Re: my fourth birth...upright position and estimated blood loss

Catherine commented on my fourth birth post, asking:
I was interested to hear about women bleeding more readily when they give birth on their knees - I have for all three and never had that problem, except for the first but that was most likely because of the length of the second stage.

I replied:
I am not entirely sure Cath, Mum said she had the same experiences as you so that's two (actually many more!) stories against one : ) It is highly likely that I misunderstood, or that the midwife was speaking only from her experience ??


Later on though I was required to do some specific reading around birth, and came across these comments on birth position and estimated blood loss:

"Blood loss appears to be higher following upright birth (Gupta et al 2004), but this may be due to the ease of measuring blood loss when upright."

• Chapman, V & Charles, C (eds) 2009, The Midwife's Labour and Birth Handbook, 2nd edn, Wiley-Blackwell, West Sussex

"Gupta and Nikodem (2000) undertook a meta-analysis of controlled studies of positions in the second stage of labour.

They noted that in all the parameters they assessed except one, a policy of upright positions led to benefits for women.

The exception was an increased risk of estimated blood loss above 500mL.

In interpreting these findings, it should be noted that 'upright' included kneeling, squatting, sitting, use of a birthing stool/chair, and use of lateral tilt, while 'recumbent' included on the back, lithotomy stirrups, lateral (without the tilt) recumbent and semi-recumbent.

It has also been observed that where maternal preference was elicited, the most frequent positive responses were from those women who had used an upright position (Sleep et al 1989)."

• Henderson, C & Macdonald, S 2009, Mayes’ midwifery: A textbook for midwives, 13th edn, Baillière Tindall, Edinburgh

Hopefully that is a lot clearer than my first reply!

My 5th Birth

Hi All,

I actually had this birth around 3 weeks ago, but as it kind of disturbed me a little I haven't written about it 'til now.

This woman and I had a very good rapport; we had had a massive chat waiting 1 1/2 hours for the doctor one time, so I got to know her birth wishes quite well. She wanted a natural, intervention-free labour and birth, then wanted to fully breastfeed afterwards. This was her first pregnancy.

Well at 10 days over her due date, she was induced. They tried prostoglandin gel; then broke her waters; and finally hooked her up to syntocinon. She dilated to 3cms, then for 3hrs was "not progressing". I was working a full 8hr shift so couldn't come in until 3:30pm. When I got in, they were just about to do another VE. I walked into her room, she was sitting in the chair (as she said it hurt so much more on the bed) and we had a little chat in between contractions. Another VE was done, still "no progress", and the doctors were talking about a c-section, which I thought was a little weird as her waters were broken only at 7am.

Well the midwife pushed for an epidural instead, as this can make the muscles relax and so dilatation continues. The doctors reluctantly agreed to offer it; the woman reluctantly agreed to have one, and it was put in. Only the anaesthetist drove in 4cms too much of the tube (catheter?) into her back, so after 4hrs of excruciating pain another anaesthetist diagnosed the problem and took some of it out. After that the pain relief was immediate and she could sleep. She was ordered nil by mouth as she might have to go in for a c-section, 2-3 hourly VE's, and given until 1am to fully dilate (the epidural went in at 5pm).

Whenever a VE was done it showed that things were progressing really well, and by 1am she was fully. All this time the fetal heart rate was perfect; but her HR was a little high, and she was febrile but as she had a cold/slight flu this was to be expected, however the doctors were not too happy about it. Her HR rose to 130bpm, and she wasn't seen to be "pushing productively". At around 2:30am the decision was made to use vacuum (without really asking for consent...it was just, this really needs to happen, though they never really said why). Well, we went down to theatre, and trialled vacuum. I was nominated scribe, so had to write down times that the individual doctors came into theatre (neonatologist?, consultant, registrar) and when vacuum was started, stopped, etc. The registrar pulled as hard as she could on the vacuum, then the consultant took over. He pulled as hard as he could, until the cap came flying off; then he tried forceps. He pulled until he was red in the face, and with an episiotomy, the baby eventually came out, at 3:20am.

Baby didn't make much of a sound; and was taken to the neonatologist. Baby was really limp, blue, not crying. The neonatologist picked his arm up and let it drop (just from a small height) and it did just that, drop. He had a 0 for muscle tone, overall a 5 at 1 min. They put O2 on him, and after allowing the parents to kiss him, took him up to special care nursery.
I went up with him and the midwife, saw that he pinked up with O2 (and that I liked the look of the midwives in there...feeling very protective of MY baby...they were fantastic). I went back to the midwive's station, and promptly fell asleep in the chair. I had to get my Mum to pick me up and slept for 12hrs straight!

Went back the next day and baby was doing okay. Over the next few days he got better little by little; my woman was expressing and feeding him, and he went from having mainly formula, to having a little bit of formula to comp the breastmilk. The hospital was fantastic in allowing my woman to stay until baby was discharged on day 5. The last night both parents and baby slept in the rooming-in nursery which was lovely; dad got a little shock from having to get up to baby in the middle of the night though : )

All that week both parents kept saying how wonderful it was to have the continuity of a student midwife, and how wonderful it was to look up in the foreign and scary theatre and see a familiar face (that was trying very hard not to show the fear that was inside!).

In the end, a lovely baby handed over to lovely parents : )