obnoxious in the birth arena, but it exists in other fields, too.


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## holly6737 (Dec 21, 2006)

This isn't my first rodeo, Broody. I've been around the NCB and HB community a long time. I used to be like you, vehemently for everything "birthy". The truth is, though, that eventually I realized that evidence based practice means just that- evidence based practice. And the "evidence" quoted in "journals" such as "Birth" Isn't really evidence at all. I went where the peer reviewed literature led. If you don't like my philosophy, that's fine with me. I have been to UC and back, so don't think that I've just drunk the westernization koolaid. Have a natural childbirth- I think that's wonderful. But do it with safe, educated, well-trained professionals (CNMs or OBs) and have a working, realistic transfer plan complete with a back-up physician in place.


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## holly6737 (Dec 21, 2006)

Marsden Wagner isn't even an OB. He's just a family practice doctor.

Quote:


> Originally Posted by *slmommy*
> 
> Originally Posted by *fruitfulmomma*
> 
> ...


----------



## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *fruitfulmomma*
> 
> This whole thread is a trainwreck...Funny how one of the most outspoken proponants of homebirth and midwifery care, and against the practice of cytotec in birthing women, Marsden Wagner, was head of WHOWomen and Children for 15 years, but I guess he is just another untrained idiot putting women's lives in danger. I'd choose a birth with the uneducated Ina May with her 40+ years of sitting with women any day over the textbook educated arrogance displayed here. You want to see truly superior outcomes??? Who cleans up *your* messes?


Every CNM I've trained with had back-up. Realistic back-up. Not back up 3 hours away or drop you off in the ER back-up, but real, actual back-up. That's why it works. Look at Great Britain. They have moderately good homebirth data. How do they do it? They do it by only employing CNM equivalents and by having a working, realistic back-up transfer system in place.


----------



## Storm Bride (Mar 2, 2005)

Quote:


> Originally Posted by *holly6737*
> 
> This isn't my first rodeo, Broody. I've been around the NCB and HB community a long time. I used to be like you, vehemently for everything "birthy". The truth is, though, that eventually I realized that evidence based practice means just that- evidence based practice. And the "evidence" quoted in "journals" such as "Birth" Isn't really evidence at all. I went where the peer reviewed literature led. If you don't like my philosophy, that's fine with me. I have been to UC and back, so don't think that I've just drunk the westernization koolaid. Have a natural childbirth- I think that's wonderful. But do it with safe, educated, well-trained professionals (CNMs or OBs) and have a working, realistic transfer plan complete with a back-up physician in place.


The problem here is the assumption that "OB" (or hospital, for that matter) equals "safe". I had a doctor and planned hospital "birth" for all but one of my pregnancies. If I could go back in time 19 or 20 years and talk to my 24 year old self, my first priority would be dodging the "safe" bullet of the obstetrical community. Plus, your advice only applies if one is deemed to be low enough risk to be "allowed" a natural birth.

I can also assure you that the peer reviewed literature is missing a lot, because there's too much we don't know, and too much they don't care about. The only negative part of my reproductive history that shows up in my records are my losses (three miscarriages and one term stillbirth). The last of those losses fits nicely into their "trainwreck homebirth" slot, and doesn't show any of the contributing factors that fall right at the feet of my previous OBs. I can guarantee you that my history looks very, very different, depending on whether you're looking at it as it was actually experienced by me or as it would appear in a study (if my records were included in one).

Frankly, I don't care about your opinions, unless you're one of those who feel they should be law. I'm not a fan of people who want the legal right to force women into abusive environments, such as L&D wards.


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## Storm Bride (Mar 2, 2005)

Quote:


> Originally Posted by *holly6737*
> 
> Marsden Wagner isn't even an OB. He's just a family practice doctor.


"Just"?

That's what most women here use for low-risk pregnancies. Midwifery (sort of - CNM equivalent) is growing, but OBs aren't used unless there's a specific indicator, and family practice doctors do a lot of prenatal and obstetrical care.

Are you intending for your posts to sound snotty and superior, or do you just not realize how they sound?


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## Storm Bride (Mar 2, 2005)

This thread has wandered way off the OP. I will say that, if I'd been lucky enough to be allowed to push a baby out of my own vagina, and some nurse had started pushing on my stomach (they did, during my c-sections) and told me it was "standard protocol", I'd have probably decked her. Hurting women to avoid something that most of them wouldn't experience, anyway, without informed consent, is just what I expect from a doctor or nurse, though.


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## BroodyWoodsgal (Jan 30, 2008)

Quote:


> Originally Posted by *holly6737*
> 
> This isn't my first rodeo, Broody. I've been around the NCB and HB community a long time. I used to be like you, vehemently for everything "birthy". The truth is, though, that eventually I realized that evidence based practice means just that- evidence based practice. And the "evidence" quoted in "journals" such as "Birth" Isn't really evidence at all. I went where the peer reviewed literature led. If you don't like my philosophy, that's fine with me. I have been to UC and back, so don't think that I've just drunk the westernization koolaid. Have a natural childbirth- I think that's wonderful. But do it with safe, educated, well-trained professionals (CNMs or OBs) and have a working, realistic transfer plan complete with a back-up physician in place.


Okay but see, you are doing it again. THIS is exactly what I'm talking about.

Don't pretend to know what the hell my views are...you have no idea. I actually land firmly in the "get ALL the info...and go where you feel most comfortable" camp. Whether that is barefoot by a river or in the most medicalized, sterile environment imaginable...I truly, truly believe that as authors of our own destiny, we should all be free to birth where it is we feel most at ease/cared for. I love homebirth.....there are women who would absolutely lose it and turn into mush in the middle of a homebirth. It's not for everyone! I am a completely powerful birther at home...I have absolutely no idea how I would cope in a hospital setting...it would be horrible for me...but it's much more peaceful for some women and because of that, they should go there. I support BIRTH CHOICE and people being free to choose WITHOUT JUDGEMENT from "professionals" like you.

My gripe is not with hospital birth...because, frankly, my view that hospitals are not the place for ME to give birth has little to do with the brick and mortar building itself..it's the people INSIDE it, who think that because of their "training" they are gods gift to vaginas everywhere who, inevitably, can't help but to smear that feeling of superiority into every patient they come across in the form of condescension and general asshat behavior.

Case in freaking point:

Quote:


> But do it with safe, educated, well-trained professionals (CNMs or OBs)


....she says, while there are "lay" midwives walking the earth with a knowledge base about birth and birthing women that makes all of the knowledge in western medicine OB textbooks combined look like a kiddie comic book that fell out of a box of cracker jacks.

Quote:


> I used to be like you, vehemently for everything "birthy".


Give me a break...another super cool attempt at minimalizing the viewpoint of a "birth loving nut job who hasn't yet seen the light" - save it for the break room in the nurses lounge or wherever it is that professionals like you hang around being awesome while you're taking a break from fixing the mistakes made by women who dared to believe that they could birth successfully out of hospital without a "super tight" back up in place.

I'm not vehemently for everything "birthy"....I'm "vehemently for" women not being subjected to asshole behavior from some eye rolling CNM who thinks she knows everything there ever was to know about birth because she read some text books that told her all about how broken and scary a process it is.

I'm "vehemently for" women not being made to feel like silly clowns when they choose a less invasive form of care, because the "evidence based" BS didn't feel right to them.

Quote:


> But do it with safe, educated, well-trained professionals (CNMs or OBs)


Seriously...read this^ again....YOU wrote that. Are you kidding me? Because the only birth professionals who are safe, educated and well trained are CNMs or OBs???

Wow. Unbelievable. Man, I wouldn't want to be you, when life decides it's time to hand you some humble pie. When you work in a profession where peoples lives hang in the balance sometimes....you cannot afford to be cocky like this. You cannot afford to be looking down on other people...you need to wake up everyday, hopeful that you will learn something new, that you will bump into someone who knows more than you...someone with the grace to take an extra minute and inform you.

I said it above and I'll say it again....there are people out there, who have not been to school for nursing or whatever, who know more about birth than you could ever dream about. Just as there are OBs out there, CNMs out there, who are so incompetent and unprofessional that they are actually maiming and killing people/babies in the process of failing at their profession.

You CANNOT sit here and say, that going to medical school makes someone a good doctor...any more than you could sit here and say that going to police training academy makes someone a good cop. Or that going to school for dancing makes someone a good ballerina.

Thanks a lot for becoming a part of the problem in birth medicine today. You're really ruining it for all the open minded OBs and CNMs out there who recognize the true value in open and solid realtionships with the lay midwives in their communities...who want to make modern medicine a more supportive model of care for birthing women. You know, attitudes like yours are the FREAKING REASON so many women CAN'T choose a "properly trained, therefore, truly professional" CNM for a homebirth...just as people with attitudes like yours are the reason it's so COMPLETELY impossible for so many women out there to have that "air tight" back up physician you speak of. Unreal.


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## SimonMom (May 19, 2004)

Quote:


> Originally Posted by *holly6737*
> 
> Marsden Wagner isn't even an OB. He's just a family practice doctor.


*scratches head* do you know anything about the medical field or are you just making this up as it goes along? lol

do *you* practice evidence based medicine? oh that's right..you're not a cnm yet, right?  wow i wouldn't trust you at all. are you up to date on currents studies done this topic? a very quick cursory search through web of science shows several studies that do not support active management or at the most very weak support for it. and yes these are just abstracts,  but maybe you should take the time to read through the actual materials and methods and results of these papers. i can't believe someone who purports to follow evidence based practices feels so strongly about an issue where there is plenty of evidence that the practice is not all that helpful and in some ways harmful.

did your school teach you how to decipher scientific literature? lol. i mean i know it's tough...but if you're going to be a cnm..you really might want to think about learning how...

here's one to get you started! pm me if you need any help understanding... 


Comparison of active and expectant management on the duration of the third stage of labour and the amount of blood loss during the third and fourth stages of labour: a randomised controlled trial

Author(s): Kashanian, M (Kashanian, Maryam)1; Fekrat, M (Fekrat, Mohsen)1; Masoomi, Z (Masoomi, Zahra)2; Ansari, NS (Ansari

oh and this next one maybe be considered in favor of your view..but it's stated several times that "there is a lack of high quality evidence" for active management of the third state. wow..i wouldn't want to base my evidence based practices on such studies as that 






   (0)







Save to:  more options
Active versus expectant management for women in the third stage of labourAuthor(s): Begley, CM (Begley, Cecily M.)1; Gyte, GML (Gyte, Gillian M. L.)2; Devane, D (Devane, Declan)3; McGuire, W (McGuire, William)4; Weeks, A (Weeks, Andrew)

*Source: *COCHRANE DATABASE OF SYSTEMATIC REVIEWS Issue: 11 Article Number: CD007412 DOI: 10.1002/14651858.CD007412.pub3 Published: 2011

oh wait..here's ANOTHER study showing no significant difference in blood loss for active vs "hands off" management


A pilot randomized controlled trial of controlled cord traction to reduce postpartum blood lossAuthor(s): Althabe, F (Althabe, Fernando)1; Aleman, A (Aleman, Alicia)2; Tomasso, G (Tomasso, Giselle)2; Gibbons, L (Gibbons, Luz)1; Vitureira, G (Vitureira, Gerardo)3; Belizan, JM (Belizan, Jose M.)1; Buekens, P (Buekens, Pierre)4*Source: *INTERNATIONAL JOURNAL OF GYNECOLOGY & OBSTETRICS Volume: 107 Issue: 1 Pages: 4-7 DOI: 10.1016/j.ijgo.2009.05.021 Published: OCT 2009Times Cited: 1 (from Web of Science)Cited References: 16 [ view related records ] *Citation Map* 

Abstract: Objective: To evaluate whether controlled cord traction (CCT) for management of the third stage of labor reduced postpartum blood loss compared with a "hands-off" management protocol. Methods: Women with imminent vaginal delivery were randomly assigned to either a CCT group or a hands-off group. The women received prophylactic oxytocin. The primary outcome was blood loss during the third stage of labor. Results: In total, 103 women were allocated to the CCT group and 101 were allocated to the hands-off group. Median blood loss in the CCT group and the hands-off group was 282.0 mL and 310.2 mL, respectively. *The difference in blood loss (-28.2 mL) was not significant* (95% confidence interval, -92.3 to 35.9; P=0.126). Blood collection in the hands-off group took 1.2 minutes longer than in the CCT group, which may have contributed to this difference. Conclusion: CCT may reduce postpartum blood loss. The present findings Support conducting a large trial to determine whether CCT can prevent postpartum hemorrhage. (C) 2009 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Now I am curious to see studies in support of active management. And strong support too...not just some wussy small link between the two  I'm not saying there aren't studies that show this, there probably are. But as a scientist..I should think you'd want to educate yourself on topics like these extensively. It's clear you are not. And part of being a scientist is being critical of studies, and running more tests, and being able to change your mind about things when there is clear evidence against it. I'm tired and dont' know what i'm talking about..except that it's bull that you call yourself evidence based. laughable really.


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## Slmommy (Jan 22, 2012)

Quote:



> Originally Posted by *holly6737*
> 
> Marsden Wagner isn't even an OB. He's just a family practice doctor.


And in the great OB = God Paradigm, you are what exactly? A nurse? that's still a few rungs below family practice dr, no? (disclaimer, I in no way subscribe to this viewpoint, but seems as though Holly does)

Holly, your attitude is soo paternalistic it's almost laughable. I am honestly terrified of hcps with this attitude. Terrified. It also really fuels the "Big Bad OB" sentiment around here, but in this case CNM. You posted on UC boards you are interested in UC from sociological viewpoint, well your type of care in no small way influenced my decision to UC, I saw a couple hcps with this attitude, No Thanks!

All of the studies katie posted supporting active management come with several caveats - "there is a lack of high quality evidence"..."adverse effects were identified. *Women should be given information on the benefits and harms of both methods to support informed choice."*

*"However, decisions about individual care should take into account the weights placed by pregnant women and their caregivers on blood loss compared with an intervention-free third stage."* 

Do you just ignore these parts? Because you so obviously know better than the researchers who wrote these studies too. What exactly does informed consent mean to you? Anything? The individual's role in determining her healthcare should stop the moment she contracts you as her mw? I hope your clients realize this.

Any hcp, in any area, who refuses to allow you the role of making decisions about your own health, is a hcp you should run from.


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## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *BroodyWoodsgal*
> 
> Okay but see, you are doing it again. THIS is exactly what I'm talking about.
> 
> ...


This is where we disagree. In order to be a licensed midwife in America, I believe you need to be properly educated (which means formal education by a proper school that is accredited). Considering how many CPMs become CPMs through the PEP process (which requires no formal education whatsoever), I can't say that that credential yields good midwives. MANA actually just now started requring a high school diploma to be a CPM. Just now. Think about that. When I graduate, I"ll have a graduate degree from an accredited institution. I'll have trained with CNMs, OBs and MFMs in multiple academic teaching institutions. You think that someone without even a high school diploma is going to be more competent? Honestly? Where is all of this anti-intellectualism coming from? Have you seen the CDC Wonder data on DEM attended homebirths compared to CNM attended hospital births? It's shameful. That speaks for itself. I, personally, have seen the neonatal deaths rack up all around me (including online) from women attempting dangerous homebirths with uneducated providers. Women who if they would have been in a hospital would have no doubt had healthy, live babies.

I'm not here to take away anyone's right to birth at home. I just want a system in place that allows women who are low risk enough to birth at home to do it in a safe, supported environment. To me, that means CNM (or equivalent) care, proper OB back-up and strict criteria for risk status. That's how you get good outcomes. You don't get good outcomes by going "Oh, yeah, you're a HBA4C's with a history of shoulder dystocia and PPH and you're a type I diabetic with + GBS a breech baby and your membranes have been ruptured for over 4 days with mec, a homebirth (Or god forbid a UC) sounds like a great idea for you!" Right now, the homebirth community is it's own worse enemy because no one wants to admit what I've been saying. Not everyone is a candidate. Lay midwives are not educated enough to attend homebirths. And as the deaths rack up, people are watching. People read this very board watching the deaths, counting them up. Don't you realize that? They don't get swept under the rug. There are people who are watching and keeping a tally. (And someone should be keeping a tally, IMO, because those babies deaths shouldn't go unnoticed.) I know for me, personally, there were 2 notable deaths here on MDC several years ago prior to me going to the dark side, and I remember thinking, "If homebirth is so safe, why did those babies die from preventable complications?" and then the wheels started turning.

As for Marsden Wagner, I suppose what I said about family practice docs was a bit harsh and unfair. Not many family practice docs do OB anymore anyway. From my experience, FP's don't get much OB experience- nowhere near the OB experience that OBs get, but that doesn't mean he's a bad doctor. I've actually read some of his writings, so I am familiar with him enough. HOWEVER, I find it quite ironic that when Marsden Wagner is saying something that you all LIKE, you tote him around as the directeor of WHO women and children. However, when the WHO says something you DON'T like (like that active management of the third stage is evidence based practice) all of a sudden the WHO doesn't know what they are talking about.


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## holly6737 (Dec 21, 2006)

I will refer anyone interested to the ACNM Clinical Bulletin on "Midwifery Education in the US", which is an excellent read. As you will see, I am not the Wicked Witch of the West trying to spit on lay midwives. Many organizations, including the ACNM and the International Confederation of Midwives (the premiere professional midwifery organizations) endorse formal education requirements for midwives in accredited schools regulated by the USDE. Additionally, there is (somewhere on the website) a comparison chart of CNMs, CMs and CPMs, which might be helpful to explain the different types of midwives and the different requirements for each credential, along with whether the credential is accredited or not.


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## Slmommy (Jan 22, 2012)

Holly, I don't really see how your rant about cpms in the US is at all relevant to the fact that you are denying women agency and informed consent in their maternal care.

I wouldn't be surprised if a few women reading this are going to seek out a cpm after reading what care they would receive from you as a cnm.


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## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *slmommy*
> 
> Holly, I don't really see how your rant about cpms in the US is at all relevant to the fact that you are denying women agency and informed consent in their maternal care.
> 
> I wouldn't be surprised if a few women reading this are going to seek out a cpm after reading what care they would receive from you as a cnm.


It's not my job to convince them to not give birth at home with a lay midwife. Women know the risks and they are the ones who will have to live with the consequences of their decisions.

I'm not understanding how I am denying women agency and informed consent in their maternal care? Is this because I practice active management of third stage?


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## fruitfulmomma (Jun 8, 2002)

It is a ridiculous oversimplification as well, that does not take into account laws governing each state and *who* is allowed to practice midwifery nor the background of every single "lay" midwife. Not a few of whom are former L&D nurses or etms or some other medical background.

And you're right Holly, I don't give a hoot what the who has to say (I don't vax my kids either!







) merely pointing out the irony that you cling so tighly to what you claim they say but are in total contrast to a man who worked there as director for many years. Guess he didn't listen to his own advice???


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## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *fruitfulmomma*
> 
> It is a ridiculous oversimplification as well, that does not take into account laws governing each state and *who* is allowed to practice midwifery nor the background of every single "lay" midwife. *Not a few of whom are former L&D nurses or etms or some other medical background.*
> 
> ...


Well then they should have no problem doing the work required to be a CNM/CM and passing the AMCB certification exam.


----------



## Slmommy (Jan 22, 2012)

Quote:



> Originally Posted by *holly6737*
> 
> I'm not understanding how I am denying women agency and informed consent in their maternal care? Is this because I practice active management of third stage?


Yes exactly. I never want a hcp who I would have to fight with to "let" my body do something it is meant to do (birth placenta), especially in absence of problems.

From everything you have said it sounds like you do not allow your patients the option of delayed cord clamping, birthing the placenta themselves, or even waiting 5,10, 15 minutes before using traction?, foregoing pit, fundal massage, etc?


----------



## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *slmommy*
> 
> Quote:
> 
> ...


What are you talking about? I said that I prefer to delay clamp. You can delay clamp and practice active management of third stage.

If a woman were to say to me, "No! I do not want you to touch my fundus!" I wouldn't force fundal massage on her. That's assault, I can't do that. However, I would HEAVILY document her refusal as well as the amount of her blood loss, as would all of the RNs working with me, in the event that it comes up in court.

When you hire a hcp, you need to look at it like going to a restaurant. You wouldn't go to Outback, for example, and try to order Chicken Marsala. Outback doesn't make Chicken Marsala. If you want Chicken Marsala, go to Carrabas or Olive Garden. You come to me at your first prenatal and you say, "I dont' want an induction at 42 weeks gestation". I say, "Our policy is to induce at 42 weeks gestation. Nothing good happens to your placenta after 42 weeks gestation and that's evidence based practice." If you can't get on board with that, you need to think about going to find another hcp. Same as if you come to me and say, "I want a waterbirth". And I say, "Hospital policy does not allow for you to birth in the water. You can labor in the water, but you can't birth in the water." In other words, waterbirth is not on this menu. Perhaps you should go somewhere else where waterbirth IS on the menu or alter your preferences.


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## Slmommy (Jan 22, 2012)

Quote:



> Originally Posted by *holly6737*
> 
> What are you talking about? I said that I prefer to delay clamp. You can delay clamp and practice active management of third stage.
> 
> When you hire a hcp, you need to look at it like going to a restaurant. You wouldn't go to Outback, for example, and try to order Chicken Marsala. Outback doesn't make Chicken Marsala. If you want Chicken Marsala, go to Carrabas or Olive Garden.


Sorry, I guess you did say you do wait for pulsations to slow or cease. Couldn't get passed your deliver, clampclamp cut, pull, pit, massage list for EVERY birth.

I agree about hiring hcp/restaurant analogy... but you just went on a huge rant about how incredibly bad Olive Garden is... no highschool diplomas, all for finding the highest risk woman possible and ignoring every.single. problem that might arise... Maybe you should just practice how you see fit, and try to have maybe a shred of respect for other hcps who practice differently or women who view birth and risks differently?

As pps already said, birth care should not be one-size fits all.


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## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *slmommy*
> 
> Quote:
> 
> ...


Here's the thing. I respectfully believe that we should have a standard of education for who is a midwife and who is not in this country that mirrors that of other developed countries. In GB, for example, a CPM certified through the PEP process would not be able to practice. We lose credibility in the US when we say anyone with any degree of education can be a midwife, be licensed by the state, bill insurance and medicaid, etc. It's too radical (in a bad way). There should be a standard. The CPM credential does not meet that standard- not according to the ACNM, not according to the ICM, not according to any developed country other than the US. You are legally allowed to birth at home with anyone you desire in attendance. I do not want to make it illegal for you to birth in your home- even birth in your home by yourself. However, the state is not obligated to endorse whoever you want to endorse as a licensed provider. We regulate many things in this country. We should regulate midwifery similarly. Look, my husband is in medical school. If he were to just say, "Eh, I don't need this "education". I want to perform orthopedic surgery in my shed! What do I need a license or a medical degree for?" that would be illegal. Why is it legal for untrained, uneducated "midwives" to attend birthing women- many of whom have complications such as PIH, previous c-section, GD, Type I or II diabetes, GBS +, breech, twins, etc.- (and if you don't believe me, just read these boards) in their home? Why should the state endorse that practice? Why should they be able to bill medicaid and Tricare for such services? Standards are important. Education is important. When you say it's not, you're making yourselves look like anti-intellectualists.


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## Slmommy (Jan 22, 2012)

I have no interest debating cpm standards/licensure/legality here. This thread was originally about the necessity of fundal massage and then turned to something somewhat on topic - the necessity or not of active management vs. intervention free, and validity of informed consent to that decision.

I don't ever recall saying that education is not important.

Funny how I see posters on mdc getting called out all the time here for making over-generalizing statements about the "big bad obs" and "medwives" but then it's ok to crap all over cpms and make really gross over-generalizing statements. This is not the first thread to that end either.

As to your husband performing orthopedic surgery in his shed... I mean really, you can't see how some people would view birth as a slightly less medical even than orthopedic surgery?


----------



## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *slmommy*
> 
> I have no interest debating cpm standards/licensure/legality here. This thread was originally about the necessity of fundal massage and then turned to something somewhat on topic - the necessity or not of active management vs. intervention free, and validity of informed consent to that decision.
> 
> ...


The only way you really know that birth is slightly less medical than ortho surgery is by ruling out pathology. If you don't do any ultrasounds, don't properly monitor bp, don't dip urine, don't do the GTT, don't test for GBS, how do you know that it's a normal low risk birth? For all you know, it's not any less medical than ortho surgery.


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## Slmommy (Jan 22, 2012)

You know I did most of those things and others based on my own situation and needs with a whole range of hcps... I understand even low risk can even turn out badly and have issues, obviously... but still, I'm willing to bet that the vast majority of births need be much less medical than orthopedic surgery...

I haven't really met anyone who contracts cpm for at-home c/s... or any ucers who attempt that.


----------



## holly6737 (Dec 21, 2006)

How many times on here, even, do you read that women aren't doing the appropriate screening tests- at least one ultrasound in pregnancy, appropriate bp management, GTT screening, GBS screening, etc? How many times do you see a woman attempting a breech homebirth/UC, a twins homebirth/UC, a homebirth with + GBS or unscreened GBS, a homebirth/UC with a type I diabetic, a UC/homebirth after c-section, etc? It's all over the place. Just scroll through a couple of pages. It's like saying, "If I never get a colonoscopy, I'll never get colon cancer." No, whether you get a colonoscopy or not, you could still get colon cancer. The difference is it will happen and you just won't know about it. YOU may be a responsible homebirther who births with a CNM who has good back-up and YOU might do the appropriate screening tests to determine that you actually are low-risk, but many of your peers do not.


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## Slmommy (Jan 22, 2012)

Quote:


> Originally Posted by *holly6737*
> 
> How many times on here, even, do you read that women aren't doing the appropriate screening tests- at least one ultrasound in pregnancy, appropriate bp management, GTT screening, GBS screening, etc? How many times do you see a woman attempting a breech homebirth/UC, a twins homebirth/UC, a homebirth with + GBS or unscreened GBS, a homebirth/UC with a type I diabetic, a UC/homebirth after c-section, etc? It's all over the place.


About as many times as I see women complaining that their obgyn/mw/hospital policy messed up their labors, coerced them into induction, augmentation, c/s, did something border-line abusive, failed to give informed consent, performed procedures against their will, etc.

We each don't have to like or personally agree with every birthing decision made by every individual. Like you pointed out, it is still legal for women to birth in some of these situations you deem terrible.


----------



## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *slmommy*
> 
> About as many times as I see women complaining that their obgyn/mw/hospital policy messed up their labors, coerced them into induction, augmentation, c/s, did something border-line abusive, failed to give informed consent, performed procedures against their will, etc.
> 
> We each don't have to like or personally agree with every birthing decision made by every individual. Like you pointed out, it is still legal for women to birth in some of these situations you deem terrible.


That's a red herring.

No, I don't have to personally agree with every birthing decision made by every individual. However, when I have my practice philosophy attacked as being too "medical", I am going to explain why my practice philosophy is what it is, and that is because of the number of irresponsible homebirthers and lay midwives and the deaths that occur as a result and the superior outcome data for hospital based CNMs. It's very clear that my management style has superior outcomes. You can see that with the CDC Wonder data. it's not difficult to do. Homebirth with a DEM has a much higher mortality and morbidity rate compared to hospital birth with a CNM. Why is that? You tell me! Lay midwives don't treat you at your peril. Just look at the posters here who have had deaths. "Hands off" leads to worse outcomes- statistically speaking (and that's what counts). And I"m not for every test in the book. I'm for evidence-based practice- which means appropriate interventions when necessary. But sticking your head in the sand and not doing the tests that might indicate an intervention is needed is not the same thing as not needing an intervention. You say, HOmebirth is safe for low risk women. I say, How do you know that you are low risk if you don't actually do anything to show that you are low risk. For all you know, you are high risk. Or, you know you are high risk, as is the case for women who have breech births or homebirth after cesarean (especially multiple cesarean), and choose to proceed anyway in spite of every piece of worthwhile evidence out there that states that what you are participating in is a dangerous situation.


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## Slmommy (Jan 22, 2012)

eh. I'm in a country with 50% c/s for all and 80-90% for women with private health insurance in metro areas. I don't think those numbers are the result of evidence based medicine. I don't think uc is the safest way to give birth, but with the options I had, it was the best option for me. I'm gonna throw out the Wagner quote one more time because I can't really express my thoughts to this end any better in regards to unnecessary interventions.

*Scientists can measure the efficacy and risks, midwives and doctors can inform the woman of the data on these two chances (better or worse) but the person taking the chances (the patient) is the only one who can legitimately decide whether one chance outweighs the other.*

I don't even really know what we are arguing about anymore? You are allowed to practice whatever medicine you want. You can also judge your superior outcomes however you would like, and continue to make gross generalizations about anyone you disagree with.


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## SimonMom (May 19, 2004)

I'm still interested in your evidence for your evidence based practices.  I'm a scientist, I am capable of reading the literature. Show it to me.  You totally glossed over any of the studies I pointed you in the direction of. You want to be believable?  Then show us the evidence. That should be easy.


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## womenswisdom (Jan 5, 2008)

Taking a chance and jumping in here. I have read the whole thread and been following along. Something you said, Holly, stuck out at me. I agree that you have the right to make decisions about how you practice, but what happens if a woman desires something other than what you have to offer? What if she goes into the community and finds that there are _no_ options for hcps who will "allow" her to do what she believes to be best for her and her baby? There are areas in which, even though something is "evidence-based", or even more dubious, the "standard of care", the alternative choice is still a reasonable one. If a woman cannot find a hcp who will provide care, then she either has to consent to something she doesn't really want (not exactly "informed consent" if the alternative is to be dropped from care, right?) or take a chance with a type of hcp that might not be optimal for her situation but will respect her ability to make her own choices.

For example, in many parts of this country, there are vbac bans in all hospitals within a reasonable driving distance (I'm talking within, say, an hour). So what is a woman to do in that circumstance? Either she consents to surgery that she may not feel is the best and safest choice for her and her baby or she hires someone that you might consider to be inadequate to provide care for her. Another example would be antibiotics for GBS, frank breech presentation, induction at x weeks, the list goes on. The issue becomes that when most or all of the available providers in an area make a decision about what _they_ will do, it directly impacts what choices are available to the women in that area.

There are benefits and risks and the only person who should get to say what course of action is appropriate is the patient, with full information. What you as a health care provider would consider the optimal choice _for you_, in your evaluation of the risks and benefits, may not be what your patient believes is the right choice _for her._ All testing and interventions come with both benefits and risks and a health care provider should not be allowed to dictate the course of care for the patient, even if the hcp truly believes that what the mother is choosing is detrimental to herself or her child. That's not their job. If you, as a midwife, do not offer space for women to make their own decisions, then they will find someone who will support them, and the person who will do so may not be the best choice for their situation. And the responsibility for that will be partly on you.


----------



## Storm Bride (Mar 2, 2005)

Quote:


> Originally Posted by *holly6737*
> 
> I'm not understanding how I am denying women agency and informed consent in their maternal care? Is this because I practice active management of third stage?


Quote:


> Originally Posted by *holly6737*
> 
> I'm not here to take away anyone's right to birth at home. I just want a system in place *that allows women who are low risk enough* to birth at home to do it in a safe, supported environment. To me, that means CNM (or equivalent) care, proper OB back-up and *strict criteria for risk status*. That's how you get good outcomes. You don't get good outcomes by going "Oh, yeah, you're a HBA4C's with a history of shoulder dystocia and PPH and you're a type I diabetic with + GBS a breech baby and your membranes have been ruptured for over 4 days with mec, a homebirth (Or god forbid a UC) sounds like a great idea for you!" Right now, the homebirth community is it's own worse enemy because no one wants to admit what I've been saying. *Not everyone is a candidate.*
> 
> ...


----------



## Storm Bride (Mar 2, 2005)

Quote:


> Originally Posted by *holly6737*
> 
> How many times on here, even, do you read that women aren't doing the *appropriate* screening tests- at least one ultrasound in pregnancy, appropriate bp management, GTT screening, GBS screening, etc?


What makes those "apppropriate"? I had GBS screening with my doctor (not in my last "birth", as that was a schedule c/s) for two babies. Both times, she commented that it was protocol, but she was unconvinced it was necessary or useful, and wasn't really supported by research. So, the doctor did screening I didn't like, that she didn't believe was necessary, because that screening was "appropriate".

GTT? I've had the GTT with all my hospital babies. I've passed with flying colours every time. Three of my babies have been over 10lbs. and my last was 9lb. 15oz. I'm obese. I've heard comments about "missed gestational diabetes" multiple times. So, the doctors apparently don't trust that test, either. Why is it appropriate? What is appropriate bp management? I have a friend who checks her own blood pressure regulary and it's fine. When she goes to the doctor, it's through the roof. White coat hypertension - most doctors know, intellectually, that it exists in at least some people. So, is it "appropriate bp management" if a woman gets a blood pressure reading at every prenatal, but never checks it otherwise? Is it "appropriate bp management" if she checks it regularly herself and shows it to her doctor, but refuses to check at the doctor's, because she knows she's prone to white coat hypertension? (The only high blood pressure reading I ever had - during a pregnancy or otherwise - was when the doctor was discussing labour management with me, and when she re-checked it 10 minutes later, when she wasn't piling on stress, it was back well into the normal range. At least she was smart enough to realize that one reading didn't necessarily mean anything.)

I've done all the tests, because I'd given up caring about myself at all by the time I had dd2, and when trying for my VBAC and VBA2C, appearing to be a good patient was important.

And, the woman I know irl (from outside the NCB community, I mean) who had the worst time of it, medically was doing everything "right", by your standards. None of the screening tests caught anything - she showed up at the ER (in the hospital where she worked - she's a nurse) because she had symptoms that concerned her. She had her c-section that night, once her HELLP syndrome was diagnosed. (Her second baby was in the care of an OB, and they thought she'd go full term...but she had another emergency c/s a month early when symptoms flared again.) So...what good did all those "appropriate" screening tests do for her? Her condition was caught, because she noticed symptoms...both times. She probably would have had exactly the same birth experience if she'd been planning a UC.


----------



## Slmommy (Jan 22, 2012)

Quote:


> Originally Posted by *SimonMom*
> 
> I'm still interested in your evidence for your evidence based practices.  I'm a scientist, I am capable of reading the literature. Show it to me.  You totally glossed over any of the studies I pointed you in the direction of. You want to be believable?  Then show us the evidence. That should be easy.


SimonMom, here are some a pp put in post #68 (which I responded to a bit already)

http://www.sciencedirect.com/science/article/pii/S0140673697094099 :done in the UK

http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.1991.tb10364.x/full done in the Netherlands, and it's a randomized, double blinded, placebo controlled study

http://ukpmc.ac.uk/abstract/MED/22071837 A 2011 Cochrane review. 6 of the 7 studies they used were in "high income" countries

also this was referenced by another poster I think:

http://apps.who.int/rhl/reviews/CD000007.pdf

but maybe Holly knows of more.


----------



## fruitfulmomma (Jun 8, 2002)

If you go to the who website then guidelines (on right) and then maternal and reproductive health you can find their publication on pph. It is pretty long, I've only skimmed through, but for what is worth their recomendation is that active management should be *offered* to all women.


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## Slmommy (Jan 22, 2012)

nm


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## holly6737 (Dec 21, 2006)

If she desires something other than what her hcp offers, she either should change her stance or she should go elsewhere. If there's no where else to go, then she should either conform to the hcp's recommendations or she has the right to choose to go without care. I completely support firing patients for going against important recommendations. For example, I know of patients who have been fired from their hcp's for refusing the rhogam shot. Absolutely. I absolutely support that. And that's not the hcp's fault if the woman ends up without care. That's the woman's fault because she didn't accept the shot. I know of kids who have been fired from pediatric practices for not getting shots. I completely support that as well. What I provide is a service. It's my license. I control what I provide. If you want something that I don't provide, you do not have the right to force me to provide it (unless you are covered by EMTALA). I also have agency.

Quote:



> Originally Posted by *womenswisdom*
> 
> Taking a chance and jumping in here. I have read the whole thread and been following along. Something you said, Holly, stuck out at me. I agree that you have the right to make decisions about how you practice, but *what happens if a woman desires something other than what you have to offer? What if she goes into the community and finds that there are no options for hcps who will "allow" her to do what she believes to be best for her and her baby?* There are areas in which, even though something is "evidence-based", or even more dubious, the "standard of care", the alternative choice is still a reasonable one. If a woman cannot find a hcp who will provide care, then she either has to consent to something she doesn't really want (not exactly "informed consent" if the alternative is to be dropped from care, right?) or take a chance with a type of hcp that might not be optimal for her situation but will respect her ability to make her own choices.
> For example, in many parts of this country, there are vbac bans in all hospitals within a reasonable driving distance (I'm talking within, say, an hour). So what is a woman to do in that circumstance? Either she consents to surgery that she may not feel is the best and safest choice for her and her baby or she hires someone that you might consider to be inadequate to provide care for her. Another example would be antibiotics for GBS, frank breech presentation, induction at x weeks, the list goes on. The issue becomes that when most or all of the available providers in an area make a decision about what _they_ will do, it directly impacts what choices are available to the women in that area.
> There are benefits and risks and the only person who should get to say what course of action is appropriate is the patient, with full information. What you as a health care provider would consider the optimal choice _for you_, in your evaluation of the risks and benefits, may not be what your patient believes is the right choice _for her._ All testing and interventions come with both benefits and risks and a health care provider should be able allowed to dictate the course of care for the patient, even if the hcp truly believes that what the mother is choosing is detrimental to herself or her child. That's not their job. If you, as a midwife, do not offer space for women to make their own decisions, then they will find someone who will support them, and the person who will do so may not be the best choice for their situation. And the responsibility for that will be partly on you.


----------



## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *SimonMom*
> 
> I'm still interested in your evidence for your evidence based practices.  I'm a scientist, I am capable of reading the literature. Show it to me.  You totally glossed over any of the studies I pointed you in the direction of. You want to be believable?  Then show us the evidence. That should be easy.


Any true scientist would work at an institution that has access to UpToDate. Log in. Look up anything you want. Otherwise, I would refer you to all of the position statements of the ACNM, the complete Varney's midwifery, the complete Williams Obstetrics, the complete William's Gynecology and the complete Gabe's Normal and Problem Pregnancies. The Green and the Gray journal are also good reads, and you should also have access to these journals through your institution.


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## Just1More (Jun 19, 2008)

Oooookay. I've been reading along, and I'd just like to say that this socialist nonsense drives me up a tree.

If I want my neighbor to privide surgical treatment to me in his garage...back off. Last I checked I lived in a free country, and all this licensing, and "true" scientist stuff has gotten out of hand. If I want to be a moron and die from it, I ought to be allowed. Thank you very much.

And, my lack of true scientist status does NOT mean that I can't read, and that I'm too stupid to understand that I am taking some significant risks with said neighbor in said garage.

Nor does it mean that I can't handle making my own decisions surrounding the birth of my babies and my care. Or that I should be denied the right based on someone's arbitrary educational status. That smacks of arrogance and foolishness to no end.

And, evidence based to one is not to another. I've yet to find a document concerning ANY aspect of health care where ALL doctors/obs/etc agree in the best model of care. So, to act like there is THE way to handle a birth is ridiculous.

I do NOT support the NBC and their movement. Movements lack thought and are dangerous.

But I absolutely support health rights, and parental rights.


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## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *Storm Bride*
> 
> *What makes those "apppropriate"?* I had GBS screening with my doctor (not in my last "birth", as that was a schedule c/s) for two babies. Both times, she commented that it was protocol, but she was unconvinced it was necessary or useful, and wasn't really supported by research. So, the doctor did screening I didn't like, that she didn't believe was necessary, because that screening was "appropriate".
> 
> ...


1) What makes them appropriate are screening recommendations by evidence-based organizations. These are all determined by the literature. Look to the AMA, ACNM, WHO and ACOG for appropriate screening test recommendations.

2) You are not understanding how the GD works. To simplify, GD is a disease that gets worse the farther along in your pregnancy you go. This is because GD is triggered, mostly, by a hormone called human plancetal lactogen. As human placental lactogen increases as your pregnancy progresses, your glucose intolerance increases. So, when we screen woman at 24 weeks gestation, we have the benefit of "catching" GD sooner, but missing women that would have screened positive at 28 weeks gestation. Likewise, if we screen at 28 weeks gestation, we are going to "catch" more GD, but we aren't going to diagnose it earlier, leaving those women who would have screened positive at 24 weeks without treatment for the 4 weeks it takes to get from 24 to 28. What's the answer? It depends on the doctor. Most CNMs I've worked with will screen at 28 weeks to catch more women. However, if there are GD risk factors (such as history of diabetes in a first line relative, history of GD or obesity), some would screen earlier (even in the first trimester) and then screen again at 28 weeks. It's not that the test is inaccurate. It has to do with the process of disease progression.

3) White coat hypertension can make your bp go up by maybe 10 points systolic, but it's not going to make a woman go from a normal bp to 150/100. If a woman is consistenly have pre-eclamptic bps in office but reports that she is not having pre-e bps at her home, I would consult with my supervising doc and probably continue to bring her in for bp checks while also running regular HELLP labs (which include liver function tests, uric acid and a CBC) with a 24 hour urine. At some point, you would decide to induce depending on how the bps are trending and what the labs look like. However, I wouldn't make that call, my consulting physician would make that call and that's why it's so important to have a consult doc to work with.

4) HELLP is a disease that comes on suddenly. You can feel fine one day, but be very not fine the next. You can look good at 12:00 and look like shit 24 hours later. You can even have a good bp and have HELLP. It's something that's diagnosed by lab work (hemolysis- so reduced RBCs, elevated liver enzymes- so increased ALT and AST, and low platelets (decreased platelet counts). In other words, there is no screening test for HELLP other than serial labs and the number to treat on that is too high to make it plausible. If her bp's had been trending well in office then there's no reason to run HELLP labs on her. It sounds to me like your friend was a medical community success story. FURTHER, I'd be willing to bet that if she would have been a UC woman, she would have just stayed home and chalked up her symptoms to being a "variation of normal" as all UCers seem to do for everything.


----------



## holly6737 (Dec 21, 2006)

Well I am a socialist (like an actual socialist), so it's natural you wouldn't agree with me then.









Quote:


> Originally Posted by *Just1More*
> 
> Oooookay. I've been reading along, and *I'd just like to say that this socialist nonsense drives me up a tree.*
> 
> ...


----------



## stik (Dec 3, 2003)

Quote:


> If you, as a midwife, do not offer space for women to make their own decisions, then they will find someone who will support them, and the person who will do so may not be the best choice for their situation. And the responsibility for that will be partly on you.


How would this even work? What is the practitioner supposed to do when faced with a patient who wants something really dangerous? I agree that patients should be making their own medical decisions, and that the responsibility of a hcp is to provide them with information about risks and benefits of various options. But there is also a point at which a provider needs to acknowledge that what a patient is asking for is outside the provider's scope of practice. Not all providers have the knowledge and skills to handle every single situation in every single environment. I don't think it's responsible for any hcp to support a patient through a situation that they aren't actually prepared to handle. They have to communicate the limitations of their practice and be honest about how those limitations affect the patient's choices. It's not responsible for anyone to pretend they can handle every imaginable situation. If a hcp commits to supporting all patients in all their decisions in all situations regardless of the limitations of their skills and resources, that hcp is just as bad as the worst choices available no matter how much they wish the patient would follow their advice.

If an OB or midwife is facing a situation in which a patient is asking for something the provider feels is unsafe, I think they have to be honest about that, about the options, about what they can and cannot do. If a patient responds by finding some quack somewhere who promises that prayer and smudging and homeopathic remedies in a non-interventive environment ensure the health and safety of mom and baby in all possible situations, the responsibility for the outcome of that situation lies with the quack, not with the practitioner who was honest about their concerns and limitations.

Which is a pretty strong argument in favor of licensing hcps, in my opinion. If you cannot recognize that some situations are too dangerous for natural birth with a hands-off appraoch, you should not be in the birth business.


----------



## Just1More (Jun 19, 2008)

Fair enough.


----------



## stik (Dec 3, 2003)

Quote:


> If I want my neighbor to privide surgical treatment to me in his garage...back off. Last I checked I lived in a free country, and all this licensing, and "true" scientist stuff has gotten out of hand. If I want to be a moron and die from it, I ought to be allowed. Thank you very much.


That's nice for you. I want to have a simple criteria that I can use to figure out which practitioners have undergone training and which have not. Licensing helps with this. It's not the alpha and omega of identifying great care providers, but it helps distinguish between providers who have education and providers who don't. Legally protecting the use of certain titles (like MD and CNM) also helps. Historically, caveat emptor has not helped people identify good options, it's just allowed society to shrug its collective shoulders when people get hurt by someone else's con.


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## Just1More (Jun 19, 2008)

I'm not saying licensing, or, perhaps, accrediting, doesn't have a place. And, I'm not saying that garage surgery is a good idea. But, I am saying that it shouldn't be illegal, and that I ought to have the right to chose it if I wish. It doesn't make me wrong, or stupid. It just means that I have a different decision making criteria than you do.

Quote:


> Originally Posted by *stik*
> 
> That's nice for you. I want to have a simple criteria that I can use to figure out which practitioners have undergone training and which have not. Licensing helps with this. It's not the alpha and omega of identifying great care providers, but it helps distinguish between providers who have education and providers who don't. Legally protecting the use of certain titles (like MD and CNM) also helps. Historically, caveat emptor has not helped people identify good options, it's just allowed society to shrug its collective shoulders when people get hurt by someone else's con.


----------



## holly6737 (Dec 21, 2006)

Word.

Quote:


> Originally Posted by *stik*
> 
> How would this even work? What is the practitioner supposed to do when faced with a patient who wants something really dangerous? I agree that patients should be making their own medical decisions, and that the responsibility of a hcp is to provide them with information about risks and benefits of various options. But there is also a point at which a provider needs to acknowledge that what a patient is asking for is outside the provider's scope of practice. Not all providers have the knowledge and skills to handle every single situation in every single environment. I don't think it's responsible for any hcp to support a patient through a situation that they aren't actually prepared to handle. They have to communicate the limitations of their practice and be honest about how those limitations affect the patient's choices. It's not responsible for anyone to pretend they can handle every imaginable situation. If a hcp commits to supporting all patients in all their decisions in all situations regardless of the limitations of their skills and resources, that hcp is just as bad as the worst choices available no matter how much they wish the patient would follow their advice.
> 
> ...


----------



## Slmommy (Jan 22, 2012)

Quote:



> Originally Posted by *holly6737*
> 
> Word.


I agree with *some* of Stik's post too. Hcps shouldn't be forced to practice care they are not comfortable with or knowledgable in, as neither should women be forced to use hcps they aren't comfortable with. But we aren't talking about a breech momma with pre-eclampsia asking to go to 44 weeks and give birth standing on her head. The original topic was expectant vs. active management and the interventions involved in active 3rd stage management.

cpm licensing talk is a whole other can of worms, but if you guys wanna turn it into that, have fun.


----------



## Just1More (Jun 19, 2008)

I agree with stik that a hcp is accountable to their own conscience, and ought to be honest about their abilities and comfort levels. I do not believe a provider should be forced to provide care. However, a woman should also not be forced to accept care. That's the issue. And, there is a significant difference between life saving measures, and "the way I think we should do things".


----------



## womenswisdom (Jan 5, 2008)

Quote:


> Originally Posted by *holly6737*
> 
> If she desires something other than what her hcp offers, she either should change her stance or she should go elsewhere. If there's no where else to go, then she should either conform to the hcp's recommendations or she has the right to choose to go without care. I completely support firing patients for going against important recommendations. For example, I know of patients who have been fired from their hcp's for refusing the rhogam shot. Absolutely. I absolutely support that. And that's not the hcp's fault if the woman ends up without care. That's the woman's fault because she didn't accept the shot. I know of kids who have been fired from pediatric practices for not getting shots. I completely support that as well. What I provide is a service. It's my license. I control what I provide. If you want something that I don't provide, you do not have the right to force me to provide it (unless you are covered by EMTALA). I also have agency.
> 
> ...


Wow. I'm a bit surprised that you don't see the connection between the attitude of "my way or the highway" and women choosing to birth with care providers you view as unqualified. Informed consent does not mean "I inform you of what I want to do and then you consent." If there is no option for refusal, then it's not informed consent. My post was meant to point out a problem with the line of thinking that care providers should just refuse to provide any care to women who make choices they don't agree with in that you wind up with women who are not consenting (in the legal sense) or are without care. That does not appear to be an ethical problem for you, though.
Quote:


> Originally Posted by *stik*
> 
> Quote:
> 
> ...


My post was intended to point out that there has to be a balance and that following Holly's logic could lead to a hairy ethical dilemma. There absolutely are situations where a hands-off birth is clearly and without doubt not safe or wise, or is outside the provider's scope of practice, but there are far more situations where the situation is not so clear cut. Should I be denied all care during my pregnancy if I refuse to an ultrasound, the GTT, a GBS screen, induction or cesarean when the care provider decides? Do I have any right, in the end, to decide anything about my own medical care? Where do we draw the line? Does a care provider have a right to dictate to the patient what her choices will be?


----------



## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *Just1More*
> 
> I agree with stik that a hcp is accountable to their own conscience, and ought to be honest about their abilities and comfort levels. I do not believe a provider should be forced to provide care. However, a woman should also not be forced to accept care. That's the issue. And, there is a significant difference between life saving measures, and "the way I think we should do things".


Who has advocated that women should be forced to accept care? I haven't seen that advocated anywhere in this thread.


----------



## holly6737 (Dec 21, 2006)

Of course you shouldn't be denied all care during your pregnancy. You have the right to find another health care provider to provide you care. You have agency to do so. If you are "fired" from one practice, what is to prohibit you from finding another that might be more in line with your philosophy?

Quote:


> Originally Posted by *womenswisdom*
> 
> Wow. I'm a bit surprised that you don't see the connection between the attitude of "my way or the highway" and women choosing to birth with care providers you view as unqualified. Informed consent does not mean "I inform you of what I want to do and then you consent." If there is no option for refusal, then it's not informed consent. My post was meant to point out a problem with the line of thinking that care providers should just refuse to provide any care to women who make choices they don't agree with in that you wind up with women who are not consenting (in the legal sense) or are without care. That does not appear to be an ethical problem for you, though.
> My post was intended to point out that there has to be a balance and that following Holly's logic could lead to a hairy ethical dilemma. There absolutely are situations where a hands-off birth is clearly and without doubt not safe or wise, or is outside the provider's scope of practice, but there are far more situations where the situation is not so clear cut. *Should I be denied all care during my pregnancy if I refuse to an ultrasound, the GTT, a GBS screen, induction or cesarean when the care provider decides*? Do I have any right, in the end, to decide anything about my own medical care? Where do we draw the line? Does a care provider have a right to dictate to the patient what her choices will be?


----------



## Storm Bride (Mar 2, 2005)

Quote:


> Originally Posted by *holly6737*
> 
> 1) What makes them appropriate are screening recommendations by evidence-based organizations. These are all determined by the literature. Look to the AMA, ACNM, WHO and ACOG for appropriate screening test recommendations.
> 
> ...


----------



## Storm Bride (Mar 2, 2005)

Quote:


> Originally Posted by *holly6737*
> 
> Of course you shouldn't be denied all care during your pregnancy. You have the right to find another health care provider to provide you care. You have agency to do so. If you are "fired" from one practice, what is to prohibit you from finding another that might be more in line with your philosophy?


We want the right to choose a provider who isn't hampered by licenses and regulations. You don't want us to have that right. To work wtih the frequently used restaurant analogy, this is basically "you can choose your restaurant, but only if you want the kind of cuisine they're allowed to serve - we've decided that Thai and Italian aren't on the menu, and if you want either of those, here's some nice Indian or Greek...your choice, of course - you should be able to choose".


----------



## Storm Bride (Mar 2, 2005)

Quote:


> Originally Posted by *stik*
> 
> If an OB or midwife is facing a situation in which a patient is asking for something the provider feels is unsafe, I think they have to be honest about that, about the options, about what they can and cannot do. If a patient responds by finding some quack somewhere who promises that prayer and smudging and homeopathic remedies in a non-interventive environment ensure the health and safety of mom and baby in all possible situations, the responsibility for the outcome of that situation lies with the quack, not with the practitioner who was honest about their concerns and limitations.
> 
> Which is a pretty strong argument in favor of licensing hcps, in my opinion. If you cannot recognize that some situations are too dangerous for natural birth with a hands-off appraoch, you should not be in the birth business.


I've had two providers who were honest with me. One of them was my unlicensed midwife. The other was the OB I went to see when I was having dd2. I liked her well enough, but my experience with OBs leads me to believe that the only reason she was honest was because I was scheduling a c/s, anyway. She didn't have to lie and omit to make me get on the table, so she didn't. Licenses don't create honesty. Informed consent is a joke. And, my non-licensed midwife never even remotely suggested that prayer and smuding and homeopathy would ensure my health or that of my baby. Actually...she's the only care provider I ever had who admitted that there are no guarantees in birth. According to the OBs, a c-section guarantees that there will be no problems. No - they don't say it in those words. But, they strongly imply it, and use that implication as their entire argument (ie. "you must have a c-section, because a healthy mom and a healthy baby are what matters" - if they don't know that such statements are implying a guarantee of both, then they're too stupid to practice medicine).


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## thegoodearth (Jun 6, 2011)

I've been following this thread for quite awhile... And I have to say that never have I wished more for a thumbs down sign than when reading some of your posts Holly, not just the one below. You come across as very pompous. I would never choose a hcp with your attitude: OB, CNM, CPM or whatever. Maybe you don't realize it but you have a "holier-than-thou" air that comes across your posts and makes you seem like a "know-it-all" that can't consider things from another perspective. Not even for a second. Your dogma (or pride) won't allow it - not sure which.

Quote:


> Originally Posted by *holly6737*
> 
> If she desires something other than what her hcp offers, she either should change her stance or she should go elsewhere. If there's no where else to go, then she should either conform to the hcp's recommendations or she has the right to choose to go without care. I completely support firing patients for going against important recommendations. For example, I know of patients who have been fired from their hcp's for refusing the rhogam shot. Absolutely. I absolutely support that. And that's not the hcp's fault if the woman ends up without care. That's the woman's fault because she didn't accept the shot. I know of kids who have been fired from pediatric practices for not getting shots. I completely support that as well. What I provide is a service. It's my license. I control what I provide. If you want something that I don't provide, you do not have the right to force me to provide it (unless you are covered by EMTALA). I also have agency.
> 
> Quote:


Edited to add:

I think womenswisdom made some very valid points to which you response was very much "my way or the highway"


----------



## holly6737 (Dec 21, 2006)

Not true. You can choose anyone you'd like to attend your birth. You are not doing anything illegal by birthing at home with a lay midwife. However, you do not have the right to have whomever you wish to attend your birth be licensed by the state. And the lay midwife that attends your birth does not have a right to advertise and practice as a midwife, when in fact she is not, according to the state. For example, Storm Bride, for you full term loss during an attempted HBA4(or3?)C's, you used Gloria Lemay, correct? You had a right to choose to birth at home, despite your risk factors. No one arrested you. You had a right to ask Gloria Lemay to be present at your birth, despite her history. No one arrested you for asking Gloria Lemay to be at your birth. However, you did not have the right to force the state to endorse or license Gloria Lemay, considering she doesn't meet any criteria for licensing. And, you did not have the right to ask the state not to bring up charges against Gloria Lemay for practicing midwifery without a license, considering she was acting as a midwife when in fact she was not one. But no one said you weren't allowed to birth at home with anyone you wish in attendance. No one wants to get the laboring woman in trouble. The laboring woman can do whatever she wants. It's the dangerous "provider" that should be regulated and fined for pretending to be something they are not.

Quote:


> Originally Posted by *Storm Bride*
> 
> We want the right to choose a provider who isn't hampered by licenses and regulations. You don't want us to have that right. To work wtih the frequently used restaurant analogy, this is basically "you can choose your restaurant, but only if you want the kind of cuisine they're allowed to serve - we've decided that Thai and Italian aren't on the menu, and if you want either of those, here's some nice Indian or Greek...your choice, of course - you should be able to choose".


----------



## womenswisdom (Jan 5, 2008)

Quote:


> Originally Posted by *holly6737*
> 
> Of course you shouldn't be denied all care during your pregnancy. You have the right to find another health care provider to provide you care. You have agency to do so. If you are "fired" from one practice, what is to prohibit you from finding another that might be more in line with your philosophy?


Quote:


> Originally Posted by *holly6737*
> 
> Who has advocated that women should be forced to accept care? I haven't seen that advocated anywhere in this thread.


These two statement can be diametrically opposed.

Let me describe a circumstance that would prevent a woman from finding another practice - one that happens every day in this country.

Women who live in areas, especially rural areas, where there are no hospitals that allow vbacs are forced to either accept medical care as dictated by the care provider or go without it altogether. There are no practices that will accept a patient who will not consent to a cesarean at 39 weeks. How do you reconcile the two statements above? What is a woman supposed to do in that situation? I'm literally asking you and would love to hear your answer.


----------



## holly6737 (Dec 21, 2006)

The woman has a choice to make. She can either birth unassisted or she can consent to the c-section at 39 weeks. Women do not have a right to force a provider to offer a service that they do not feel comfortable providing. That's the bottom line of it. You hire your hcp, but you do not own them. And neither do they own you. You can walk at any time.

Quote:


> Originally Posted by *womenswisdom*
> 
> These two statement can be diametrically opposed.
> Let me describe a circumstance that would prevent a woman from finding another practice - one that happens every day in this country.
> Women who live in areas, especially rural areas, where there are no hospitals that allow vbacs are forced to either accept medical care as dictated by the care provider or go without it altogether. There are no practices that will accept a patient who will not consent to a cesarean at 39 weeks. How do you reconcile the two statements above? What is a woman supposed to do in that situation? I'm literally asking you and would love to hear your answer.


----------



## Storm Bride (Mar 2, 2005)

Quote:


> Originally Posted by *holly6737*
> 
> Not true. You can choose anyone you'd like to attend your birth. You are not doing anything illegal by birthing at home with a lay midwife. However, you do not have the right to have whomever you wish to attend your birth be licensed by the state. And the lay midwife that attends your birth does not have a right to advertise and practice as a midwife, when in fact she is not, according to the state. For example, Storm Bride, for you full term loss during an attempted HBA4(or3?)C's, you used Gloria Lemay, correct? You had a right to choose to birth at home, despite your risk factors. No one arrested you. You had a right to ask Gloria Lemay to be present at your birth, despite her history. No one arrested you for asking Gloria Lemay to be at your birth. However, you did not have the right to force the state to endorse or license Gloria Lemay, considering she doesn't meet any criteria for licensing. And, you did not have the right to ask the state not to bring up charges against Gloria Lemay for practicing midwifery without a license, considering she was acting as a midwife when in fact she was not one. But no one said you weren't allowed to birth at home with anyone you wish in attendance. No one wants to get the laboring woman in trouble. The laboring woman can do whatever she wants. It's the dangerous "provider" that should be regulated and fined for pretending to be something they are not.


I had an unlicensed midwife. I don't discuss her identity, for a variety of reasons. My provider in that pregnancy didn't ever pretend to be anything she isn't - not once, not ever. The state may or may not have had the legal ability to charge my provider, but they don't have a moral right to do so. There was police involvement, and the basis of it was that the poor labouring woman must have been led astray. Because, once again - it couldn't possibly be the actions of the licensed medical professionals that pushed me into a decision that the medical establishment doesn't approve of. I obviously must have been led astray by some kind of Kool Aid. Incorrect. *I* was desperate to avoid the involvement of medpros. Period. (I was desperate enough to disregard my chosen provider's advice to transfer, and it was my call t put off that decision too long. If my provider were proved to have waited too long to advise me to transfer, they'd have howled for her blood. But, I'm just a stupid labouring woman who couldn't have made any decision on my own, so I'm not responsible. There are various factors that contributed to my decisions during that labour. But, if one person deserves the blame for my son's death, it's me, not my provider. The fact that it's the provider people want to go after is just more evidence of the underlying arrogance of the "health" care profession. All the decisions must have been hers, right? After all, the patient/client/pregnant woman has no responsibility for, or authority over, herself.)

I have no interest in forcing the state to license or endorse anybody. I don't give a crap about the state's licensing.


----------



## Storm Bride (Mar 2, 2005)

Quote:


> Originally Posted by *holly6737*
> 
> The woman has a choice to make. She can either birth unassisted or she can consent to the c-section at 39 weeks. Women do not have a right to force a provider to offer a service that they do not feel comfortable providing. That's the bottom line of it. You hire your hcp, but you do not own them. And neither do they own you. You can walk at any time.


Got it. Care providers can't be forced to provide actual care. That makes things very clear. (You're also full of it. Women have been taken to court to try to force them into doing what the doctor wants them to do.)


----------



## Slmommy (Jan 22, 2012)

Quote:



> Originally Posted by *thegoodearth*
> 
> I've been following this thread for quite awhile... And I have to say that never have I wished more for a thumbs down sign than when reading some of your posts Holly, not just the one below. You come across as very pompous. I would never choose a hcp with your attitude: OB, CNM, CPM or whatever. Maybe you don't realize it but you have a "holier-than-thou" air that comes across your posts and makes you seem like a "know-it-all" that can't consider things from another perspective. Not even for a second. Your dogma (or pride) won't allow it - not sure which.


I kinda think Holly is just having fun making really insulting statements and watching us fall over in frenzy.

All of this WHOLE thread... over whether or not women should ALWAYS, in every scenario, have fundal massage.


----------



## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *Storm Bride*
> 
> Got it. *Care providers can't be forced to provide actual care.* That makes things very clear. (You're also full of it. Women have been taken to court to try to force them into doing what the doctor wants them to do.)


That's right. That's absolutely correct. You do not have a right to force a care provider to give you care that he/she feels is unsafe. You don't have that right. We have agency. We have rights ourselves. You don't own us. Like it or not, that's the way it is (and thank God for that!). For example, you can't walk into a general surgeons office and say, "I want an appendectomy." and have the right to force that general surgeon to perform an appendectomy. Don't you see how that would be crazy? I would not longer be the captain of my own ship. I would no longer have control over my own actions, my own practice. That's insane.


----------



## thegoodearth (Jun 6, 2011)

Totally agree. I'm thinking the same thing now.

Quote:


> Originally Posted by *slmommy*
> 
> Quote:
> 
> ...


----------



## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *slmommy*
> 
> Quote:
> 
> ...


I"m just procrastinating studying for boards to be honest with you. I"m not here to have fun. I really should be going actually....

I do think every woman should have fundal massage. I mean, if I do fundal massage a couple of times after delivery of the placenta and your uterus is clamping down nicely and the pit is going in, then I don't have to sit there and knead it. But some fundal massage, yeah. That's evidence based practice, as per the WHO, the ACNM and the ICM, as I've said repeatedly.


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## Just1More (Jun 19, 2008)

Storm Bride, I am so impressed with your take on such a hard situation.

*hugs*

Quote:


> Originally Posted by *Storm Bride*
> 
> I had an unlicensed midwife. I don't discuss her identity, for a variety of reasons. My provider in that pregnancy didn't ever pretend to be anything she isn't - not once, not ever. The state may or may not have had the legal ability to charge my provider, but they don't have a moral right to do so. There was police involvement, and the basis of it was that the poor labouring woman must have been led astray. Because, once again - it couldn't possibly be the actions of the licensed medical professionals that pushed me into a decision that the medical establishment doesn't approve of. I obviously must have been led astray by some kind of Kool Aid. Incorrect. *I* was desperate to avoid the involvement of medpros. Period. (I was desperate enough to disregard my chosen provider's advice to transfer, and it was my call t put off that decision too long. If my provider were proved to have waited too long to advise me to transfer, they'd have howled for her blood. But, I'm just a stupid labouring woman who couldn't have made any decision on my own, so I'm not responsible. There are various factors that contributed to my decisions during that labour. But, if one person deserves the blame for my son's death, it's me, not my provider. The fact that it's the provider people want to go after is just more evidence of the underlying arrogance of the "health" care profession. All the decisions must have been hers, right? After all, the patient/client/pregnant woman has no responsibility for, or authority over, herself.)
> 
> I have no interest in forcing the state to license or endorse anybody. I don't give a crap about the state's licensing.


----------



## stik (Dec 3, 2003)

Fundal massage is a low-risk method of treating pph that has a long history of working and has few side effects. If you gave birth with any kind of care provider, someone checked your fundus after the placenta was delivered. If it felt huge and floppy, that person probably proceeded to pummel you in the stomach for a while, because that it what care providers do to encourage the uterus to clamp down so that bleeding stops faster, really no matter what their philosophy is on active management of the third stage. If you had a c-section, they probably did it before stitching you up. Fundal massage is described as a treatment for PPH in all the UC materials I have seen. I'm kind of boggled that fundal massage has been viewed with such skepticism in this thread.

Personally, I am not a fan of cord traction, and my experience with fundal massage was pretty unpleasant. I asked my hcps about their philosophy on managing the third stage, and we were able to communicate in a mutually respectful way that allowed all of us to voice our concerns and decide on an approach that addressed everyone's priorities.

I think Holly is being very honest about her protocols, and I think that kind of honesty is needed. I would much rather have an OB or CNM who is transparent in her intentions than one who lies to me during pre-natals and then acts unilaterally while I'm in labor.


----------



## SimonMom (May 19, 2004)

Quote:


> Originally Posted by *holly6737*
> 
> Quote:
> 
> ...












i'm asking you







you are debating this. are you incapable of finding these studies? i could be convinced if you find them and show them to us. the onus is on you, my dear.


----------



## SimonMom (May 19, 2004)

i remember fundal massage in at least 2 of my 3 births, however i'm more questioning holly's insistence on cord traction and pit for everyone. i bet she didn't even bother to look at the studies i posted. which just shows to me that she has one view, and that's all. she's not willing to inform herself past what she already believes.


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## Just1More (Jun 19, 2008)

Especially when it gets into the sticky arena of parental vs. child rights. Does the mother get to choose care for herself AND her child? Or just herself? Or how about only her unborn child? Or maybe only her unborn child up to x weeks pregnant? When does the state get to make these decisions? Should it ever get to? Who gets to define "imminent danger"?

Honestly, I don't have answers. I find the topic quite disturbing, mostly because I can only see an all or nothing approach. And, I neither wish the state to have all authority, nor for children to be unprotected.

But, yes, it's totally not true that a person, once they have submitted to standard care, can always just walk away.

Quote:


> Originally Posted by *Storm Bride*
> 
> (Women have been taken to court to try to force them into doing what the doctor wants them to do.)


Back on topic...no, routine fundal massage is not necessary. A fundal check? Sure. Painful massage. No.


----------



## Slmommy (Jan 22, 2012)

Quote:



> Originally Posted by *stik*
> 
> I'm kind of boggled that fundal massage has been viewed with such skepticism in this thread.


It was her original assertion that fundal massage is absolutely.necessary.in.every.single.birth or the mother will always lose an "uncommon amount" of blood.

Like I said, Holly can practice however she wants, but speaking in these absolute terms is simply not true.


----------



## holly6737 (Dec 21, 2006)

Oh please. Get on UpToDate yourself. You are perfectly capable of doing so. I'm not going to spoon feed material to anyone claiming to be a scientist. If you are a scientist, it is within your abilities to both look up the protocols for yourself and understand them.

Quote:



> Originally Posted by *SimonMom*
> 
> 
> 
> ...


----------



## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *slmommy*
> 
> Quote:
> 
> ...


Fundal massage isn't this 20 minute procedure. It can last 10 seconds if the uterus clamps down appropriately and lochia begins to decrease or it can be 5 minutes or more if bleeding persists. It's a feel thing. The duration of fundal massage depends on the situation- and yes, I maintain that my philosophy includes some fundal massage as a part of every birth.


----------



## stik (Dec 3, 2003)

ACOG has issued a statement opposing using court orders to force women into specific treatment protocols. It has happened anyway in a few cases, but I think it's worth noting that the broad medical consensus is that it's poor practice, it reflects horrible doctor/patient relationships, and doctors who do that are asshats.

Holly has a protocol. She's been taught it. It's evidence-based. It has good results. She's comfortable with it. She's honest about it, so if you don't like it you can easily not hire her. There are other CNMs and OBs who don't automatically use cord traction or pit, and the fact that a bunch of people here are shocked by the existence of fundal massage is clear evidence that not everyone does that either.


----------



## Storm Bride (Mar 2, 2005)

Quote:


> Originally Posted by *holly6737*
> 
> That's right. That's absolutely correct. You do not have a right to force a care provider to give you care that he/she feels is unsafe. You don't have that right. We have agency. We have rights ourselves. You don't own us. Like it or not, that's the way it is (and thank God for that!). For example, you can't walk into a general surgeons office and say, "I want an appendectomy." and have the right to force that general surgeon to perform an appendectomy. Don't you see how that would be crazy? I would not longer be the captain of my own ship. I would no longer have control over my own actions, my own practice. That's insane.


But, care providers can - and do - have that power over women. Do you not see how that's insane? You're talking about people having no power over their own practice, while women are deprived of power over our own bodies. You talk a good game about how we can make the choices we want, but you're all for the only providers who will support those choices being pursued legally. Is it crazy that doctors can be banned from performing procedures that they feel are safe, or lose hospital privileges or face disciplinary action? Care providers do have their hands tied, and their decisions made for them, on a regular basis, just not by their patients, who are the ones most profoundly affected by those decisions.

I'm so, so glad I'm through my reproductive life and out the other side.


----------



## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *Storm Bride*
> 
> But, care providers can - and do - have that power over women. Do you not see how that's insane? You're talking about people having no power over their own practice, while women are deprived of power over our own bodies. You talk a good game about how we can make the choices we want, but you're all for the only providers who will support those choices being pursued legally. Is it crazy that doctors can be banned from performing procedures that they feel are safe, or lose hospital privileges or face disciplinary action? Care providers do have their hands tied, and their decisions made for them, on a regular basis, just not by their patients, who are the ones most profoundly affected by those decisions.
> 
> I'm so, so glad I'm through my reproductive life and out the other side.


But why should I be forced to provide for you a service that I feel is dangerous just because you wish to pursue it? Why should the state be obligated to make legal a dangerous medical practice just because you wish to participate in it?


----------



## Plummeting (Dec 2, 2004)

Quote:


> Originally Posted by *holly6737*
> 
> The woman has a choice to make. She can either birth unassisted or she can consent to the c-section at 39 weeks. Women do not have a right to force a provider to offer a service that they do not feel comfortable providing. That's the bottom line of it. You hire your hcp, but you do not own them. And neither do they own you. You can walk at any time.


That's not "consent". In order to give informed consent, you cannot be coerced. If a doctor is threatening to drop you as a patient in your 39th week if you don't do what (s)he wants, then you no longer have the ability to give "consent". All you can do is either refuse or give in to her/his demands. That's not consent.


----------



## lilikoi (Jul 13, 2010)

Holly- They really should offer a class in your program on how to interpret scientific literature. It doesn't look like you can actually do this on your own. People here have posted a few scientific studies that clearly show that this is not black and white and you refuse to answer their questions. What the WHO, the ACNM and the ICM do is interpret data that they see fit, and come up with a series of recommendations that may apply to the *majority*. Some of us don't live in Africa. Most of us are well nourished. If I want to be treated like cattle, I will look for a vet.

I want evidence based practice to be used when I look for a provider. I want someone who is capable of understanding original research and can keep up with new literature, not just pointing to recommendations that may not apply to me as an individual or relying on outdated recommendations. As others have pointed out here, if you really follow evidence based practice, you should read the original peer review literature. Come on, you can do it! And if you need access to those pdfs people have mentioned, just pm me. I will be happy to share them with you.


----------



## Storm Bride (Mar 2, 2005)

Quote:


> Originally Posted by *stik*
> 
> ACOG has issued a statement opposing using court orders to force women into specific treatment protocols. It has happened anyway in a few cases, but I think it's worth noting that the broad medical consensus is that it's poor practice, it reflects horrible doctor/patient relationships, and doctors who do that are asshats.
> 
> Holly has a protocol. She's been taught it. It's evidence-based. It has good results. She's comfortable with it. She's honest about it, so if you don't like it you can easily not hire her. There are other CNMs and OBs who don't automatically use cord traction or pit, and the fact that a bunch of people here are shocked by the existence of fundal massage is clear evidence that not everyone does that either.


I don't actually give a crap what ACOG (or the SOGC, for that matter) say about anything. I see the court orders as a natural extension of the attitude the medical profession, as a whole (yes - there are exceptions) has towards pregnant/birthing women.

I personally have no idea what third stage protocols my medical professionals might have - one has to get to third stage to find out that kind of thing. If Holly's honest about her protocol, that's great (she says she is, but I've never had a licensed provider who actually told me much, and moms don't always know what questions to ask). Women can choose to go elsewhere if they don't want "gentle cord traction". As long as licensing boards are forbidding anyone from providing care without said traction, the woman still has choices.


----------



## stik (Dec 3, 2003)

You can find another provider, even late in pregnancy. Or, you can show up at the hospital in labor and sign AMA forms for procedures you don't want. They cannot turn you away. They are unlikely to seek a court order for treatment.

If you feel you need that particular doctor, then you have some reason to feel that doctor's advice has value, and you should probably consider taking it.


----------



## holly6737 (Dec 21, 2006)

Yes, your choices are to either 1) refuse or 2) not refuse. It's the providers choice to either keep you as a patient or not. Both of you have agency. Both of you have the right to choose. But I believe at 39 weeks patient abandonment would begin to be a legal issue, which is why it is so important to have these conversations at the beginning of pregnancy while you both have time to determine if it's a good patient/provider match.

Quote:


> Originally Posted by *Plummeting*
> 
> That's not "consent". In order to give informed consent, you cannot be coerced. If a doctor is threatening to drop you as a patient in your 39th week if you don't do what (s)he wants, then you no longer have the ability to give "consent". All you can do is either refuse or give in to her/his demands. That's not consent.


----------



## holly6737 (Dec 21, 2006)

Picking individual pieces of literature that support your viewpoint does not determine evidence based practice and it does not determine standard of care. It takes more than one (or two) pieces of literature to create practice protocols. If you have a problem with how the WHO, the ACNM, ACOG or the ICM interpret the vast body of literature, then by all means, please write to them and inform them of their errors.

Quote:


> Originally Posted by *lilikoi*
> 
> Holly- They really should offer a class in your program on how to interpret scientific literature. It doesn't look like you can actually do this on your own. People here have posted a few scientific studies that clearly show that this is not black and white and you refuse to answer their questions. What the WHO, the ACNM and the ICM do is interpret data that they see fit, and come up with a series of recommendations that may apply to the *majority*. Some of us don't live in Africa. Most of us are well nourished. If I want to be treated like cattle, I will look for a vet.
> 
> I want evidence based practice to be used when I look for a provider. I want someone who is capable of understanding original research and can keep up with new literature, not just pointing to recommendations that may not apply to me as an individual or relying on outdated recommendations. As others have pointed out here, if you really follow evidence based practice, you should read the original peer review literature. Come on, you can do it! And if you need access to those pdfs people have mentioned, just pm me. I will be happy to share them with you.


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## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *stik*
> 
> You can find another provider, even late in pregnancy. Or, you can show up at the hospital in labor and sign AMA forms for procedures you don't want. They cannot turn you away. They are unlikely to seek a court order for treatment.
> 
> If you feel you need that particular doctor, then you have some reason to feel that doctor's advice has value, and you should probably consider taking it.


That's a good point. You are always covered under EMTALA if you are in active labor.


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## Storm Bride (Mar 2, 2005)

Quote:


> Originally Posted by *stik*
> 
> *Fundal massage is a low-risk method of treating pph that has a long history of working and has few side effects*. If you gave birth with any kind of care provider, someone checked your fundus after the placenta was delivered. If it felt huge and floppy, that person probably proceeded to pummel you in the stomach for a while, because that it what care providers do to encourage the uterus to clamp down so that bleeding stops faster, really no matter what their philosophy is on active management of the third stage. If you had a c-section, they probably did it before stitching you up. Fundal massage is described as a treatment for PPH in all the UC materials I have seen. I'm kind of boggled that fundal massage has been viewed with such skepticism in this thread.


A treatment is something one uses when a condition is present. If there is no PPH, then performing fundal massage isn't a treatment. As for side effects...the OP described is as torture. Putting pregnant and post-partum women through hell "just in case" is absolutely standard of care, in all kinds of ways. That doesn't mean it has few side effects. It just means that excess pain for the pregnant/post-partum woman isn't considered to be relevant. The only time the medical profession cares about what a pregnant/labouring/post-partum woman is going through is when they sell you on the epidural.

I have no objection to fundal massage as a treatment for PPH...but PPH doesn't occur in 100% of births.


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## Storm Bride (Mar 2, 2005)

Quote:


> Originally Posted by *slmommy*
> 
> Quote:
> 
> ...


You know...I missed that. WTF? How can it be the loss of an "uncommon amount' of blood, if every woman would lose it without fundal massage? That doesn't even make sense.


----------



## Storm Bride (Mar 2, 2005)

Quote:


> Originally Posted by *holly6737*
> 
> Yes, your choices are to either 1) refuse or 2) not refuse. It's the providers choice to either keep you as a patient or not. Both of you have agency. Both of you have the right to choose. But I believe at 39 weeks patient abandonment would begin to be a legal issue, *which is why it is so important to have these conversations at the beginning of pregnancy* while you both have time to determine if it's a good patient/provider match.


There's a reason that the expression "bait and switch" is so prevalent in NCB/VBAC circles. I've never experienced a full on bait and switch, but one of my OBs sure seemed to have a different perspective as my pregnancy progressed. The only thing he stayed constant on was his repetitious "offer" of a tubal.


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## lilikoi (Jul 13, 2010)

Oh, no. I don't think you understood what I was trying to say. I apologize. I was trying to tell you to read the papers other have provided and also the ones you also provided. It didn't seem like you understood them since in some of their recommendations were misinterpreted by you. Please read them! Others here have already tried to tell you this but I don't think you are open minded enough. And no, I don't think these organizations are wrong. Their recommendations are just not right for every women on earth and I am grateful for that! Evidence based means reading the original literature, understanding it, and applying to real situations.

Quote:


> Originally Posted by *holly6737*
> 
> Picking individual pieces of literature that support your viewpoint does not determine evidence based practice and it does not determine standard of care. It takes more than one (or two) pieces of literature to create practice protocols. If you have a problem with how the WHO, the ACNM, ACOG or the ICM interpret the vast body of literature, then by all means, please write to them and inform them of their errors.


----------



## Slmommy (Jan 22, 2012)

Quote:



> Originally Posted by *Storm Bride*
> 
> You know...I missed that. WTF? How can it be the loss of an "uncommon amount' of blood, if every woman would lose it without fundal massage? That doesn't even make sense.


post 28 and 29

Holly: "It is an imperative part of the birthing process, unless you want to lose an uncommon amount of blood."


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## holly6737 (Dec 21, 2006)

No, I read them. And I read that woman's post. I didn't acknowledge it because it seems that she picked studies that supported her viewpoint as opposed to looking at the overall spirit of the body of literature. To get an idea of what the entire body of literature conveys, one looks to recommendations and meta-analysis. These are much more worthwhile to determine practice standards as opposed to individual studies, as one can find an individual study to support one's viewpoint if you only look hard enough.

Cochrane: http://www.ncbi.nlm.nih.gov/pubmed/10908457

"Routine 'active management' is superior to 'expectant management' in terms of blood loss, post partum haemorrhage and other serious complications of the third stage of labour. Active management is, however, associated with an increased risk of unpleasant side effects (eg nausea and vomiting), and hypertension, where ergometrine is used. Active management should be the routine management of choice for women expecting to deliver a baby by vaginal delivery in a maternity hospital. The implications are less clear for other settings including domiciliary practice (in developing and industrialised countries)."

National Guideline Clearinghouse:

http://www.guideline.gov/content.aspx?id=15263

"Active management of the third stage of labour (AMTSL) reduces the risk of PPH and should be offered and recommended to all women. *(I-A)*"

And that is rated the highest level of evidence and is based on RCTs.

Dynamed:

*"Active management of third stage of labor:*

*active management of third stage of labor should be used to decrease postpartum blood loss, length of third stage and incidence of postpartum hemorrhage*


active management of third stage of labor includes 3 components
uterotonic drug (for example, oxytocin) on delivery of anterior shoulder
controlled cord traction to deliver placenta
uterine massage"


Access to this is provided by institutions. It sounds as if you would have access to it, so to view it, just search "overview of labor & delivery" on dynamed and click on "management of third stage". It goes into much more detail, including references, for your viewing pleasure.

ICM Statement PDF, November 2006:

"Active Management of the Third Stage of Labour (AMTSL)

Data support the use of active management of the third stage of labour (AMTSL) by all skilled birth attendants regardless of where they practice. AMTSL reduces the incidence of PPH, the quantity of blood loss and the use of blood transfusion4, and thus should be included in any programme of interventions aimed at reducing deaths from PPH.
The usual components of AMTSL include:




Administration of oxytocin∗ or another uterotonic drug within one minute after the birth of the baby



Controlled cord traction∗∗



Uterine massage after delivery of the placenta as appropriate"


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## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *slmommy*
> 
> Quote:
> 
> ...


That's right. Fundal massage is in imperative part of the birthing process. It prevents PPH. That's accepted by basically every major medical organization in the world, as I have noted.


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## Slmommy (Jan 22, 2012)

Quote:



> Originally Posted by *holly6737*
> 
> That's right. Fundal massage is in imperative part of the birthing process. It prevents PPH. That's accepted by basically every major medical organization in the world, as I have noted.


I guess I should've just asked a long time ago... can you show me the evidence that all women (particularly those with natural/non-augmented births) will always have pph or uncommon blood loss 100% of the time when fundal massage is not performed?

I am only objecting to your use of absolutes.

I stated many times in the beginning that I fully understand fundal massage can be very necessary in some scenarios.


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## holly6737 (Dec 21, 2006)

Where did I say that all women without fundal massage will hemorrhage? That's a ridiculous assertion. I don't believe that so I never would have said it.

What I said was that all women should get fundal massage unless you are okay with a PPH. You can't know who is going to hemorrhage and who is not. You CAN know that more women are going to hemorrhage without fundal massage as opposed to with fundal massage. So, if you don't want a PPH, you should get fundal massage.

It's the same concept as the pertussis vaccine. The pertussis vaccine prevents pertussis infection. So, if you don't want pertussis, you should get the vaccine. That doesn't mean that 100% of people without the pertussis vaccine will get pertussis. That means that the pertussis vax prevents pertussis, so unless you want to get pertussis, you probably should get the pertussis vax, since the pertussis vax makes that end result less likely.

Quote:


> Originally Posted by *slmommy*
> 
> Quote:
> 
> ...


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## Slmommy (Jan 22, 2012)

Quote:


> Originally Posted by *holly6737*
> 
> Fundal massage is standard protocol, and *should be done in all births*. It's a part of the "active management of third stage" which is encouraged by the WHO. It prevents uterine atony and PPH. *It is an imperative part of the birthing process, unless you want to lose an uncommon amount of blood.* It can hurt, but it's very important. Nurses and midwives don't push on your belly to hurt you, they push on your belly to control postpartum bleeding.


unless you want to lose an uncommon amount of blood, pretty much sounds like a gaurantee - that I will pph and/or want to.


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## katelove (Apr 28, 2009)

Before I comment I just want to clarify something. When you talk about "fundal massage" are you talking about actively rubbing the fundus before there are signs of placental separation?

I'll comment further when I'm sure we're talking about the same thing.


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## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *katelove*
> 
> Before I comment I just want to clarify something. When you talk about "fundal massage" are you talking about actively rubbing the fundus before there are signs of placental separation?
> I'll comment further when I'm sure we're talking about the same thing.


No, that's not what I'm talking about at all. Fundal massage prior to placental separation can cause partial separation of the placenta which can actually increase bleeding. Only massage the fundus after the placenta has been delivered. But I'm sure you already knew that.


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## holly6737 (Dec 21, 2006)

That's your interpretation, but that's not what was said.

Quote:


> Originally Posted by *slmommy*
> 
> unless you want to lose an uncommon amount of blood, pretty much sounds like a gaurantee - that I will pph and/or want to.


----------



## BroodyWoodsgal (Jan 30, 2008)

Quote:


> Originally Posted by *holly6737*
> 
> That's your interpretation, but that's not what was said.


No...I think any reasonable person would say that is pretty much what you were saying there. I can't think of many other ways that could be interpreted. Or really even one other way.


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## Slmommy (Jan 22, 2012)

Originally Posted by *holly6737* 

Fundal massage is standard protocol, and *should be done in all births*. It's a part of the "active management of third stage" which is encouraged by the WHO. It prevents uterine atony and PPH. *It is an imperative part of the birthing process, unless you want to lose an uncommon amount of blood.* It can hurt, but it's very important. Nurses and midwives don't push on your belly to hurt you, they push on your belly to control postpartum bleeding.

Quote:


> Originally Posted by *holly6737*
> 
> That's your interpretation, but that's not what was said.


Ok. I guess on top of having extremely different views of birth and the ncb community, we are also speaking different languages.


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## holly6737 (Dec 21, 2006)

Nope. Not what I said. You can read into what you will, but that's not what I said. I will never concede that point as I would never say that. It's a ridiculous assertion and I don't make ridiculous assertions. 

You should get fundal massage if you don't want to hemorrhage, as fundal massage prevents PPH. It's a simple concept. Fundal massage prevents PPH. If you dont' want a PPH, you should get fundal massage. That does not mean 100% of people without fundal massage will PPH.

You are focusing on this part of the argument in order to distract from the greater issue, which is the fact that fundal massage is recommended by every major medical organization as a part of active management of third stage and is evidence-based practice. (What you are doing is called a red herring. It's a logical fallacy and I'm not going to waste my time on it further.)

Quote:



> Originally Posted by *BroodyWoodsgal*
> 
> No...I think any reasonable person would say that is pretty much what you were saying there. I can't think of many other ways that could be interpreted. Or really even one other way.


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## Plummeting (Dec 2, 2004)

Quote:


> Originally Posted by *holly6737*
> 
> Why should they be able to bill medicaid and Tricare for such services? Standards are important. Education is important. When you say it's not, you're making yourselves look like anti-intellectualists.


CPMs can't bill Tricare. They aren't authorized providers.


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## Plummeting (Dec 2, 2004)

Quote:


> Originally Posted by *holly6737*
> 
> But no one said you weren't allowed to birth at home with anyone you wish in attendance. No one wants to get the laboring woman in trouble. The laboring woman can do whatever she wants. It's the dangerous "provider" that should be regulated and fined for pretending to be something they are not.


Have you any idea how paternalistic this sounds? You're essentially saying that the poor, pitiful, laboring women are essentially too dumb to be active participants in something you think is wrong. It's like the old idea of jailing abortion providers, but not the women who get the abortions. Well, it's nice and all that you don't want to punish pregnant women - I appreciate the sentiment - but the idea that it's only the providers at fault really DOES suggest that the women were gullible and stupid. If midwives don't misrepresent themselves, then the women know what they are getting. If they do, then that's another issue entirely, and surely worthy of punishment, but if they don't, then why should they be punished over the women? Honestly. I know this is a difficult idea for people to wrap their minds around, because it sounds so nice, and friendly, and caring to not punish the poor, pitiful, pregnant women, who were just too dumb to know better, but the fact of the matter is that if a woman knowingly hires a midwife with whatever background, then that woman is complicit in whatever "crime" you think it is that the midwife is committing. If you disagree, you are essentially assigning the mentality of children to pregnant women - saying they aren't intelligent enough to know better. You really can't get more paternalistic than that. (And remember, I specifically stated that this applies only when women are well aware of their midwife's particular background, education, etc. It's a different story when a midwife misrepresents herself, so please don't try to conflate the two issues and pretend that they're all the same. They aren't.)


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## holly6737 (Dec 21, 2006)

If there were a man going around calling himself a "lay surgeon", removing the appendix's of people in your neighborhood in their living rooms, do you think he should be charged with practicing medicine without a license?

Quote:


> Originally Posted by *Plummeting*
> 
> Have you any idea how paternalistic this sounds? You're essentially saying that the poor, pitiful, laboring women are essentially too dumb to be active participants in something you think is wrong. It's like the old idea of jailing abortion providers, but not the women who get the abortions. Well, it's nice and all that you don't want to punish pregnant women - I appreciate the sentiment - but the idea that it's only the providers at fault really DOES suggest that the women were gullible and stupid. If midwives don't misrepresent themselves, then the women know what they are getting. If they do, then that's another issue entirely, and surely worthy of punishment, but if they don't, then why should they be punished over the women? Honestly. I know this is a difficult idea for people to wrap their minds around, because it sounds so nice, and friendly, and caring to not punish the poor, pitiful, pregnant women, who were just too dumb to know better, but the fact of the matter is that if a woman knowingly hires a midwife with whatever background, then that woman is complicit in whatever "crime" you think it is that the midwife is committing. If you disagree, you are essentially assigning the mentality of children to pregnant women - saying they aren't intelligent enough to know better. You really can't get more paternalistic than that. (And remember, I specifically stated that this applies only when women are well aware of their midwife's particular background, education, etc. It's a different story when a midwife misrepresents herself, so please don't try to conflate the two issues and pretend that they're all the same. They aren't.)


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## Plummeting (Dec 2, 2004)

Performing surgery is not the same as attending vaginal births, and you know it....or maybe you don't. I have no idea. I kind of assume you do, since you know damn well your training, which is sufficient to prepare you to attend births, is not sufficient to prepare you to perform c-sections. However, if people are silly enough to have some neighborhood dude removing their appendixes, and they know he's not a real doctor and isn't licensed, etc., etc.,, then you either punish them ALL or punish no one. Otherwise, you are saying that the people who use him are morons, too stupid to understand what they're doing, and were therefore tricked. What you are saying right now is that EVERY woman who has ever used an unlicensed midwife in this country was too stupid to understand what she was getting, and therefore, while the midwife should surely be punished, the woman, who was obviously not intelligent enough to be considered an active participant in a crime, should not. She's essentially not mentally fit to stand trial for her participation in said crime.


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## Plummeting (Dec 2, 2004)

Why is it that, in every other scenario, we punish BOTH parties involved in crimes? What's so different about buying drugs, for instance? If I go buy crack from some dealer on the corner, the cops don't assume that I was tricked. The law says I'm a criminal, too, because I was willfully engaged in criminal behavior. We prosecute johns just like we prosecute prostitutes. We don't say one was less guilty than the other (short of women who've been forced into prostitution). We assume that BOTH parties were mentally fit. However, when it comes to any sort of treatment of our health and/or bodies, suddenly all us patients are just idiots? We can't be guilty of anything because we're too stupid to know better? How come I'm smart enough to know whether I should buy crack, but I'm not smart enough to know whether I should use an unlicensed midwife? Makes no sense.


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## erigeron (Oct 29, 2010)

Not to stick my head into a hornet's nest here, but those laws regulating medical providers are because the state has an interest in making sure medical providers fulfil our duty to the public. As a medical provider, I am bound by certain laws if I want to continue legally practicing in my state, and I am subject to action if I break those laws. Patients are subject to no such laws, nor should they be. The "both parties to a crime" discussion isn't really relevant because patients are not legally held to any particular standard of conduct in an interaction with a medical provider that they aren't in other situations. The "crime" in question is committed by a medical provider who violates the rules of his/her profession, or by someone who hasn't met the standards to be called a medical provider but calls him/herself one anyway. Part of the reason that non-providers can't misrepresent themselves as providers is because they could do so in order to fool patients. The issue of whether a particular patient chooses that situation fully aware of the non-provider's qualifications isn't really relevant, because the legal smackdown is not about the patient, it's about the person who's calling themself a provider.

There are all sorts of instances along these lines where someone who is operating in a particular way has to obey particular laws, while those who use their services don't. If I own a restaurant and you come to eat there, then I get shut down for health code violations, you can't get in trouble for having eaten at my restaurant, even if you knew I was violating the health code and chose to eat at my restaurant anyway. That's because the law regulates me as the restaurant owner but not you as the customer. Etc.


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## lilikoi (Jul 13, 2010)

"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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## Slmommy (Jan 22, 2012)

Quote:


> Originally Posted by *lilikoi*
> 
> "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.


Thank you for posting this.

Quote:


> Evidence-based practice involves the active participation of patients in making decisions about their care. Though foreboding in concept, the premise is simple: evidence-based decision-making requires that _consumers comprehend their diagnosis and engage in a reasoned assessment of available treatment options_ and the benefits and risks associated with each.
> http://www.medscape.com/viewarticle/470303_2


I don't see how this is much different than the Marsden Wagner quote.

Scientists can measure the efficacy and risks, midwives and doctors can inform the woman of the data on these two chances (better or worse) but the person taking the chances (the patient) is the only one who can legitimately decide whether one chance outweighs the other.


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## holly6737 (Dec 21, 2006)

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.

Quote:


> Originally Posted by *lilikoi*
> 
> "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.


----------



## holly6737 (Dec 21, 2006)

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.


----------



## Slmommy (Jan 22, 2012)

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?


----------



## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *slmommy*
> 
> 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.


----------



## Slmommy (Jan 22, 2012)

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*
> 
> 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* 

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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## holly6737 (Dec 21, 2006)

"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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## lilikoi (Jul 13, 2010)

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!

Quote:


> Originally Posted by *slmommy*
> 
> 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.
> 
> ...


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## Slmommy (Jan 22, 2012)

Quote:



> Originally Posted by *holly6737*
> 
> 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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## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *slmommy*
> 
> Quote:
> 
> 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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## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *lilikoi*
> 
> 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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## lilikoi (Jul 13, 2010)

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!

Quote:


> Originally Posted by *holly6737*
> 
> 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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## Slmommy (Jan 22, 2012)

Quote:



> Originally Posted by *holly6737*
> 
> 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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## BroodyWoodsgal (Jan 30, 2008)

Oh my god you guys, are you still talking to Holly about this?












































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.









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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## Storm Bride (Mar 2, 2005)

Quote:


> Originally Posted by *holly6737*
> 
> 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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## Dia (Nov 23, 2006)

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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## holly6737 (Dec 21, 2006)

Quote:


> Originally Posted by *Storm Bride*
> 
> 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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## Storm Bride (Mar 2, 2005)

Quote:


> Originally Posted by *holly6737*
> 
> 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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## SimonMom (May 19, 2004)

This thread is still going?  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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## Katie8681 (Dec 29, 2010)

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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