The ICM Protocol
As a midwife, you expect normalcy in birth but you prepare for complications. Hemorrhage is a killer for sure, but so very often more harm is done in the process of trying to avoid problems. Yanking on placentas is a no-no, but how often do you see this done in the hospital? Something as unnecessary as active management of the third stage of labor is then done to counteract the problems caused by interfering with the process in the first place! What follows is an editorial I wrote when the International Confederation of Midwives first came out with the protocol of active management of third stage.
[Editor’s note: This editorial first appeared in Midwifery Today, Issue 71, Autumn 2004.]
The International Confederation of Midwives (ICM) and the Federation of Gynecologists and Obstetricians (FIGO) recently made a clandestine and potentially dangerous decision about midwifery practice. A new protocol was established privately before being introduced to member countries at the ICM conference in Trinidad: ALL midwives and doctors should “offer” all birthing women active management of third stage. This means every woman would be “offered” a shot of 10 IU of synthetic oxytocin within one minute of the delivery of her baby. This is to be done with controlled cord traction and uterine massage. In other words the placenta is pulled out of her—probably causing the hemorrhage in the first place. I put quotes around “offered,” because we all know most doctors either do just what they want or bully women with lies. Here is a letter from one of our readers:
I’m a certified doula, childbirth educator and a fan of your Web site. It’s now protocol at Duke Medical Center and Chapel Hill’s stand-alone birthing center to administer a shot of Pit to all moms as soon as the baby’s anterior shoulder has birthed. I’m sure it’s just a matter of time until this is the case at all our area hospitals. I’ve encouraged my latest Duke client to state on her birth plan that she does not want this routinely, but only if she’s bleeding too much. The doctor who first read this at her last appointment had a problem with this and proceeded to scare my client. It seems I did hear about a study on delayed cord clamping that compared active management of third stage (including immediate clamping, Pitocin shot and tugging to remove placenta) with not doing these things and found significantly less hemorrhaging in the active management group. I’m guessing this is what this new protocol is based on. I can’t believe that was a good study. Does anyone know anything about this? It seems a shame for a mom to avoid Pit, only to have to have it postpartum, even if it doesn’t look like she needs it. My current Duke client may be assertive enough to refuse, but I’d like something more to stand on. Please help.
—Sheryl Mika, Durham, North Carolina
As you can see, the medical community cannot be trusted to “offer” active management of third stage. They are oriented toward intervention in birth, so expecting them to understand physiological birth is a dream.
The motivation for the move is to save lives. Hemorrhage is a killer of women. But I don’t think this is a well-thought-out decision. Most deaths from hemorrhage occur in poor countries. The mandate is not needed in the West, where women seldom die from hemorrhage (a miracle, since so many hemorrhages are iatrogenic). The many techniques to stop hemorrhage are well developed and taught. Internal or external bi-manual compression with a shot of Pitocin is easily administered, if needed, even at home. Many herbs are helpful, and an array of tricks of the trade can prevent or control hemorrhage.
My immediate objection is that Pitocin disturbs the mother’s own oxytocin at the time when it is highest. It is designed by God to help her get to know her baby. One can only wonder if this disturbance has influenced our society toward detachment and violence. Why can’t the medical culture trust and encourage this beautiful process of birth?
There are many issues associated with this, but the biggest effect on midwives is that you, by trusting birth, will be going against a stated global protocol, should you decide against this routine invasive procedure. It can, of course, be a life saver, but midwives should be free to use their own judgment. There is already a tremendous witch hunt going on against midwives. It seems to have escalated recently, especially in the United States. Even direct entry midwives have often had to become more medicalized in order to practice legally. This decision could have dangerous and far-reaching effects on the midwifery model of care. States may bring it into their guidelines and protocols.
This issue fuels my severe frustration with the state of childbirth and midwifery today. My goal has always been for women to have beautiful and rewarding births, but so few women get this chance. I am only heartened by the knowledge that you, too, are fighting for women and their babies.
For more about this issue see Midwifery Today E-News, Issue 6:15.
[Editor’s Note (from Nancy, the managing editor of Midwifery Today): I recently attended a birth at a hospital. It was a beautiful experience, but unnecessarily stressful. I felt I had to fight in order for my friend to be able to have a natural birth. Once the baby was pushed out, I watched as the doctor put 600 mg of Cytotec inside my friend to stop the bleeding. The mom was unaware that she was given a dose of Cytotec since the doctor didn’t consult with her or her husband about it. It wasn’t until we debriefed about the birth a week later that she became aware of the Cytotec. She was wondering why her brain felt foggy after being clear-headed all the way through a very hard labor. I let her know that the doctor gave her drugs and she felt grieved that her bonding time with her son was disrupted because of these drugs. It seemed they were given to her for no apparent reason—the amount of blood was normal, and the whole birth up to that point had been drug free. This experience makes me wonder how often mothers are given drugs without their knowledge or consent.]
— Jan Tritten, mother of Midwifery Today
Jan Tritten is the founder, editor-in-chief and mother of Midwifery Today magazine. She became a midwife in 1977 after the amazing homebirth of her second daughter. Her mission is to make loving midwifery care the norm for birthing women and their babies throughout the world. Meet Jan at our conferences around the world, or join her online, as she works to transform birth practices around the world.
— Nancy Halseide is the managing editor of Midwifery Today magazine and co-owner of Eugene Birth Education. She and her husband are parents to two lovely daughters, both born drug free.
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MamaBaby Haiti Seeks Staff Midwives
MamaBaby Haiti, a birth center dedicated to improving neonatal and maternal mortality rates in Haiti, is seeking staff midwives for 2012.
NARM qualified preceptor
Live on site in Haiti
3–6 Month commitment minimum
Duties: overseeing prenatal, birth, postpartum care, attending births, coordinating student midwife activities, teaching midwifery skills
Benefits: Living expenses & modest stipend
Send resume and cover letter: firstname.lastname@example.org
Homebirth in the Czech Republic
A group of women in the Czech Republic filed a complaint at the European Court of Human Rights in Strasbourg. Their complaint was regarding the lack of official registration needed for midwives in order to deliver babies at home. This fact, coupled with the fact that insurance companies won’t cover homebirth midwives, has made homebirths virtually impossible.
Even though homebirths are common in many parts of Europe, the Czech Republic authorities oppose the practice. Homebirths are technically legal, but the conditions imposed on homebirths make it virtually impossible resulting in only about 500 homebirths each year. In Western Europe, an estimated three percent of all births happen at home.
The Czech medical world frowns heavily upon homebirth. Dr. Petr Velebil, from Prague’s oldest maternity hospital, Podolí, said, “The home is simply not the safest environment in which to give birth. This is why the Czech medical community tries its utmost to convince pregnant women of the benefits of giving birth in a medical facility, which is prepared and therefore equipped to deal with any potential complications. These complications are usually sudden, immediate, and they require immediate medical attention.”
— Cameron, R. “Homebirths back in spotlight as group of pregnant women take their case to European Court of Human Rights.” Cesky Rozhlas. January 17, 2012. http://www.radio.cz/en/section/curraffrs/home-births-back-in-spotlight-as-group-of-pregnant-women-take-their-case-to-european-court-of-human-rights.
You want to be a midwife, but where do you start?
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Putting an End to Women’s Global Slaughter: Bleeding to Death
Everyday events are rarely newsworthy. The media typically induces emotional reactions through constant reports of deaths related to disease, accidents, murders, human conflicts and natural disasters, which explains our widespread tendency to ignore the amplitude of chronic problems. Few people realize that, according to the most authoritative public health reports, more than half a million deaths related to pregnancy and birth occur every year. Bleeding is the single most common cause of maternal death worldwide. The WHO estimates that there are 14 million obstetric haemorrhages a year.(1)
These deaths are to a great extent preventable. Most of them will be avoided on the day when we have rediscovered the basic needs of women in labour and of newborn babies.
In the age of “evidence-based medicine,” it is becoming strange to refer to daily clinical lessons. However, I find it useful to summarize what I learned from decades of practice. We need this perspective because the results of the current randomized controlled trials are of limited use among those who have acquired a good understanding of birth physiology. In these trials, conducted in large conventional departments of obstetrics, the physiological processes are highly disturbed, both in the study groups and in the control groups.(2,3)
Over the years I have come to the conclusion that postpartum haemorrhages are almost always related to inappropriate interference. Postpartum haemorrhage would be extremely rare if a small number of simple rules was understood and observed. I am so convinced of the importance of these simple rules that I have twice agreed to attend a homebirth, although in each case I knew that the woman’s previous birth had been followed by a manual removal of the placenta and a blood transfusion. I take this opportunity to summarize my own attitude during the third stage of labour, in order to stress the differences between my experience and the “expectant” or so-called “physiological” management used in randomized studies.(4)
First, it is important to create the conditions for the “fetus ejection reflex,” which is a short series of irresistible contractions without any room for voluntary movements.(5) This means that the need for privacy and the need to feel secure are met. The opportunity for the fetus ejection reflex occurs when there is nobody around but an experienced, motherly, silent and low-profile midwife sitting in a corner and, for example, knitting (knitting or a similar repetitive task helps the midwife to maintain her own level of adrenaline as low as possible).(6)
- AbouZahr, C. 2003. Global burden of maternal death and disability. Br Med Bull 67:1–11.
- Prendiville, W, et al. 1988. The Bristol Third Stage Trial: Active Versus Physiological Management of the Third Stage of Labour. BMJ 297 (6659): 1295–300.
- Rogers, J, et al. 1998. Active Versus Expectant Management of Third Stage of Labour: The Hinchingbrooke Randomised Controlled Trial. Lancet 351 (9104): 693–99.
- Odent, M. 1998. Don’t Manage the Third Stage of Labour! The Practising Midwife 1 (9): 31–33.
- Odent, M. 1987. The Fetus Ejection Reflex. Birth 14 (2): 104–05.
- Odent, M. 2004. Knitting Midwives for Drugless Childbirth? Midwifery Today 71:21–22.
— Michel Odent
Excerpted from “Putting an End to Women’s Global Slaughter: Bleeding to Death,” Midwifery Today, Issue 74
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Belly dance and pregnancy: a perfect pair!
|Learn how to do it with Dance of the Womb: A Gentle Guide to Belly Dance for Pregnancy & Birth. This 2-disk DVD set includes a 45-minute warm-up and six dance chapters that teach specific movements and their uses during labor. You’ll also see belly dance in practice during labor, as well as a beautifully filmed 50-minute homebirth documentary. To Order
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Enjoy the birth stories of three couples
Just $18, this 42-minute DVD will show you various ways of giving birth, including waterbirth and squatting. The couples also discuss why they decided that homebirth was the best option for them. The audio in Homebirth Stories is in Hebrew; the subtitles are in English. To Order
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Learn from Expert Midwives.
Wisdom of the Midwives, the second volume in the Tricks of the Trade series, is packed full of useful ideas and techniques. You’ll learn about counseling as a tool in your birth kit, nutrition and healthy birth, herbs, homeopathy, Chinese medicine, premature rupture of membranes, first stage and more. Order the book.
Read this review from the current issue of Midwifery Today magazine:
- Childbirth in the Age of Plastics—by Michel Odent
Excerpt: Plastic has invaded our lives on almost every level, from the interiors of metal food cans to baby bottles and diapers. It has had a massive impact on medicine, too.
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Q: What methods have you found to be most helpful with postpartum bleeding?
— Midwifery Today
A: Put a piece of placenta in the cheek or under the tongue.
— Rowan Bailey
A: Putting baby to breast soon after birth!
— Cecilia Gerard Garrison
A: I once popped a friend of mine on the thigh to get her attention and said, “If you do not stop bleeding right now, I am going to call the rescue squad!” She turned off like a faucet, although I suppose you can only use this on women you know very well.
— Babz Covington
A: Careful attention to assisting normal labor progress, promoting adequate hydration in labor, encouraging the woman to keep an empty bladder, paying close attention to 3rd and 4th stages. Promoting breastfeeding ASAP.
— Kim Perry
A: Have mom drink liquid chlorophyll during labor.
— Freida Miller
A: My last birth was unassisted; everything was fine for the first 15 minutes then I stood up and blood was literally gushing out of me. I popped a Yunnan Bai Yao and the bleeding stopped in 30 seconds.
— Amber Gray-Windels
A: In the 70s and 80s we had women take six or so alfalfa tablets because of the vitamin K for six weeks before the due date. Those mamas clotted up nicely.
— Jan Tritten
A: Yunnan Bai Yao works wonders, and I have seen it stop major bleeds, as does having mum put a piece of her placenta on the side of her cheek. I have also seen other midwives gently talk to the mom’s body about stopping the bleeding, and telling mom to relax and picture her body not bleeding anymore. I know it may sound a bit silly, but I have seen this work, too.
— Taylor Lepri
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Nettle is a superb source of vitamin K and increases available hemoglobin, both of which decrease the likelihood of postpartum hemorrhage. Fresh nettle juice, in teaspoon doses, slows postpartum bleeding.
— Susun Weed, herbalist and author of women’s health books
Preterm birth is more likely to end in retained placenta because the body doesn’t think it needs to let go of it yet. Use appropriate workload and nutrition guidelines to prevent preterm labor.
— Birth a Miracle Services, offering professional labor support and childbirth classes
If you’d like to share a bit of wisdom from the Web, please send a 4–5 sentence excerpt, accompanied by a link, to firstname.lastname@example.org.
Make the vision of natural birth available for all to see.
Ask your library to order natural birth and midwifery books for you. When a mother has more information about natural birth available to her, she can make more educated decisions about how she wants to birth her baby. Making requests is easy; here’s how.
Chatting in the Spas at Bad Wildbad
We welcome you to another fabulous year in Germany. The theme of our conference is “Midwifery: Birth Care for a Global Future.” The conference will take place in Bad Wildbad on October 17–21, 2012. We LOVE going to Bad Wildbad because of the great classes, amazing teachers and, of course, for the spas and saunas. Oh, and we have so much fun in the spas after class time relaxing our full minds from all of the great teaching! I especially like the mint and eucalyptus saunas; there are so many different pools that we soak in one for a while then all troop to another one. We tell birth stories and discuss the issues and ideas we learned during the day. Midwives and birth practitioners never stop talking birth even when they are relaxing in pools and saunas.
We have the paper programs in the office now so if you want one e-mail email@example.com with your name and postal address. If you would like a stack to give out to your network and friends, we will send them to you. Please forward this link to your network: http://www.midwiferytoday.com/conferences/Germany2012/. This has shaped up to be an important and rich conference. The thing that would make it better is to see YOU there.
— Jan Tritten
When I was in labor, my 3-year-old daughter kept coming up and checking on me. She would see me laboring on the toilet and say, “It’s okay, Momma. You can do it!” Then she would hurry downstairs to finish making birthday cupcakes with her grandma. Her encouragement made me feel like a superwoman, and when the time came to push, my daughter had a front row seat and watched as her new baby sister was born. You can never underestimate children and the blessing they receive when they are allowed to participate in the birth process.
— Nancy Halseide, managing editor at Midwifery Today
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