Third Stage of Labour Approved – May 2009 for Review – May 2014

WESTSIDE MIDWIVES at Jericho Village ♦ Camille Bush, RM, Kate Blake, RM, Carole Miceli, RM Writing a Birth Plan

A birth plan is a way of communicating with the midwives, doctors, and nurses who care for you in labour. It tells them about the kind of labour you would like to have, what you want to happen and what you definitely want to avoid. It's not written in stone because the best birth plans acknowledge that things may not go according to plan. You need to write the plan in such a way that your nurse, doctor, or midwife doesn't feel she has her hands tied. She may need to recommend a course of action which is not what you had originally hoped for, but which is in the best interests of you and/or your baby.

Before you start writing:

Get as much information as you can:

• Go to prenatal classes. A good prenatal teacher will help you make the best choices for you. Classes that we recommend are: Jeanne Lyon’s, Childbearing Society, Birthing from Within, and a few others. Please ask us for information if you need help choosing one.

• Talk to women who have given birth at the hospital you are going to, or to women who have had a home birth, if that's what you are hoping for. Find out how easy or difficult it was for them to get the kind of care they wanted.

• Talk to your partner or the person who will be your birth companion. What sort of labour and birth would they like you to have? How do they see their role?

Then jot your 'birth wishes' down on a piece of paper -- just as they come to mind. You can sort them out later.

What to include in your plan

Here is a list of headings that you might want to use in your birth plan. You certainly don't have to use them all. Perhaps only a few are really important to you. Perhaps there are others which you can think of which aren't included here.

Birth companion Write down who you want to be with you in labour. Do you want this person to stay with you all the time, or are there certain procedures or stages in labour when you'd prefer him or her to leave the room? You are not limited to only one person – we are happy to have whomever your choose to have with you.

Positions for labour and birth Labour is a process, often one that takes many hours. You will most likely use many different positions in your labour.

WESTSIDE MIDWIVES at Jericho Village ♦ Camille Bush, RM, Kate Blake, RM, Carole Miceli, RM Pain relief Say what kinds of pain relief you want to use, if any, and in what order (for example, you might prefer to try Entonox (laughing gas) before an epidural).

Water Birth If your hospital is open to water birth, or if you are renting one to use at home, write down whether you want to use it for pain relief and/or to give birth in.

Care of the Newborn You will need to communicate with your care provider your preferences for newborn treatments. This includes eye care, Vitamin K, PKU, and plans for circumcision. We will discuss the options during pregnancy and make note of your preferences.

Third stage (delivery of the placenta) You may be offered an injection to speed up the delivery of the placenta, called "active management" of this stage of labour. We will discuss the pros and cons of active management vs. physiologic.

Feeding the baby Be clear about whether you want to breastfeed or bottlefeed. Also be clear about whether your breastfed baby is allowed to have any bottles. If you definitely don't want her to have bottles, say so.

Unexpected situations Some women write down what they want to happen if their baby has to go the newborn intensive care unit (NICU). They might want to be allowed to care for him as much as possible themselves, and to be transferred with him to another hospital if a transfer is necessary. They might ask for their partners to be allowed to stay with them at the hospital.

Special needs

You may have very special needs that you want to mention in your birth plan. If you have a disability, write about the kind of help you will need in labour. Say whether there is any special equipment that would assist you.

If you have particular religious needs, make sure that you include these. It might be important for you to have certain rituals carried out when your baby is born. Or you might require a special diet during your hospital stay. Write all of these things down. Hospitals and health professionals are committed to being culturally sensitive and treating people as individuals. WESTSIDE MIDWIVES at Jericho Village ♦ Camille Bush, RM, Kate Blake, RM, Carole Miceli, RM

What is a Doula?

Birth Doula:

 A woman trained and experienced in childbirth who provides continuous physical, emotional and informational support to a woman during labour, birth, and the immediate postpartum period.

Postpartum Doula:

 A woman trained to care for new families in the first weeks after birth providing household help, advice with newborn care and infant feeding, and emotional support.

Eleven studies showed the following effects of Doula support:

Effects on Birth Outcomes:

 Labours are shorter  There are fewer complications  Cesarean rates are reduced  There is less need for oxytocin to speed up labour  Need for forceps is reduced  Women request less pain medication and epidurals

Effects on the Mother:

 Greater satisfaction with their birth experience  More positive assessments of their babies  Less postpartum depression

Effects on the Baby:

 Babies have shorter hospital stays with fewer admissions to special care nurseries  Babies breastfeed more easily  Mothers are more affectionate to their babies postpartum

Effects on the Health Care System:

 The cost of obstetrical care is dramatically reduced  Women are pleased with the personalized care they receive

The Benefit of continuous support in labour is recognized by:

 The World Health Organization (WHO)  The Medical Leadership Council (an organization of over 1200 U.S. Hospitals)  The Society of Obstetricians and Gynaecologists of Canada

How Doulas Practice:

 Privately – hired directly by clients  As hospital employees WESTSIDE MIDWIVES at Jericho Village ♦ Camille Bush, RM, Kate Blake, RM, Carole Miceli, RM  As volunteers in community or hospital programs

We are happy to provide you with contact information for several doulas that we can recommend. Please let us know if you are interested.

WESTSIDE MIDWIVES at Jericho Village ♦ Camille Bush, RM, Kate Blake, RM, Carole Miceli, RM

Signs of Labour

Signs that labour may begin soon:

 Lower back ache – similar to the feeling like when you’re getting your period  Cramping, or an increase in Braxton-hicks. May be accompanied by discomfort in thighs  Soft bowel movements – may be accompanied by cramps or digestive upset.  Bloody Show – vaginal mucous tinged with red or pink blood. This is a sign that your cervix is beginning to change.  Nesting instinct: sometimes a burst of energy and desire to prepare for baby, sometimes it is wanting to withdraw and be alone and mentally prepare.

Signs of Early Labour:

 More regular contractions or cramps  Loss of appetite  Feeling “weird” or nauseous

What to do in early labour:

 If it is nighttime – try to sleep.  If it is daytime, carry on with life as normal. Try to distract yourself and not focus on labour. You can call your midwife and give her a head’s up that you might be in early labour.  Take a shower or a bath  Keep eating and drinking

Signs of True (more active) Labour:

 Contractions begin to increase regardless of what you are doing.  Contractions become more regular, last longer, and become more uncomfortable  You cannot walk or talk during the contraction and you need to focus.  There may be leaking or a gush of amniotic fluid

What to do in Active Labour:

 Try walking – if you are in active labour it will increase the contractions, if not the will slow down.  Breathe deeply and slowly through contractions. Focus on relaxing your entire body. Try to get into comfortable positions where you can completely relax.  Switch to eating lighter foods and keep drinking

Call your midwife when:

 Your First Baby: WESTSIDE MIDWIVES at Jericho Village ♦ Camille Bush, RM, Kate Blake, RM, Carole Miceli, RM

During the late night hours we kindly ask that you page us when:

 You are having contractions every 4 to 5 minutes apart (counting from the beginning of one contraction to the beginning of the next contraction).  Your contractions are approximately 60 seconds long.  You have been having these contractions for at least one hour in duration.  You can no longer walk or talk through the contractions.

 Your Second, Third, Fourth…Baby:

During the late night hours we kindly ask that you page us when:

 You are having contractions approx. 5 minutes apart.  You have been having contractions for approx. one hour.  You feel any rectal pressure or that the labour is progressing quickly.

“What should I do if my water breaks?”

 If your water breaks at night, and you are NOT having contractions, put a pad on and go back to sleep. This is nature’s way of telling you that you will be going into labour within the next 24 hours! Call the midwife and let her know your water broke first thing in the morning.  Page the midwife if your water is meconium stained (green or brown), has a foul odour, or if the baby is no longer moving. Also page if you are GBS positive.  If your water breaks at night and you ARE having contractions, please page the midwife and let her know. Labour has a tendency to “pick up” once the water has broken.

Daytime Hours:

 Please page the midwife at ANY point in your labour and let her know what is happening. This way she can clear her schedule, get some rest, and get ready to attend your birth!

Pager #:

604-571-7686

WESTSIDE MIDWIVES at Jericho Village ♦ Camille Bush, RM, Kate Blake, RM, Carole Miceli, RM

What You’ll Need for Labour and Birth

You will want to have your things ready for your birth about a month before your due date. If you are planning a hospital birth you will want to plan on being there for 24-36 hours. If you are planning a home birth, we will provide a list of needed medical supplies. It is a good idea to put all of the items together in one place (maybe near the door) along with the car seat so you can have it when needed.

Below is a list of items to consider. Don’t feel like you need to pack everything on the list – just what you feel you would like.

For the Mother:

o Pajamas, night-gown, or t-shirt – one to labour in and one for after birth. o Slippers or shoes easy to put on o Underwear (at least 3 pairs), nursing bra and pads, socks o Personal hygiene items: toothbrush, hairbrush, lip balm, hair ties, etc. o Change of clothes to go home in o Large sanitary pads o Massage oil o Pillow from home in a distinctive pillow case o Snacks and drinks o CD’s or MP3 and player o BC Care card o Camera

For the Partner:

o Change of clothes and personal care items o Money for food, phones, and parking o Swimsuit if you are wanting to accompany the mother into the shower o Sleeping bag and pillow o Snacks and drinks o List of friends and family to call after the baby is born

For the Baby:

o Undershirt and sleeper o Diapers o Blanket o Car seat o Cap and booties o Receiving blankets WESTSIDE MIDWIVES at Jericho Village ♦ Camille Bush, RM, Kate Blake, RM, Carole Miceli, RM

Medical Pain Relief Options in Labour

Pain Relief Option Benefits Side Effects Nitrous Oxide (Entonox) and  Can be used right up until birth  Only recommended for 2-3 hours. Oxygen. Commonly known as  The Woman in labour holds the face  May make some women feel dizzy and have laughing gas. mask and breathes in the amount temporary tingling or numbness in their face she requires. or hands.

Narcotic Pain Medications  Can be given either Intramuscularly  May make the baby sleepy. If a narcotic is (i.e) Fentanyl or Morphine (IM) or Intravenously (IV) given near birth, it may affect the ability of  Most given by IM will work within 20- some babies to breathe and breastfeed. 30 minutes and will last 2-4 hours.  Usually given before the late part of the first  Most given by IV will work within 2-3 stage of labour due to its effect on the baby at minutes and will last 1-2 hours. birth. This way, it can wear off before the  In general, narcotic medications will baby’s birth. make most women feel sleepy and  May make some women feel drowsy, dizzy, relaxed. or nauseated.  Will only dull the pain, but will not take the pain away.

Epidural / Spinal  Used at any time during labour  Women may have to stay in bed as they will Local anaesthetic is injected into  Provides the most effective pain not have good control of their legs the space around the spinal cord, relief  Women may shiver at first and may itch from providing pain relief from the waist  Women in labour can have more the medication down. During a caesarean birth, medication if needed  Blood pressure will be checked frequently pain relief is from the breastbone  May be used for a caesarean birth  Most women will need to have an IV during down. so women can be awake during the the epidural birth  Women usually have a fetal monitor during an  Women generally do not feel epidural, which may restrict movement drowsy or groggy  Women may have a catheter inserted into their bladder to drain urine.  Women may not feel the urge to push or be able to push well  Increased risk of forceps delivery  Pain relief may not be complete  Some women have a headache after an epidural

Pudendal Block  May be given at the time of birth.  May affect the ability of some babies to Local anaesthetic is injected to breastfeed immediately after birth. numb the nerves around the vagina. This blocks the pain in the vagina, vulva, and perineum.

General Anaesthetic  Is used when an epidural or spinal is  A woman may react to anaesthesia or other Completely asleep during not possible or unsafe to give. medications during surgery. This can be caesarean and birth  Is used when there is not enough dangerous to her health. An example of a time to place an epidural reaction is her blood pressure dropping  Is used in an emergency situation quickly.  Her throat may feel dry and sore after the anaesthetic. This is due to the breathing tube placed in her windpipe while she’s asleep.  She may feel nauseated and vomit after the surgery. Table is adapted from “Baby’s Best Chance”

Labor Support: the “Cliff Notes” version. (This is just a reminder of what we covered in class. Call your caregiver if questions arise.)

Possible Signs: Crampy, irritable backache, PMS symptoms, nesting urge, Flu-like Symptoms. Preliminary Signs: Bloody show, water breaking, pre-labor contractions (irregular; discomfort mostly in the front of the belly; change or stop if you change your activity, eat or drink) Positive Signs: Progressing contractions (longer, stronger, closer together), cervical dilation.

Early Labor What’s Happening: Cervix effaces from 50-100%, dilates to 4 cm. Contractions 6-30 minutes apart. 30-45 seconds long. Mom may want to focus during contractions, but can walk or talk if desired. Can usually relax between contractions. Early labor can last 2-24 hours or more. Breathing techniques: No special breathing techniques are needed. However, many moms find it helpful to begin now with breathing patterns which are useful in later labor: Begin and end contractions with a cleansing breath, use deep abdominal breathing through the contraction. Comfort Techniques: Alternate rest and relaxation with distracting activities. Being active (going for walks, dancing, shopping) can help labor to progress, but it’s very important not to exhaust yourself. Try to be relaxed, and treat this as a vacation day. If labor is moving very slowly, consult with caregiver about the possibility of using natural augmentation methods such as nipple stimulation, orgasm, or acupressure. What should support people do: Time contractions occasionally (every few hours, or when things seem to change significantly.) Time six contractions in a row, and record: when the contraction began, how long it lasted, and how long it had been since the start of the last one. Encourage mom to eat, drink, and go to the bathroom at least once an hour.

Active Labor What’s Happening: Cervix completely effaced, dilates from 4-8 cm. Contractions 3-5 minutes apart, lasting 40-70 seconds. Contractions are more intense, mom may not be able to walk and talk during contractions. Mom tends to become focused. May last from 30 minutes to 10 hours. A suggestion for when to go to hospital: 5-1-1. When contractions are no more than five minutes apart, lasting for at least one minute, with that pattern established for at least one hour. Breathing Techniques: Deep abdominal breathing for as much of the contraction as is comfortable. Over the peak of the contraction, use hee-hee breathing or hee-hee-blow or slide. Comfort Techniques for Active Labor: Warm bath. Touch: Massage, Effleurage (light stroking), Counterpressure on Sacrum, Double Hip Squeeze. Hot/Cold: Heating Pads, Ice Packs, or Cool Cloths on her forehead and back of neck. Vocalization: Singing, Moaning. Sensory Distractions: Music, Aromatherapy, Picture to Use as Focal Point. Relaxation Techniques: Touch Relaxa- tion, Visualization, Breathing in Energy and Strength, Breathing out Tension. Encouragement and Support. Try to phrase things as positive suggestions, not criticisms. What should support people do? Remind mom to drink after each contraction, and go to the bathroom once an hour. Help with Comfort Techniques. Establish Rituals by doing the same thing on each contraction, for as long as that works, then switching to new ritual. Let her rest when she needs to, but remind her that being physically active can help labor progress.

Transition What’s Happening: Cervix dilates to 10 cm. Contractions 2-3 minutes apart, 60-90 seconds long. Intense. Mom may be discouraged, scared, angry. May be trembling, hot/cold, nauseous. How long will it last? 10 minutes to 2.5 hours. Average is 1-1.5 hours in first time moms. Breathing Techniques: Hee-hee breathing or hee-hee-blow. Counted hee-hee-blow, where partner tells mom how many hee-hees to do before each blow. Partners breathe with her. Comfort Techniques: Any of the techniques and positions from active labor. Follow her cues. What should support people do? Stay very close to mom, establish eye contact. Give short and simple directions, don’t ask a lot of questions. Speak calmly, and help to reassure her.

Second Stage: Birth What’s Happening: Cervix has dilated, baby has descended and is ready to be delivered. Con- tractions may be accompanied by a strong urge to push. (May feel like a need to have a bowel movement.) Mom’s vocalizations may change to deep grunts or groans. How long will it last? Anywhere from a few minutes to three hours. Typically 1-2 hours. When should mom start pushing? Consult with caregivers before starting to bear down. Breathing Techniques: With each contraction, take in a deep breath, then tuck chin down to chest, and bear down for five to seven seconds, while exhaling or gently holding breath. Then relax and breathe. Then bear down again. In between contractions, breathe normally and rest. Comfort: Any of the ideas above. A cool cloth on her forehead or neck is especially popular. What should partners do: Help support mom in chosen position. Help guide pushing efforts and breathing. Lots of encouragement and reassurance. Reinforce caregivers’ suggestions.

Department of Midwifery

Third Stage of Labour Approved – May 2009 For Review – May 2014

Preamble Guidelines outline recommendations, informed by both the best available evidence and by midwifery philosophy, to guide midwives in specific practice situations and to support their process of informed decision‐making with clients. The midwifery philosophy recognizes the client as the primary decision maker in all aspects of her care and respects the autonomy of the client (1). The best evidence is helpful in assisting thoughtful management decisions and may be balanced by experiential knowledge and clinical judgment. It is not intended to demand unquestioning adherence to it’s doctrine as even the best evidence may be vulnerable to critique and interpretation. The purpose of practice guidelines is to enhance clinical assessment and decision‐making in a way that supports practitioners to offer a high standard of care. This is supported within a model of well‐informed, shared decision‐ making with clients in order to achieve optimal clinical outcomes.

The Third Stage of Labour The third stage of labour starts at the birth of the baby, and finishes with the expulsion of placenta and membranes, and bleeding is controlled. At the birth of the baby there is an oxytocin surge causing rapid contraction of the uterus resulting in a reduction in the size of the placenta as blood transfuses to the baby. At about half its original size the placenta detaches, and the ‘living ligatures’ of oblique muscle fibers contract around the maternal blood vessels to prevent excessive bleeding. There is also a temporary increase in the blood clotting mechanisms within the mother. Fifty percent of placentas deliver within five minutes and 90% within 15 minutes of the baby's birth (2). Magann et al (2005) concluded the risk of PPH increases after 10 minutes, and after 30 minutes the risk is six times normal. The uterus continues to contract after the birth of the placenta (3). Gyte (2006) points out that although divided into stages, labour is more a continuum with each proceeding phase affecting what follows (4). Labour is controlled by a fine balance of neurological, hormonal, physiological and psychological interactions (5). This should be borne in mind when deciding on the management of the third stage of labour, and in the review of the evidence for active management.

Management Options The third stage may be managed or physiological. Physiological third stage: After the birth of the baby the cord is left intact and the baby is held skin to skin by the mother and preferably breastfeeding. The normal stimulation of the nervous system and hormonal processes result in the separation of the placenta and the contraction of the uterus. The attendant should not pull or interfere with the cord. Physiological facilitation of the birth of the placenta is facilitated by the baby suckling, use of movement and gravity, maternal pushing efforts with contractions, empty bladder, good hydration and watchful waiting. This process may take up to an hour (6). This process can be adversely affected by fear, immobility, dehydration, poor nutrition, exhaustion, separation of mom and baby and lack of emotional support. Any interference which delays the oxytocin surge and the maternal clotting systems may result in higher blood loss. Any interventions in labour may affect this process, including use of pharmaceuticals, operative vaginal birth, and traumatic birth such as shoulder dystocia (7).

Page 1 of 4 Third Stage of Labour May 2009 Department of Midwifery

Midwives should be clear about the components of physiological management in order to ensure safe practice (8). The RCM (2005) suggests that ‘physiological third stage can be seen as the logical ending to a normal physiological labour’ (9). It allows the physiological changes in the uterus to take their natural course (10). With physiological management, a uterotonic (oxytocin), is usually not given unless uterine tone is poor (11). Active management of third stage: There are two commonly used methods to actively manage the third stage of labour. 1) The administration of an oxytocic after birth of the anterior shoulder, prompt clamping and cutting the cord and controlled cord traction with guarding of the uterus and fundal massage. (12). 2) Administration of an oxytocic within one minute of birth, clamping and cutting the cord with delaying for 1 to 3 minutes to help prevent anemia of the newborn, and use of controlled cord traction to deliver placenta, followed by fundal massage (13). Active management has been shown to reduce the occurrence of postpartum hemorrhage by over 40%, with prophylactic treatment of 22 women to prevent one hemorrhage (14). It is the recommended course for all women by the SOGC, ICM and FIGO in all settings. Trials of active management have consistently demonstrated reduction in PPH, both in the developing and developed world. However there is a wide range of methods used in these trials, and there are no trials distinctly differentiating between truly physiological birth and medicalised birth. There can be no assumption that these results would replicate in the low risk healthy homebirth population, or the low risk healthy hospital birthing women with whom Canadian midwives work. Risk factors for PPH indicating active management • Distended uterus, eg. Polyhydramnios, multiple pregnancy • Uterine muscle exhaustion, eg. prolonged labour • Intra amniotic fluid infection • Uterine abnormalities eg. Fibroids • Pre‐existing blood clotting disorders eg. Von Willibrands • Blood clotting disorders in pregnancy eg DIC associated with intrauterine death or APH • Operative vaginal delivery • Pre‐eclampsia • Previous history of PPH or retained placenta • Induction/augmentation • Precipitous labour • Retained placenta longer than 15‐30 minutes/parts of placenta, accretia, previa Advantages and Disadvantages of active management Therapeutic use of active management has made a major contribution to reducing maternal mortality and morbidity. There is debate as to whether prophylactic active management for all women is warranted, although current guidelines from SOGC advocate active management for all women. • Likely less blood loss at birth but anecdotal evidence suggests that lochia after the immediate postpartum period may be more (15). Not clear in research whether this is clinically significant. • Less anaemia <90 Hb but not indicated in the studies as to effect on women’s day to day lives. • Shorter third stage, mean of 4 minutes shorter, with fewer women having a third stage >40 minutes. • When ergometrine is a component of management there is an increase of adverse effects such as

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headache, nausea and increase in blood pressure (16). However the use of ergometrine for active management is not routine in BC. • Larger heavier placenta – this may be overcome by unclamping the cord and allowing it to drain. • More chance of rhesus iso‐immunization in Rh neg women with early cord clamping, due to back‐flow from the cord into the maternal circulation. • Rarely, snapping of the cord and inversion of the uterus are side effects of active third stage (17). • There are no direct benefits to the baby from active management (except for prevention of PPH in mother). Early clamping of the cord may contribute to breathing difficulties in babies, especially if premature. There is a lower hemoglobin in early cord clamping, with lower iron stores shown in some studies at 3‐6 months (18).

Decisions on management The woman must at all times be given the information she needs to help make decisions on management options. It is reasonable to offer physiological management to women who have had physiological labours provided she is fully informed of the risks and benefits and elects to have physiological management. However it is extremely important that the midwife is competent in physiological management and is able to support the woman in a watchful and patient manner, utilizing normal physiological methods to assist in the birth of the placenta such as nursing, mobilization, empty bladder, calm, warmth and confident support. It is important not to ‘mix’ methods, and if the midwife feels she needs to assist in the third stage then full active management should be chosen. It has been shown that controlled cord traction without oxytocin for example will increase the risk of hemorrhage. There is inconclusive evidence on the safety or effectiveness of taking only one or two components of active management. A major difference was found between physicians and midwives in the management of third stage. Physicians routinely implemented active management of the third stage of labor; while midwives preferred expectant approaches, principally based on women's preference. Provincial data did not show differences in postpartum hemorrhage or transfusion rates by practitioner type. Current practice guidelines of third stage management recommend active management of third stage, as a recent study found 98.7% of BC midwives polled are aware. Of these 82 midwives in the study, 51.2% agree with this practice guideline recommendation, and 17% agreeing that "routine active management of third stage should be the norm." Response rates indicating that "oxytocin should be given with the anterior shoulder" were the following: obstetricians 71.1%, family physicians 68.3% and midwives 26.7%. It seems reasonable to delay the active management of third stage for one minute after delivery of the baby to maximize the benefit to the baby of increased placenta‐to‐baby transfusion. Any intervention has the potential to interfere with the hormonal, neurological and psychological aspects for a safe third stage, and therefore women should be advised that in certain circumstances it may be necessary to change plans to an active management of third stage.

REFERENCES

1. College of Midwives of British Columbia. Philosophy of Care. http://www.cmbc.bc.ca (accessed 20 Dec 2006). 2. Magann EF. 2006 Timing of placental delivery to prevent post‐partum haemorrhage: lessons learned from abandoned randomised clinical trial. Aust N Z J Obstet Gynaecol. 2006; 46(6): 549‐51. 3. Magann el al. The length of the third stage of labour and the risk of postpartum hemorrhage. Obstet Gynecol. 2005; 105(2): 290‐3.

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4. Gyte G. NCT Evidenced based briefing, Third Stage of Labour (Parts 1 & 2). New Digest. 2006; 35(01): 24‐28. 5. Anderson T. Out of the laboratory, back to the darkened room. MIDIRS Midwifery Digest. 2002; 12(1): 65‐9. th 6. Fraser DM, Cooper M (eds). Myles Textbook for Midwives, 14 ed. Edinburgh: Churchill Livingstone; 2003: 508‐517. 7. Royal College of Midwives. Evidence based guidelines for midwifery‐led care in labour. London: RCM; 2005. http://www.rcm.org.uk/college/standards‐and‐practice/practice‐guidelines/. Gyte, G.

8. Featherstone E. Physiological third stage of labour. British Journal of Midwifery 1999; 7(4): 216‐221. 9. Royal College of Midwives. 10. Fraser, DM & Cooper, M. 11. Ibid. 12. Schuurmans N, MacKinnon C, Lane C, Etches D. Prevention and Management of Postpartum Haemorrhage. SOGC Clinical Practice Guidelines No.88. Journal Soc Obstet Gynaecol Can. 2000; 22(4): 271‐81. 13. ICM & FIGO. Joint statement on postpartum hemorrhage. 2006. Accessed at http://www.pphprevention.org/files/FIGO‐ ICM_Statement_November2006_Final.pdf 14. Schuurmans et al. 15. Wickham S (ed). Midwifery Best Practice. Edinburgh: Books for Midwives, 2003: 101‐112. 16. Ibid. 17. Prendeville W. and Elbourne D. Care during the third stage of labor. In: Chalmers I, Enkin M, Kierse M, eds. Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press, 1989: 300‐309. 18. Prendeville W, Elbournce D. Gyte, G.

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Department of Midwifery

Vitamin K Prophylaxis Approved – June 2009 For Review – June 2011

The best evidence is helpful in assisting thoughtful management decisions and may be balanced by experiential knowledge and clinical judgment. It is not intended to demand unquestioning adherence to it’s doctrine as even the best evidence may be vulnerable to critique and interpretation.

The purpose of practice guidelines is to enhance clinical assessment and decision‐making in a way that supports practitioners to offer a high standard of care. This is supported within a model of well‐informed, shared decision‐ making with clients in order to achieve optimal clinical outcomes.

Vitamin K Deficiency Bleeding

Hemorrhagic disease in the newborn or, according to the Committee of the International Society on Thrombosis and Hemostasis, vitamin K deficiency bleeding is thought to occur due to a lack of Menaquinone producing bacteria in the intestinal tracts of babies (2). There are three types of Vitamin K Deficiency Bleeding (VKDB): Early VKTB, Classical VKTB, and Late VKTB. Each varies in its time of onset and affected site. Early VKTB: Onset occurs between 0‐24 hours. Usually the result of a predisposing factor such as preterm intracranial hemorrhage, trauma at birth or an infection. The following sites are affected: cephalohematoma, umbilicus, intracranial, intra‐abdominal, intrathoracic and gastrointestinal. Classical VKTB: Onset occurs between days 1‐7. The affected sites are: gastrointestinal tract, umbilicus, nose, needle prick sites, circumsion, and intracranial. Late VKDB: Onset occurs between 2 weeks to 6 months. The cause at this time appears to be idiopathic. The affected sites: intracranial (30‐60%), skin, nose, gastrointestinal tract, needle‐prick sites, umbilicus, urogenital tract, intrathoracic. Late VKDB has a 14% fatality rate (3). VKDB can lead to spontaneous bleeding beneath the skin, from the nose, stomach, intestines, wounds or intracranial bleeding. This bleeding can lead to permanent brain damage or death. The morbidity correlates with the severity of the vitamin K deficiency. Vitmain k is a fat soluble vitamin of which there are two types. Phylloquinone (vitamin K1) is found in some green plants. Menaquinone (vitamin K2) is synthesized by bacteria in the human gut. This second type of vitamin K accounts for 90% of the vitamin K found in the liver which is necessary for the synthesis of prothrombin and clotting factors II, VII, IX, and X. A deficiency in vitamin K leads to increased coagulation time and potentially spontaneous bleeding (long term it can affect the ability of the body to regulate calcium and bone development).

Prevalence The incidence of VKDB is thought to be between 5‐25/100,000 with a median of 7.1/100,000 in developed countries for untreated neonates (4). However, the administration of IM vitamin K reduces this approximately 1/1 million (5).

Page 1 of 3 Vitamin K Prophylaxis June 2009 Department of Midwifery

Risk factors

¾ Drugs taken in pregnancy (anticonvulsants, anticoagulants, tuberculostatics, and cephalosporins) ¾ Marginal vitamin K in breast milk (not to be taken as an endorsement for formula) ¾ Inadequate milk intake ¾ Late onset of feeding (colostrum has higher concentrations of vitamin K than breast milk) ¾ Malabsorption of vitamin K (liver or bowel disease) ¾ More common in summer months ¾ More common in males ¾ Prematurity ¾ Instrumental delivery ¾ Perinatal asphyxia ¾ Surgical procedures such as circumcision

Clinical signs and symptoms ¾ Hematomesis (vomiting of blood) ¾ Prolonged jaundice ¾ Melena stools (difficult to differentiate from meconium) ¾ Failure to thrive ¾ Prolonged bleeding at puncture sites ¾ “warning bleeds” such as bleeding from the umbilicus, nose or mouth (6)

Diagnosis The diagnosis is established by performing clotting studies. Prothrombin time (PT), usually reported as the INR, is prolonged, but partial thromboplastin time (PTT), thrombin time, platelet count, bleeding time, and levels of fibrinogen, fibrin‐split products, and D‐dimer are normal.

Prevention Vitamin K is recommended as a prophylaxis for VKDB and has been administered routinely since the 1950’s in North America. The risk of a baby developing VKDB can be reduced to 1/1million by the administration of exogenous Vitamin K within six hours of birth (7). There are two routes of vitamin K administration: intramuscular and oral. Currently intramuscular is the recommended route of administration (8). However, research has shown that three oral doses of Vitamin K can produce the same indices of coagulation factors as one intramuscular dose. The effectiveness of oral Vitamin K against VKDB has not been determined largely due to the fact that the incidence of this condition is so rare (9). Intramuscular This route is recommended for its high efficacy rate and high compliance rate. It is given as a single dose of 1.0 mg (>1500g) or 0.5 mg (<1500g). Oral This may be an alternative for parents who decline the IM route out of concern for the pain it might cause. In this case the BCPHP recommends administering vitamin K in 3 doses of 2mg each: at the first feed, at 2‐4 weeks, and at 6‐8 weeks. This route is thought to reduce the incidence of VKDB to 4/1million (10).

Some disadvantages of Vitamin K Prophylaxis ¾ A retrospective British Study conducted in the early 1990s reported an association between Vitamin K administration and childhood leukemia. Further research has been conducted and the findings have not been duplicated (11).

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¾ Oral administration poses some challenges in that babies may regurgitate some of the medication, compliance over several weeks is required, there is no oral form licensed in Canada, and the cumulative amount of oral vitamin k administered is six times the IM dose (12).

REFERENCES

1. College of Midwives of British Columbia. Philosophy of Care. http://www.cmbc.bc.ca (accessed 20 Dec. 2006).

2. Latini G, Quartulli L, De Mitri B, et al. Intracranial Hemorrhage associated with Vitamin K Deficiency in a Breastfed Infant After Intramuscular Vitamin K Prophylaxis at Birth. Actra Paediatr 2000; 89(7): 878‐886. Cesa G. et al. Prophylaxis in Less Developed Countries: Policy Issues and Relevance to Breastfeeding Promotion. American Journal of Public Health 1998; 88(2): 203‐209.

3. Cesa G. et al.

4. Ibid.

5. American Academy of Pediatrics??? (referenced in text under ‘Prevalence’, nothing listed in reference list)

6. Beischer NA, et al. Obstetrics and the Newborn. 3rd ed. Toronto: Harcourt Brace and Company; 1997.

7. British Columbia Perinatal Health Program. Guideline 12 ‐ Vitamin K1 Prophylaxis. 2001. http://www.bcphp.ca/Newborn%20Guidelines.htm (accessed date?). American Academy of Pediatrics???(referenced again)

8. Beischer NA, et al.

9. Puckett RM, Offringa M. Prophylactic vitamin K for vitamin K deficiency bleeding in neonates. Cochrane Database of Systematic Reviews 2000, Issue 4.

10? Sutor AH, von Kries R, Cornelissen EAM, et al. Vitamin K deficiency bleeding (VKDB) in infancy. Thrombosis and Hemostasis 1999; 81: 456‐461.

10? Sutor, AH. Vitamin K Deficiency Bleeding in Infants and Children. Seminars in Thrombosis and Hemostasis 1995; 21(3): 317‐ 329.

11. Clark, G. Committee: Vitamin K cancer risk unproven despite British study: Intramuscular injection remains recommendation. AAP News 1993; 9(2): 9.

12. British Columbia Perinatal Health Program.

?? Pankaj P, Mikhail, M. Vitamin K Deficiency. 2008. http://emedicine.medscape.com/article/126354‐overview (accessed 24 June 2009). (not referenced in guideline??)

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Department of Midwifery

Newborn Eye Prophylaxis Approved – May 2007 For Review – May 2012

The best evidence is helpful in assisting thoughtful management decisions and may be balanced by experiential knowledge and clinical judgment. It is not intended to demand unquestioning adherence to it’s' doctrine as even the best evidence may be vulnerable to critique and interpretation.

Background Opthalmia neonatorum (ON) is diagnosed by conjunctival inflammation within the first 30 days of the newborn period (2). ON is most frequently acquired following a vaginal birth where an infected mother passes the organism to her infant. Further risk factors include prolonged rupture of membranes and localized eye injury from birth. Untreated cases may result in blindness, corneal damage and infantile pneumonia (3). Chlamydia trachomatis (CT) is the most common pathogen causing ON in North America, while Gonococcal infections cause more severe complications (4). Organisms such as Staphylococcus albus or aureous, Streptococcus pneumoniae, E coli, Bacillus proteus or Pseudomonas aeruginos and herpes virus have been named less frequently as pathogens of ON. Health regulations in British Columbia state that all newborns are to receive ophthalmic chemical prophylaxis within the first hour of birth to decrease incidence of infectious conjunctivitis, however parents are permitted to decline such treatment following informed choice discussions (2). Erythromycin antibiotic ointment is the current prophylaxis of choice in Canada, as it is an effective agent against gonococcal infections, though less efficacious for Chlamydia. Current research continues to test agents with high efficacy for both pathogens with few adverse effects.

Prevalence The transmission rate of Chlamydia and/or Gonorrhea from an untreated mother to her infant is 30‐50 percent, where 50 percent of affected mothers are asymptomatic (2).

Incidence The incidence of ON in North America is 0.3/1000, where 20 percent of cases develop corneal damage and 3 percent exhibit blindness (3). Newborn eye prophylaxis decreases the frequency of these complications to 7.4 percent of Chlamydia infections and 0.03‐1.0 percent of Gonorrheal infections.

Definition Erythromycin antibiotic (0.5%) is in the form of a topical ointment when used as prophylaxis against ON, prepared in single dose ampules (10mL) (2). May cause inflammation, redness and swelling of the eye area. May also decrease eye openness and inhibit visual response therefore disrupting visual interaction between mother and baby.

Page 1 of 3 Newborn Eye Prophylaxis May 2007 Department of Midwifery

Contraindications • Allergic or sensitive to erythromycin

Technique (2) • Prophylactic topical ophthalmic administration given within one hour of birth • One ampoule per baby to avoid cross contamination • A line of ointment 1‐2cm long is placed in the lower conjunctival sac • Gently massage closed eyelids to aid in absorption and dispersion of ointment • Remove any excess ointment from eye area after one minute if desired with sterile gauze • Do not rinse

Refusal of Prophylactic Treatment • Mother (or parents) must sign a written statement of declination, stating that she (they) understand the benefits and risks of the treatment as explained by the midwife (2). • Benefits to Treatment o Decreases incidence of ON and complications of ON o Protects infant when CT and GC screening tests in pregnancy are falsely negative o Protects infant when CT and GC or other infections are asymptomatic o Protects infant when maternal CT and GC status is unknown o Protects infant when if fidelity/sexual health of client or her partner are at question or not certain o In areas where bacterial opthalmia is prevalent, routine prophylaxis may be useful5 • Risks to Treat: o May cause inflammation, redness, and swelling of eye area o May negatively affect bonding between infants and parents due to possible inhibition of visual functioning and decreased eye openness

Responsibilities Associated with Newborn Eye Care • Offer and perform CT and GC screening in pregnancy to all clients • Recommend treatment of CT and GC in pregnancy for clients who test positive and offer re‐screening closer to the end of pregnancy • Conduct an antenatal informed choice discussion about eye prophylaxis for the neonate • Ensure clients comprehend benefits and risks of prophylactic treatment versus no treatment • Observe for signs and symptoms of ophthalmic conjunctivitis in ALL newborns, as ON occurs within the first 30 days of life. o If signs and symptoms present, swab discharge for culture and sensitivity, treat promptly with erythromycin unless otherwise indicated. Consult if necessary. o Differentiate signs of ON with “sticky eyes” that are common in the first few weeks of life caused by blocked lacrimal ducts (7). o Chlamydia conjunctivitis: usually appears within 5‐14 days, develops from a watery to purulent discharge (8). o Gonorrhea conjunctivitis: usually appears within the first week, discharge is copious and purulent, often with redness and swelling (8). o Blocked lacrimal ducts: Parents can cleanse the eyes starting inside then outward with a clean cotton ball dipped in warm sterile water and can apply breast milk directly into the eyes to cleanse and prevent infection. Teach parents how to massage lacrimal ducts with clean fingers to open up blocked ducts. Gently massage in an upward motion (toward the nose) about six times at every diaper change. Massaging applies pressure so the fluid in the ducts eventually drains (8).

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REFERENCES

(1) College of Midwives of British Columbia. Philosophy of Care. http://www.cmbc.bc.ca (accessed 20 Dec 2006)

(2) British Columbia Reproductive Care Program. Newborn Guideline 11: Eye Care and Prevention of Opthalmia Neonatorum. March 2001.

(3) Schaller UC et al. Is Crede’s prophylaxis for opthalmis still valid? Bulletin of WHO 2001; 79(3): 262‐263.

(4) Enkin M, Keirse M, Renfrew M, Neilson J. A Guide to Effective Care in Pregnancy and Childbirth 3rd ed. Oxford, UK: Oxford University Press.

(5) Cunningham FG, Gant NF, Leveno KJ, Gilstrap LC, Hauth JC, Wenstrom KD. Williams Obstetrics. 21th ed New York (NY): McGraw‐Hill Medical Publishing Division; 2001.

(6) Zar, Heather J. Neonatal chlamydial infections. Pediatric Drugs 2005;7(2):103‐110.

(7) Sears W, Sears M. The Baby Book: Everything you need to know about your babyfrom birth to age two. 2nd ed. USA: Little, Brown and Company; 2003.

(8) Bennett V.R., Brown L.K. Myles Textbook for Midwives. 13th ed. London(UK): Churchill Livingstone; 1999.

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