Dr John Stevenson
Jane Munro’s thoughts on Midwifery Guidelines are valuable and provocative. I would like to respond to her request for comment from readers.
Regarding methodology, I will state my prejudices which are firmly based on fact. Women’s views are absolutely basic. When the labouring mother is in charge, and carefully informed, and nothing is done without her consent, and her decisions based on her expert attendant’s advice are respected, and when labour is allowed to proceed at its own pace without any intervention or hurry-up, then the outcome is optimal regarding safety and satisfaction. I am glad Jane has given particular weight to finding women’s views despite this being such an extremely under-researched area.
Secondly, midwives’ research and reviews. I am strongly of the opinion that midwives’ input would be very valuable if based on their own insights and experience, but any research and reviews based on publications by male obstetricians must be viewed with a great deal of healthy scepticism.
Thirdly, prospective randomised controlled trials are useless, as I shall show later. George Bernard Shaw (or was it Mark Twain?) was spot-on when he said “There are lies, there are damned lies, and there are statistics.” Statisticians can lecture plausibly, even convincingly, that they are aware of all the pitfalls in interpretation of research findings and know how to dredge up the facts infallibly, especially when applied to prospective randomised controlled trials which are regarded as the ultimate in fail-safe research. But what the statisticians are expert at is dredging up the ‘facts’ that the researcher wants to prove, (possibly more subconsciously than deliberately).
As my experience increased, I performed fewer and fewer vaginal examinations, aware that they were invasive and embarrassing. They are probably advisable to reassure the midwife when she is new to her profession. Many of my later clients had no vaginal examinations at all. Sometimes the labouring mother wants to know the state of her cervix, and I am prepared to do a vaginal examination on request, but before doing so I point out to the mother that she may be very disappointed by my finding. As a general rule, the cervix opens very slowly to half way, then very quickly to fully, and if someone is only 3 cm after ten hours, that does not mean another full day’s labour lies ahead. In my opinion, support people are vitally important in helping a woman through labour. The right support people are chosen by the pregnant mother from trusted relatives and friends, and it is essential that they know how stressful labour can get, so that they are committed to confident encouragement with no possibility of’ panic. Under those circumstances the labouring mother is far less likely to worry about how her cervix is.
When I began attending home births, I made it my rule to listen to the foetal heart hourly during first stage, and quarter-hourly during second stage. Of course any abnormality detected would warrant listening far more often, but that hardly ever happened. I think the standard fifteen seconds is adequate, rather than a full minute. The foetal heart generally remains normal throughout first stage. But in assessing this, it is important to know what the usual reading was throughout pregnancy, and also allow for the time of day. (I once detected a rate of only 100 at 3 am.) Problems can arise if you do not know what variations to expect in second stage. For most of second stage the foetal heart usually remains normal, but some babies’ hearts can become erratic in second stage, without indicating any serious problem. Some babies are sensitive and excitable. Moulding of the skull can be a stimulus. When the baby’s head is on view, you should not try to check the heart, because it sometimes happens that the oxygen is cut off when it has descended to the perineum, owing to shrinkage of the uterus over the placental site, cutting off maternal supply to the placenta. When this happens, the baby’s heart slows drastically, and if you don’t expect it, you could think that the baby was in trouble, when actually it isn’t, because the slowing of the heart is a reflex action to conserve oxygen, but baby is quite safe because the normal polycythaemia in term babies ensures very adequate reserves of oxygen. Even when baby becomes blue, it is not in danger, it still has reserves. A shocked baby is not blue, but pale grey. If you detect a slow heart when the head is on view, all you need to do is tell yourself that baby must be delivered within twenty minutes. It will usually pop out in a fraction of that time.
I strongly disagree that every midwife must take personal responsibility for being trained and regularly updated in all methods of foetal monitoring, That sounds like it came from a high-tech interventionist obstetrician, Hands-on experience is the essential qualification, together with peer review of problems, and by that I mean mutual consultation amongst midwives only (although obstetrical opinion might be quoted).
I agree that this should be regarded as an unnecessary intervention, but it must be remembered that on rare occasions, unusually tough membranes can hold the baby back, and therefore should be considered as one possible cause of failure to progress in the second stage. In any case amniotomy will make palpation of the head easier in assessing other possible causes of delay in the second stage.
I agree absolutely that there is no good evidence to justify arbitrary time limits on the length of the second stage. The standard obstetrical decree of one hour for primigravidae and a half hour for multigravidae is just plain absurd. I have had many second stages lasting three or four hours and, on very rare occasions, as much as seven or eight hours.
When the head is crowning (which I define as the perineum more than five cms dilated), it is worth watching the posterior perineum, which often becomes extremely tightly stretched. In that case, I rub my fingers on baby’s scalp to pick up vernix and mucus and then very gently massage the posterior perineum from side to side, always ready to desist immediately if the mother does not like that. (Important: keep fingers away from the anus). At the same time your cupped hand can very gently restrain too-rapid progress which might foster a tear; on the other hand if progress in crowning seems too slow, it can be aided by gently wobbling the vertex from side to side by gentle finger-pressure. I am not sure what is meant by ‘hands-on technique’ and ‘hands-poised technique’, whatever they are, any technique should be sensitive to the baby’s condition and mother’s wishes. I certainly agree that episiotomy is an unnecessary intervention with significant risks and side-effects. Amongst over 1,300 home births I performed three episiotomies.
I am passionately opposed to the concept of active management versus physiological management, as originally proposed twelve years ago in the Bristol Third-stage Trial, which I will comment on shortly. I strongly advise that those terms should be scrapped, and not used at all. Instead, midwives should use what I call common sense management.
I always carry a glass quart jug for measuring blood loss, and a shallow soft-plastic cup to scoop it up with. The purpose of this is that one can see in an instant, at any time, what the total blood loss is to date. As soon as the baby is born, it is placed in the mother’s arms at once, and from a distance of a of a metre or two the attendant should watch the baby’s breathing movements, reflexes, colour and general condition, while at the same time keeping a watch out for bleeding.
If there is no bleeding, the placenta should not be disturbed, but should be allowed to remain in place while the uterine bed under it consolidates, so that within half an hour it is safe to say there will be no bleeding. Several minutes after the birth I usually ask mother to tell me if she gets more contractions or an urge to push, or pelvic discomfort.
I think it is useful to notice when the cord pulse stops, which is usually about ten minutes after the birth, but occasionally can be as early as one minute or as late as thirty minutes. Contrary to popular belief there is no circulation through the cord once the baby is born. The pulse in the cord is simply the baby’s heartbeat echoing down the cord. The cessation of pulsation is not simultaneous along the cord, but begins at the maternal end and gradually progresses towards the baby’s umbilicus.
Next in common sense management we should consider cases where there is bleeding. It is fairly common for a gush of blood to appear about four minutes after the birth, corresponding with the next contraction. While it might look scary, it is usually only an ounce or two, and nothing to worry about. Infrequently, however, the blood keeps on accumulating, and this is where the measuring-jug is so valuable. If the placenta is not expelled before the loss reaches one pint (jug half-full), then I would say to the mother, “You are losing too much, we should get the placenta out”. If the cord has not yet been cut, I would ask the father to hold the baby close to the mother’s side and ask him to watch that the cord is not pulled tight. Then I would get mother to squat over a bowl and ask her to push, at the same time using gentle traction on the cord with a wobbling motion. If the placenta is not delivered within minutes, I would then massage the uterus upwards through the abdominal wall, again with gentle wobbling traction on the cord and with the mother pushing. The placenta generally comes away easily, and a little massage of the uterine fundus stops further bleeding. A pint loss is no big deal for a full-term mother, but the reason I take action then is because if the placenta is stubborn and its delivery difficult, then by the time we have finished the total loss could be considerably more, even double, which is much less desirable but usually no disability.
I have found syntometrine to be hardly ever necessary. (I am disinclined to trust oxytocin alone). Troublesome bleeding is usually the result of low implantation of the placenta, overlapping into the lower segment. In such an event the injection is not as effective as would be theoretically expected. Common sense management of third stage means taking action when necessary, and waiting when it is not. To decide beforehand on either active or passive management is the reverse of common sense.
This brings me to the Bristol Third-Stage Trial, which is a monumental example of how a prospective randomised controlled trial can be manipulated with the help of statisticians to give the answers obstetricians want. This trial compared active management, consisting of intravenous oxytocin as the anterior shoulder was delivered, immediate clamping and cutting of the cord, and delivery of the placenta at once by cord traction, with ‘physiological’ management, which was delineated by the Bristol obstetricians as not giving oxytocin injection, of not touching the cord, not touching the uterine fundus, but only verbally encouraging the mother to put baby to the breast. (Note that most babies are not interested in suckling in the first half hour). If you set out to compare a policy of intensive precipitous intervention with a policy of sitting back and watching the patient bleed, the rush in-and-rip-it-out policy will be seen to be safer. Does any sane person agree that this is the way to get the answers we want? The trial had to be stopped before it was half way through because the alarming haemorrhages were considerably more common in the ‘physiologically’ managed group (and much more common in both groups than in common-sense managed home births). The trial supposedly ‘proved’ that active management was the only safe way for the third stage. But the whole trial was riddled with false premisses and mistaken deductions. If readers are interested in a careful analysis of the Bristol Third Stage Trial, please let Margaret [Margaret Jowitt , editor] know, and it will be forthcoming.
Best wishes for happy midwifing to you all.
Dr. John Stevenson
10/7/99 Melbourne, Australia
Dr John Stevenson was a GP in a southeast suburb of Melbourne. After nearly twenty years he accidentally became involved in home births.
At first he could not understand why a woman would want to give birth at home, but within the first dozen home births he was impressed by the exquisite joy of the parents, and more importantly, by the palpably overt occurrence of maternal bonding, which in those days could not be seen in hospitals, where it was partly or completely wrecked by hospital procedure.
Dr Stevenson became an enthusiastic advocate of home births and had to give up general practice, and in eight years attended 1,110 successful home births with a safety record better than hospitals.
However the newly formed Australian College of Obstetricians and Gynaecologists became alarmed and approached the Medical Board regarding de-registration. They were informed that nothing could be done without a complaint, so the medical Superintendent of Queen Victoria Hospital was delegated to write to patients to solicit complaints, using confidential hospital records to obtain names and addresses. (Only transferred patients were able to be solicited). After finally obtaining two rather frivolous complaints, de-registration was very straightforward because the verdict had been decided long before the Medical Board inquiry began, and even before complaints had been solicited.
Dr. John has attended over 200 homebirths since de-registration. He is still an enthusiastic advocate of decent gentle natural birth because of the importance of maternal bonding to the long-term welfare of the child.
AH updated 27 September 1999