Midwife in Malawi (part 4)

My fourth week as a midwife in Malawi. This week I have been thinking about management of the placenta and the third stage of labour. This is the time it takes after the baby is born for the placenta to be born.

In my hospital based training as a midwife in the UK, I almost always saw what is described as “active management” of the third stage. At the majority of homebirths I have supported in the last few years, we have used “expectant” or “physiological management”. https://yourmidwife.org.uk/full-care-homebirth-or-hospital-birth-support/ I am surprised to realise that I haven’t written about management of the placenta in previous blog posts. It is something that I discuss with my clients and is a feature of most people’s birth plans. So, what do these terms mean?

Active management of the placenta involves interventions by the midwife (or doctor). Shortly after the baby is born, an injection of oxytocin is given to the woman. This provokes a strong contraction of the uterus. As that contraction occurs the placenta will start to detach. The midwife then applies traction to the umbilical cord to draw the placenta out. The judgement about how much traction to apply and when is a skill student midwives need to learn under close supervision. With active management the third stage is normally completed within a few minutes of the baby’s birth, almost always within 20-30minutes. During this time the midwife is an active participant and some women feel this to be highly intrusive of their initial moments with their baby.

Expectant management (physiological) relies on nature working effectively and efficiently. We know that a woman seeing, smelling & holding her baby provokes a surge of natural oxytocin. If the woman is well, and the process is not interrupted, a strong and sustained contraction will then spontaneously occur and the woman usually feels the weight of the placenta moving down. Commonly she will then squat (or sit on the loo) and the placenta will be expelled without any interference. Any urine in the bladder can slow this process, so the loo is a great place. Often the woman will pee and the placenta follows shortly afterwards. This process has two fundamental requirements- a healthy woman whose body is not exhausted, and an environment in which the natural process can occur. As with all of labour, adrenaline (a hormone related to stress, uncertainty and fear) can interfere with this. Those emotions can come from the woman or from others around her. Certainly I feel that the environment of home is usually conducive whereas the environment of a busy hospital ward may not be. https://sarahbuckley.com/leaving-well-alone-a-natural-approach-to-the-third-stage-of-labour/#:~:text=Third%20stage%20is%20complete%20when,for%20both%20mother%20and%20baby. In my experience the time for this process to take place naturally is usually a little longer than with active management. My role in that time is to “hold the space” and be quietly watching over mum and baby as they greet one another for the first time. Keeping her warm, feeling safe and protected. The process is expected to be completed within one hour. If there is delay or concerns about bleeding in this time the plan can change to active management.

The timing of separating mum and baby by clamping and cutting the umbilical cord, and how this is affected by the choice of active or expectant management, is one which causes much debate and one which I will write about another day.

Working as a midwife in Malawi, in a country with poor resources and low numbers of midwives, this is an area of care where it would be easy to assume that the natural way would be commonplace. I am learning that the view that “natural is usually best” often reflects our privilege as those living in a high income, industrialised country where most women are fit and well when they have their babies.

The third stage of labour can be extremely dangerous. The placenta detaches from the wall of the uterus, leaving a large raw area with many disrupted blood vessels. Some blood loss at this stage is expected, but it is possible for high volumes of blood to be lost very quickly. Blood loss over 500ml is considered to be a postpartum haemorrhage (PPH), but the loss can be much greater than this. If the woman is well and the process proceeds effectively, the uterine muscles clamp down in a long sustained contraction as the placenta detaches. Because the blood vessels run between the muscle fibres this effectively closes them & allows from blood to clots and so avoids excessive bleeding. Issues that increase the chance of bleeding include the placenta not detaching effectively or completely, the uterine muscles being unable to clamp down effectively, tearing of tissues, and blood conditions in which the woman has inadequate resources to enable blood to clot. These are referred to a the 4 Ts (tissue, tone, trauma and thrombin) https://geekymedics.com/postpartum-haemorrhage/

Postpartum haemorrhage is the highest direct cause of death in Malawi, meaning that management of the placenta is always active management. None of the people I have asked have even heard of physiological management as an option. The maternal mortality rate has been reported to be 449 deaths per 100,000 births, compared to 0.4 per 100,000 in the UK. In Malawi 25% of these deaths are thought to be due to PPH. https://iscollab.org/wp-content/uploads/BR_APPHC_ProgBrief_MalawiOverview.pdf It has been calculated that worldwide 1 woman dies every 6 minutes because of PPH, most of these in sub Saharan Africa. PPH is something that every midwife in the world thinks about and seeks to avoid. As a midwife in Malawi, death due to PPH is sadly far from an unusual experience.

The privilege we have in the UK is immense. The privilege of choice. The privilege of knowing that the process of birth in the UK is generally very safe. The privilege of access to skilled care and the necessary drugs when things get complicated.

The factors that lead to these truly awful statistics in places such as Malawi are obviously multiple. When the body is utterly exhausted – from malnutrition, the need to walk a long distance to access care, an excessively long labour and so on, muscle function will be poor, meaning that poor uterine tone is a major threat. This is compounded if the woman has had multiple pregnancies, or the uterus has been stretched by a multiple pregnancy or excess amniotic fluid. Anaemia is a massive issue in Malawi (malnutrition and conditions such as malaria and worm infestation) and this has a direct effect on the ability of muscles to work well, and also means that women have very much less ability to cope with blood loss. In my base hospital here there is only occasional opportunity to check haemoglobin (Hb) levels, something I take for granted in the UK. I feel concerned if a woman’s Hb is below 100g/L As a midwife in Malawi it is viewed as being totally normal to have an Hb around 70. At this level losing blood means that the oxygen carrying ability of the blood will be significantly impaired, and nutritional deficiencies mean that the body will struggle to make new haemoglobin. In my UK practice I suggest checking the haemoglobin level at the start of pregnancy, around 28 weeks and again around 35weeks. If the haemoglobin drops I can readily check if iron supplements will help (or if there is another cause). If iron supplements are indicated we have multiple choices available. In the Malawian healthcare system it is expected that common drugs and supplements such as ferrous sulphate can be “out of stock” for weeks or months and so simply unavailable.

A retained or partially separated placenta is an immediate threat to the woman. In the UK, this is something dealt with as a medical intervention in a hospital, generally using spinal anaesthesia. As a midwife in the UK I am unlikely ever to perform a manual removal of a placenta but this is something which student midwives expect to undertake here. Remember, there are almost no drugs, so a spinal (or any other pain relief) is simply not an option. Women here are stoic and simply accept that things happen to them, and are done to them which are extremely painful. They have been taught by their life experiences that life is tough. After labour and birth, with whatever interventions have occurred and without pain relief, they lie down for an hour (it is timed), then get up, gather their things and leave the delivery ward. I am in awe of their strength.