Sunday, 6 January 2013

Avoiding PPH?

Just read a very interesting article in Midwifery Matters magazine, the Manchester issue (Winter 2012) Issue 135 P. 21. It is an article on A Novel Way to Prevent Postpartum Haemorrhage? Judy Slome Cohain, the author, puts forward a natural method of delivering the placenta without drugs and without excessive blood loss. Sounds good.
Study days attended have taught me that the 3rd stage (expulsion of the placenta) can be done in two ways:
  • Active management where an intramuscular injection of Syntometrine (if you are normotensive) or Syntocinon (if you have high blood pressure) is given into your thigh muscle immediately after the birth. The cord is clamped and cut. The injection causes the uterus to contract strongly and push the placenta away from the uterine wall. After noting signs of detachment, the midwife will then pull the placenta out by pulling on the cord. This usually takes about 10-15 minutes.
  • Physiological management where no drugs are given. The cord is left to pulsate and so give baby extra blood needed to perfuse the newly working lungs. Mum, dad and baby are settled onto a bed or other comfortable place and the midwife awaits mum feeling an urge to push the placenta out while watching for excessive blood loss. This can take up to an hour.
Judy's 3 4 5 Protocol, goes back in time to when women did not bleed excessively after giving birth. Judy explores the history of post partum haemorrhage (PPH) and how women in the past avoided it.

  • (3) Skin to skin contact is initiated immediately after the birth. The cord is left to pulsate and is not cut before 3 minutes after the birth. The midwife does not touch the cord or the uterus. After 3 minutes the cord can be clamped and cut and the baby kept with mum or given to dad.
  • (4) The new mum is asked to do "a good deep squat with her bottom almost touching the floor". This is over a low bowl or other implement to catch any blood loss or the placenta. Mum is then asked to push even if she does not feel a contraction or urge to push. 
  • (5) If the placenta has not been expelled by 5 minutes then the midwife is allowed to gently pull on the cord to lengthen it out of the vagina and reassure mum that the placenta is low and to keep pushing.
Mum stays in a low squat while she continues to push. When the placenta has been expelled, mum is made comfortable and given a maternity pad to wear and baby is returned to initiate breast feeding. It is advised to massage the uterus through the abdominal wall to expell any clots, if the pad becomes soaked during the next 5 minutes then an injection of an oxytocic is to be considered. If a woman has a history of PPH then an oxytocic can be offered after the placenta has delivered whether she is having a PPH or not. (Why not just give the injection in the first place anyway and avoid the risk of another PPH right from the start of the 3rd stage if you are going to give it anyway?)

A retained placenta is diagnosed if mum has been pushing for 25 minutes and medical assistance is advised. This method of delivering the placenta is said to avoid a placenta being trapped by the cervix closing after the birth as it should be out after 5 minutes. The baby's lungs are well perfused by the extra blood from not cutting the cord till 3 minutes have elapsed and mum keeps most of her blood by expelling the placenta quickly.

Judy is asking for maternity units to participate in a multicentre study of her protocol and can be reached at