Last summer, I was speaking to a producer of one of the popular cable TV so-called 'reality' shows about the births he had witnessed. He said his crew had filmed only one home birth, and the woman had a severe postpartum hemorrhage requiring ambulance transport to the hospital. (She recovered fully.) It's not that such transfers never happen - the research literature cites a rate around 0.6-1.2% of planned home births - but I wondered why it had to happen in that particular birth for the whole world to see. It occurred to me that one possibility is that the presence of a camera crew may have in fact predisposed the woman to excess blood loss.

A theory put forth in a new paper by Carolyn Hastie and Kathleen Fahy suggests that there may be something to my hunch. In Optimising psychophysiology in third stage of labour: Theory applied to practice, the two Australian researchers discuss how environmental factors such as lack of privacy, bright lights, and the presence of strangers may disrupt the normal hormonal adaptations that occur in the immediate postpartum period. They apply a theory of 'midwifery guardianship' to propose optimal care in the third stage of labor (that is, after the birth of the baby until the birth of the placenta). For this second installment of our Consider the Source series, Dr. Fahy agreed to answer some questions about Carolyn Hastie's and her work. We talked about the what the research on active third stage management does and doesn't tell us, why midwifery theory matters, and best practices in conducting research on the prevention of postpartum hemorrhage in low-risk women.

Thank you to both of these important researchers!

Science & Sensibility: In your article, 'Optimising psychophysiology in third stage of labour: Theory applied to practice,' you critically review the evidence for active management of the third stage of labor. What are some of the strengths and limitations of that body of literature?

: My full critique of the four randomised trials and the Cochrane meta-analysis of Active versus Expectant 3rd Stage Management has been published. In Australia, NZ and the UK the policy to use 'active management' of the third stage is based on the aforementioned research. My critique argues that existing studies do not provide a valid reason for imposing active management on women who are at low risk of postpartum hemorrhage. Subject selection in the randomised trials was not restricted to woman who were at low risk of postpartum haemorrhage and therefore they cannot be satisfactorily generalized to women who are at low risk. The study samples included a substantial proportion of women who are at known risk of postpartum hemorrhage which biases the results of the randomised trials and the Cochrane Review which is based on them. Secondly, none of the randomised trials were able to report on the provision of third stage of labour care where all the components of holistic psychophysiological third stage were included in the study, where care was given to women in a home or home-like environment, and where the midwives had the right knowledge, attitudes and skills to support normal physiological processes. Indeed, my analysis shows that in the trials underpinning the Cochrane review 'expectant management' is best described as 'not active management' rather than an entirely different midwifery model of third stage care. What we mean by holistic psychophysiological care is detailed in our paper 'Optimising psychophysiology in third stage of labour'. In essence, a midwife supports a woman to safely experience an undisturbed third stage by ensuring all of the following: 1) the woman is well prepared to work with the natural process of placental birth; 2) the woman feels loved and that she is in safe environment 3) the woman and baby are healthy 4) labour and birth have been undisturbed; 5) the midwife knows how to act as a guardian in undisturbed third stage and 6) both woman and midwife are willing to switch to active management if the situation changes. Research about the effectiveness of midwifery care in undisturbed third stage for women at low risk of PPH urgently needs to be conducted.

Kathleen Fahy

Science & Sensibility: Many midwives practicing in birth centers or the home birth setting do not routinely use active management of third stage, despite the fact that active management is supported by 'Level 1' evidence, recommended by national and international bodies, and generally considered the standard of care within the obstetric community. Based on your analysis of the research, are women giving birth in these settings at excess risk of problems related to postpartum blood loss?

: There is no research evidence about third stage care for the group of women who are at low risk and electing to birth at home or in a birth centre with a skilled midwife. We are clear that supporting a woman to birth her placenta in a psychophysiological manner is not 'expectant management' as defined in the Cochrane Review. Optimising psychophysiology in third stage of labour requires both the woman and midwife to be knowledgeable and the midwife really needs to be skilled and experienced in this form of 3rd stage care.

Carolyn Hastie

Our research team have submitted a paper that reports on a cohort study which compared the PPH outcomes for women who were at low risk of PPH based on whether they were intending to have an active or physiological third stage of labour. We compared the results for a major maternity unit and a midwifery-led stand alone birth centre. The results are very pleasing but we cannot declare them publically until the paper is published. Sorry!

Science & Sensibility: You developed the theory of Birth Territory and Midwifery Guardianship and apply it to third stage care in your article. Why is it important to develop midwifery theory? What is involved with theory development? How can or should theory influence research and practice?

Fahy: Scientific knowing should be based on both theory and evidence. The evidence should confirm or change the theory and the theory should suggest the research questions and provide a logical framework for understanding and applying research evidence. In the drive for evidence-based practice we have almost lost the link between theory and evidence which is central to both science and to practice.

In a simple sense 'theories' are the stories we tell ourselves about what is, has or will happen: most of our theories are informal and untested. In order to develop and test a theory for practice the first step is to write it down as a scientific theory.

A scientific theory presents a systematic view of phenomena by specifying the inter-relationships between concepts using definitions and propositions. The purpose of scientific theory is to describe, explain and predict (in our case about midwifery practice). A concept is an abstract idea of phenomena, objects or actions. For example, two concepts from Birth Territory Theory are 'terrain' and 'jurisdiction'. The concept of 'terrain' denotes the physical features and geographical area of the individual birth space, including the furniture and accessories that the woman and her support people use for labour and birth. 'Jurisdiction' means having the power to do as one wants within the birth environment. 'Power' is an energy which enables one to be able to do or obtain what one wants. Propositions are statements of relationship between two or more concepts. Propositional statements provide theory with descriptive, explanatory or predictive powers. For example, a propositional statement in the theory of Birth Territory is 'the less familiar the environment is to the woman the more likely she is to feel fear and uncertainty'.

Science & Sensibility: Many people are familiar with conventional risk factors for postpartum hemorrhage, such as induction of labor, an overdistended or exhausted uterus, and maternal clotting abnormalities. In your paper you list other risk factors, including 'lack of midwifery guardianship by a trusted midwife,' 'lack of appropriate birth environment (e.g., bright lights, cold temperature, noisy, strangers in the room), and 'lack of immediate and sustained mother and baby skin-to-skin contact.' What is the basis for your assertion that these pose a significant risk of excess blood loss?

Fahy: Carolyn and I learn more about this all the time. It seems that bioscience; particularly the fields of neuro-biology and psychophysiology, are now confirming what Carolyn's 30 years+ of homebirth practice of working with women had taught her. In a nutshell woman and babies need to feel safe, warm and loved in order for their psychobiology to function optimally. We have added a few references so that you can see the ever increasing field of study which explores the role of intentional and attentional brain processes, stress response and environmental factors which impact a woman and baby's psychophysiology and lead to either disruption in or optimisation of normal physiological functioning. We could give you a huge number of references from a number of scientific fields. Here is a good start.

Cacioppo, J. T., Tassinary, L. G., & Berntson, G. G. (2007). Handbook of psychophysiology (3rd Edition ed.). New York: Cambridge University Press.

Lipton, B. H. (2005). The Biology of Belief. Santa Rosa: Mountain of Love/Elite Books.

Rossi, E. L. (2002). The Psychobiology of Gene Expression (First ed.). London: WW Norton & Company.

Sandman, C. A., Glynn, L., Wadhwa, P. D., Chicz-DeMet, A., Porto, M., & Garite, T. J. (2003). Maternal Hypothalamic-Pituitary-Adrenal Disregulation during the Third Trimester Influences Human Fetal Response. Developments in Neuroscience, 25, 41-49.

Segerstrom, S.C. & Miller, G.E. (2004) Psychological Stress and the Human Immune System: A Meta-Analytic Study of 30 Years of Inquiry, Psychology Bulletin, 2004 July; 130(4): 601-630. doi: 10.1037/0033-2909.130.4.601. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1361287

Sterling, P. (2004). Principles of Allostasis: optimal design, predictive regulation, pathophysiology and rational therapeutics. In J. Schulkin (Ed.), Allostasis, Homeostasis, and the costs of Adaptation (pp. 36). Cambridge: Cambridge University Press.

Tops, M., van Peer, J. M., Korf, J., Wijers, A. A., & Tucker, D. M. (2007). Anxiety, cortisol, and attachment predict plasma oxytocin. Psychophysiology, 44(3 %R doi:10.1111/j.1469-8986.2007.00510.x), 444-449.

Tsigos, C., & Chrousos, G. P. (2002). Hypothalamic-pituitary-adrenal axis, neuroendocrine factors and stress. Journal of Psychosomatic Research, 53(4), 865-861.

Uvnas-Moberg, K. (2003). The Oxytocin Factor: Tapping the hormone of calm, love and healing. Cambridge: Da Capo.

Wadhwa, P. D., Culhane, J. f., Rauh, V., Barve, S. S., Hogan, V., Sandman, C. A., et al. (2001). Stress, infection and preterm birth: a biobehavioural perspective. Paediatric and Perinatal Epidemiology, 15 (Supplement), 17-29.

Science & Sensibility: In your article, you describe in great detail the elements of physiologic care in the third stage of labor. As someone who spends a lot of time reading the scientific literature, I know that descriptions of the process and context of intrapartum care are extremely limited or absent in many studies, which makes it impossible to know what factors were at work in the background that may have contributed to observed outcomes. In your opinion, what are the most important factors of the birth environment or care process that researchers should describe when they publish their findings on third stage outcomes? Can these be objectively measured and described?

Fahy: Wow, that is a hard question. I often compare the flimsy way that obstetric interventions are described and not quality controlled at all with the detailed definitions and careful quality controls that are included for a drug trial (e.g. chemical makeup, dosage, storage, route of administration, interactions to be avoided, etc). This is a major problem with the RCTs for 3rd stage care and also for the Breech Trial. (That was a disaster of junior doctors who didn't know how to assist women to birth certain presentations of breech babies vaginally being given the responsibility of supervising the births; no wonder that in Western countries the results were poor but in developing countries where the skills for breech births have not been lost the outcomes were better for vaginal birth group).

So, I think a careful protocol needs to be developed in all the detail that is necessary. Only staff who have been taught and tested in providing the intervention should be allowed to provide it. There should be ongoing QA during the trial. A summary of the protocol, training and QA should be included in the published research report but the full protocol should be available upon request for critique and replication purposes.

Science & Sensibility: What research are you currently working on or planning?

Fahy: I am currently involved in a) a qualitative study of women's experiences of attending the emergency department with bleeding or pain in early pregnancy. b) a retrospective cohort study to determine the relative strength of the presumed 'causes' of PPH. c) I'm chief investigator of the following studies being done by PhD students: 'Group-based antenatal education for Thai women who are at risk of preterm birth'; 'A theory and evidence-based intervention to promote and prolong breastfeeding'; 'Factors affecting midwives' decision-making in 2nd stage labour'; 'What can a midwifery manager do to reduce PPH rates at a tertiary maternity unit; 'Group-based antenatal education aimed at reducing perineal trauma for women in Malaysia: what do women want?' My wonderful graduating PhD student Jenny Parratt is about to submit her PhD on 'How do women change in the childbearing year and what factors have a positive impact on their sense of self?'

Carolyn's Masters Research concerned inter-professional interactions between doctors and midwives in delivery suite and the perceived impact of these interactions on the health outcomes for women and babies. Her PhD is concerned with developing, with women, an internet-based antenatal education program. Carolyn is also co-supervising 3 of my PhD students (above).

Kathleen Fahy is an Australian professor of midwifery, a researcher, a theorist, a writer and a practitioner. She is the mother of two daughters and is in a happy partnered relationship, with a lovely network of supportive friends and family. When not thinking about how to make pregnancy, birth and early mothering a healthy and happy experience Kathleen likes to walk in nature and practice Tai Chi.

Carolyn Hastie is a mother, grandmother, midwife and academic who has worked in private practice midwifery and education for over 35 years. Carolyn recently established a public health, stand alone midwifery-led maternity service including homebirth services in NSW, Australia which was awarded, following three years operation, Best Health Care Unit of the Hunter New England Area Health Service. Carolyn is now at the University of Newcastle teaching midwifery.

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