#294 | Physiologic Birth of the Placenta in Water, Optimal Cord Clamping and Preventing Postpartum Hemorrhage with Barbara Harper [Season 4 Reprise]

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Onto the show:

In this episode, we have Barbara Harper on the podcast with us. Barbara is a midwife, author, and the founder of WaterBirth International, which she founded exactly 40 years ago. She is a world-expert in birthing and to this day travels the globe educating obstetricians, nurses and midwives on physiologic birth.

Few mothers are given the opportunity to birth their placentas in the water, but is it really necessary to move women post-birth into a bed to complete the third stage (placental birth) of labor?  In order to explain whether this is the right choice for any mother and baby, Barbara walks us through the most common causes of postpartum hemorrhage, how to prevent it, and the critical understanding of newborn transitional physiology: what she says is literally the most important moment in any human being's life.

Is fundal massage necessary? When is the optimal time to cut the cord? What is the case for keeping the cord attached until the placenta is fully birthed? Is manual extraction of the placenta ever justified? These are some of the questions we answer in today's episode with Barbara.

Barbara Harper

Waterbirth International

#100 | The Benefits of Water Birth: Interview With Barbara Harper of Waterbirth International

#122 | Provider Green Lights: Interview with Barbara Harper on Holistic, Respectful & Supportive Birth Providers

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Transcript

So incredibly much is happening that transition is massive for a baby when a baby is born, and we are in there, vigorously, rubbing them, shaking them, spanking them, hanging them upside down. How can this poor body of a brand new baby go through this incredible transition that it has to make smoothly when there's so much disruption?

Barbara, you had told us about a woman whose placenta took a very long time to come out --

-- this will curl a provider's hair. It was six hours.

So there was no urgent medical situation at hand, which I think is the first thing we all have to appreciate because they're rushing women. Now they're just pressuring them and rushing them and tugging and giving them fundal massage.

I never cut the cord until the placenta delivered and after the placenta delivered assist the most important most critical period in every human being's life.

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Good Day Good morning. Good evening, wherever you work, this is Barbara Harper coming to you from Boca Raton, Florida. I am privileged to be with I with Trisha and and Cynthia down to birth. And for those of you who don't know me, I'm the founder and director of waterbirth International. And this, this is a historic year. Because I started researching water birth in 1983. So this is our 40th year, this is my 40th year of basically focusing my whole entire life around labor and birth and water. So I'm excited to talk about different issues today. So let's get into it.

So Barbara, this is the third time we're recording with you, you were the star of our episode 100, where you taught us all about water birthing, which is one of the top episodes we recommend personally to our clients and anyone else who's listening. And then you came back for a really interesting discussion in Episode 122. We called it provider green lights in which you shared how you travel the entire world educating and bringing water birthing as an option for women everywhere with your key objective of educating the nurses and doctors who are supporting those women. Because the problem begins with the lack of understanding and knowledge in those medical providers. And you've brought them to tears at your workshops, and you've converted them and change them with scientific and spiritual knowledge. And you've been so wonderful to support us on our Patreon livestream a couple months ago, so that all of our followers could meet you and spend time with you. And we're just always so grateful to you. So today, we're delighted to have you back as always. And this time the conversation was precipitated by a question we received on Instagram that I didn't really feel I can answer. The question was, can you birth your placenta in the water? Should you birth the placenta in the water? Should you not birth it in the water? At my own two births, I was asked to get out of the water before the placenta is came out. So it's easy for me to assume that was the quote, right thing to do. But I would never assume that. So I reached out to you. And we decided that we would have you answer us all here in this episode. So thank you for being here. And what what do you want to? Why do you want to tell us about that?

Well, that is a great question to start off. And my immediate answer to that the person that sent that question in is it's it should be up to the mother. However, when I teach to providers, about making the decision for active management of third stage, or expectant management of third stage, you have to start prenatally. You have to you have to start your decision making process with if it's a multipurpose woman if she's had more than one baby, you look at her previous births. And did she have any any difficulties with birthing the placenta? You also have to go back and start examining the research on why we do active management.

I don't want to interrupt but can we before we go further, because I know once we get started, we're gonna, we're gonna go deep on things. Can you explain the difference between active management and expectant management of the placenta, and I was just gonna go to there Trisha. And I want you to jump in when elfa from your nurse midwifery experience and what the what the factors are expectant management is I expect a physiologic third stage. I've had a woman that's has a physiologic labor, everything's been normal. She she's had a physiologic second stage, babies come out beautifully. There has not been any problems whatsoever. And I expect a physiologic third stage that the placenta is going to detach from the wall of the uterus. Typically, on the third contraction after the birth of the baby. It's the biggest contraction of the whole entire labor. And this is how you can tell woman who's holding her baby. And if her contractions were to birth the baby in second stage, every two minutes, then about six minutes, she's going to go, Oh, this one hurts. She's so happy. I call it waiting for the grimace. And so that just means that this big contraction if we go back to Barney's midwifery textbook, Varney says right there and physiologic management of third stage, the uterus has this huge contraction and changes shape, which forces the placenta off the wall of the uterus. And the placenta then, in volutes, it folds in on itself and drops down into the introit. Us and that contraction that fundus is still working, and it pushes down and pushes the placenta into the vaginal vault. And all of that happens without any drugs, without any financial pressure, without any poking without any prodding without any pulling on the cord, it just happens. And that is expected management. So along comes postpartum hemorrhage. And sometimes the vessels of the uterus don't seal off for one reason or another. And I'll go into reasons in in just a moment. And you want to increase the contract ability of the uterus, you want to prevent postpartum hemorrhage. And you want to rush the placenta out before the end of six minutes or 10 minutes or 15 minutes or 20 minutes, because all of those times are normal. And so you give an immediate injection of an oxy toxic, which is traditionally Pitocin or Syntocinon. And, and sometimes combined with meth origin, so that you get this huge clamp down of the placenta, which forces are of the uterus, which forces the placenta out. And you're banking on that all of the uterine vessels are going to close. And you want to do that within the first 10 minutes after birth. So the the protocol for active management is to give the OXA toxic if she isn't on Pitocin already, she's had a normal vaginal birth, and almost everywhere, every hospital that I go to that does facilitates physiologic birth, they still give Pitocin they still want to control and get the placenta out a s a p, and that is active management you are causing the uterus to contract and so many hospitals that I've been in, they'll do fundal pressure, they'll push down on the top of the uterus after the baby's out and and massage it deeply which is very painful, and give the injection of course the baby's not connected, that they've clamped and cut the cord And the wrap a hemostat around the cord. And, and you hold on to it and you do controlled cord traction. And until you feel that pop, and and then you guide the placenta out you deliver the placenta.

When you described the use of Pitocin, which has become routine, unfortunately, and many women are now receiving it through an IV if they have had an IV port, and they're not even being told, which is unethical, if not unlawful, but what you just described really emphasize, I think, to me the risk for the first time ever, it's not just like this general risk of drugs like Pitocin. But are you saying that it is very successful at getting the placenta out? Does it primarily do it by that contraction of the uterus? Or does it primarily do it by sealing off those vessels? Because physiologically, the placenta is an effect of those vessels sealing off and in essence, dislodging the placenta or you saying Pitocin doesn't do it that way. So there's this risk of successfully getting the placenta out. But now those vessels can be exposed and there's a higher risk of hemorrhage. Because it's doing it backwards, if that's how the drug is doing it. Is that how you're saying it happens?

Yes, it's, it's in physiologic birth. We wait. We wait for the vessels, the recall them retro placental, they're behind the placenta. And that's, that's where the two layers, I should have brought my placenta with me. The layers are, aren't there, it's in a suitcase, because I take it to class.

You know, most listeners are actually envisioning a placenta when you say that not some model that good that you're saying good luck.

So, you know, the placenta is the first thing that forms in in embryology, the placenta is the very first thing, the uterine vessels are the very first thing that that form as the embryo becomes a fetus. So those vessels are attached to the woman's uterus, and they have to disengage, they have to detach. It's not just about the uterus, but it's about the closure of the vessels that go from the fetus, through the placenta, back to the mother, this is the biggest reason for delayed cord clamping and optimal cord clamping is the delivery of the placenta with an intact cord attached to the baby. So, you consider it that delayed cord clamping can be done. Three minutes, two minutes, we argue over 90 seconds, 30 seconds, you know, all of those it can be anything but optimal cord clamping is to treat the the baby and the placenta as one unit. And to to birth the placenta in the time that it takes for baby to crawl up to the chest and stay in the place of what I call the sanctuary. In Spanish, the sanctuary in Hebrew, the meek, gosh, the meek dosh is the place inside the Ark of the Covenant where God resides. Yeah, so there's there is a spiritual aspect about this as well. So yes, the uterine vessels are going to seal off. And then the contraction comes that changes the shape of the uterus and expels the placenta. All of the research was done for active management to prevent postpartum hemorrhage to seal those vessels off quickly by the force of the Pitocin by the force of the contraction that you're going to make the uterus artificially contract and evacuate the uterus quickly to prevent postpartum hemorrhage and shut the placenta down, shut the uterus down. And that's why we do the fundal pressure and the fundal massage in order to get any plots that were behind the uterus out and evacuate those as well. The question that I always propose and I think your your expert that you I love to listen to her podcast with you as Rachel read. And and the the person that I look at for all of the advice on delayed cord clamping, or all of the articles that have been The research has been done by Judith Mercer CNM at the University of Rhode Island is the Rhode Island State College. And she was the first CNN to receive NIH funding national institutes of health funding to do a randomized controlled trial in 2002. She published in midwifery journal, she published the first comparative analysis of waiting at least one minute. And it was done on premature babies that were prior to 35 weeks born in by cesarean. And the results of delayed cord clamping, were that all of the babies that had delayed cord clamping left the NICU sooner than the babies that had immediate cord clamping. So in that first in that first study, they talked about hypovolemia versus the premature baby neonate, receiving more blood volume. And of course, with blood volume comes more iron. And if we look at a 2018 article that was published in the pediatric journal, where Judith Mercer and a group of neonatologist and a group of neurology pediatric neurologists got together, and they looked at a four minute delay of cord clamping. And they looked at ferritin levels at four months. And the reason that the pediatric neurologists were involved was because they proved by Mr. eye on those four month old babies, that those babies had a much higher rate of myelin cessation of the neurons in the brain. And so I stand in front of audiences of doctors and in medical schools, and then with midwives. And I say, if you clamp the core too soon, you're preventing the brain from organizing the actual structure of the things that will create intelligence and empathy. And and all of these things that that take place, when when we either have delayed cord clamping, and if we're gonna have delayed cord clamping, why can we not wait for optimal cord clamping physiologic birth of the placenta?

That's a strong argument for optimal cord clamping.

It's a very strong argument. What was your view?

I want to go back for a second. Because I know when you were discussing fondle massage, we get a lot of questions about that. And I wanted to just make one comment on it before we move on to the next thing. My understanding of funnel massage is that if you're given Pitocin fondle massage, actually, the addition of fondle massage with Pitocin has no additional benefit, it does not help prevent any further postpartum hemorrhage. Additionally, funnel massage while the placenta still attached is not a good idea. So really, we should be keeping our hands off the belly. Fun. The massage is, in my opinion only needed after the baby's born, if there is excessive bleeding and you're trying to manage if you're trying to manage a hemorrhage, and even then don't go to the fundus go to the to the symphysis pubis where where's the where's the blood coming out? You know, don't you you're just messing with it. So the question that I asked everybody, okay, we've all read. Many people haven't read Judith Mercer's articles I send them after every workshop, I send them at least nine articles that were written by Judith Mercer and a few that were written by Rachel Reed. And please read this research. Look at it yourself. Make your own decisions I want I want doctors and midwives to make informed decisions also, after they've looked at the research, but Mike, and then I go on to the research on postpartum hemorrhage how to prevent a PPH how to manage a PPH how to assess the At last with a PPH, what constitutes a PPH? postpartum hemorrhage? So and as I look at the articles about preventing postpartum hemorrhage by active management of third stage, no, nobody mentions where the baby is, where's the baby? Well, the baby's cord was immediately cut and put over onto the warmer, it is not with the mother.

Right as if it's an unrelated issue, you're saying,

as if the baby's not an essential component to helping prevent postpartum hemorrhage or stop when that's an action. They've separated the unit, keep it together, and this doesn't happen.

Exactly, exactly. Oh, my God, you know, it's like that I can see the light bulbs go off when I'm in these groups of doctors and midwives. And, and, and then their questions kind of.

For years, I've talked with women about, again, couples about the fact that one intervention leads to the next, but what I think most people fail to understand is separation of mother and baby is an intervention. It's a very extreme intervention. Separation of mother and baby is an intervention. And I think most of us are conditioned only to think of medical or chemical interventions. But we have to think of these biological interventions.

The risk of separation, the risk associated with separation of mother and baby is actually like extreme. It's dangerous. It's it's a massive intervention. And if we changed one thing, in birth, if we kept moms and babies together, we could dramatically influence breastfeeding rates, reduced postpartum, hemorrhage, postpartum depression, all kinds of things are influenced by this.

And so this also means that you have to understand that physiologic third stage, it's perfectly normal to facilitate through the water and in the water. There's there's no difference between physiologic third stage on the bed, and physiologic third stage of water. If you've had a physiologic second stage in the water, then you sit there and wait now with my own third birth, I birthed in an outdoor hot tub. Then the evening before Thanksgiving was Thanksgiving Eve. And it was in Southern California. And we had put a tent over the hot tub, we built a structure, I had supervised the whole thing. We had to heaters, like you see in a restaurant, outdoor restaurant seating area, we put the heaters there, the propane heaters. And so it was nice and cozy and warm and all of that. But I had a I had a typical third baby on again, off again, labor. And when I got into the tub, it was about two hours from start to finish. Four hours all together for the labor. And I call it wham bam, Thank you, ma'am. baby's born into the water. And then we sat and we've waited for the placenta. And I personally, as a former active midwife, I never cut the cord until the placenta delivered and after the placenta delivered and then I left it up to the couple. And even today when I'm facilitating a birth with someone with a with another midwife at the birth center, where I work, the bliss, birth and and women's Wellness Center. We will birth the placenta in the water. And it usually is about 20 minutes to a half an hour and 20 minutes and half an hour with the light slow with no talking with just observing the baby. And yes, by state law, I have to take her blood pressure every 15 minutes during that time. And I need to listen to the baby's heart sounds and breath sounds in that time. But I do it. So unobtrusively that the mother and father are just they're the mother or aunt or partner. Sometimes it's two women sometimes it's mother and father. Sometimes it's mother and grandmother were whoever she wants to support her, they can just be there with the baby. And that is essential her physiologic third stage, it's even more important not to interrupt that skin to skin and ask her questions and, and distract her oxytocin, because she's getting the highest peak of oxytocin that she will have for her entire lifespan in those 20 minutes after birth. And so if we turn on the lights and forced the placenta out and get the injection and Okay, get out of the lab, it's right, you know, rush, rush, rush, rush, rush. That's why you have breaking hemorrhage.

It's so important. I always tell moms when I'm doing prenatal, even breastfeeding consults with them, or any type of prenatal consult about birth, how important it is to stay in your birthstone after the baby's born, because in the hospital, especially. As soon as the baby's out, it's all bells and whistles and excitement. And nobody's thinking really about the mom anymore. And the mom isn't even thinking about the mom anymore. She's all the attention is, you know, going to the baby, which of course is somewhat normal, but you really have to kind of rein it in and keep yourself in check and know that this birth is not over until until the placenta is born. And if we can stay in that zone and stay in the bonding and keep it calm and quiet and dark, like you just said and stay just engaged with our baby. And of course keep the unit together, which is so critical. The placenta comes easily. But when it's all disrupted, and the mom is completely thrown out of her labor zone, of course, the call center is going to struggle coming because you've just shut it all down.

Exactly. Exactly. Cynthia.

Barbara, I have two questions on what you just talked about. One is the fact that I understood that. It was my understanding at the start of this episode that you said most placentas come out on the third and traction, which really surprised me. I had a whole lot of questions in my head when you mentioned that. And I was planning on coming back to it. And now you said 20 to 30 minutes. So what did I misunderstand?

Let me just clarify, there's two differences. Okay, the placenta separates from the wall of the uterus after three contract.

Oh, doesn't necessarily come out yet. Got it.

So sometimes it's just right there in the intro to set the vagina. And it's up to the brother to push it out. And I tell women that that it's going to be up to you to release it. And in in the past couple of years that I've been working in reverse center. I'll tell them mom, put your fingers inside and tell me it's the placenta right there. And they'll go, Oh my gosh, it's really squishy. And I said Now look, you just pushed out this beautiful baby, you release this gorgeous baby. Now comes the easy part. This one has no bones. There's no Ed there's no pelvis. Just take a deep breath and make those same sounds that you made when you release the baby. And those placentas just come right out. And we have the floating bowl ready. You don't I don't I don't have the the the cord clamp and the cord cutter and I don't bring those to the tubs I don't don't bring those to the bedside. What I do bring is the bowl. And then I'll grab a Ziploc bag and I'll put the placenta in the ziplock bag and zip it closed with just the cord sticking out. And then I'll get a plastic grocery bag that has handles and I take it and I have the placenta in the grocery bag to the Father. Well I'll put the ticket the mom out of the tub. I'll put the baby on the father's chest and give him the bag to hold. I say you hold this while we help the mom over to the bed and we just take it slowly slowly get in bed I'll take the baby from the father's chest to the to the whaler the grandmothers chest and you should see those moms take off their shirts when those grandmothers when I tell them Well Baby wants to be skin to skin with you. Okay and and then have the grandmother present the baby to the mom in the bed. Everything's done. Everything's done. When to a wave the baby went away. Well, I've just checked the baby completely while the baby is on the mother's chest in the tub. I've done a full neurologic exam, eyes, hearing, cry, listen to heart tones listen to breath sounds go ahead.

Just to clarify, when you say you've done a complete exam, much of that is just your observations. You're not not taking the baby through this series of neurological tests, right? This is this is you, looking at the baby's movements while watching how the baby breathes. I'm sure you do listen with a stethoscope. But there are so many ways that you can evaluate the baby without even touching them.

I call it masterly observation, and masterly inactivity. You know what you're looking for? As a matter of fact, when the baby's eyes are open and blinking, that is the highest neurologic proof that this baby is in its body. What's the first thing I say to babies after they're out? I say it in my mind, because they're mind reader's what your mind thinks the baby perceives, what your mind thinks the mother perceives. So what's the first thing that I say? Sometimes I say it out loud. But I want the baby to hear the mother's voice. And so I say, How come? You've made your antibody? This is amazing. And do you know that the first breath, the very first breath that the baby emits is an exhale to get rid of the buildup of carbon dioxide within the lungs cells? Because if you go back and read Judith Mercer, neonatal transitional physiology, the lungs have to fill with blood, the lung capillaries that surround every single of vlR space have to fill with blood to take the fluids out of the lungs. Now, fluids don't come out of loans by holding a baby upside down or rubbing a baby or stimulating a baby.

Barbara The other question I had for you was that you said something that our mutual friend Nancy Waner, midwife and author Nancy Waner says she always leaves the cord intact until the placenta is entirely out. And I once asked fancy why, and I just want to hear why you have the same practice. Manti said that, if a baby is still attached and has any difficulty breathing needs oxygen, that placenta will continue to deliver any necessary oxygen to the baby provided that the cord is intact. Is that your same rationale? Or do you have a different one?

I have, I have three different reasons. Number one, the most important is that every single human being on the planet needs to fill the lungs with blood from the placenta immediately after the baby's born.

So you mean the capillaries in the tissue of the lungs? You don't mean filling the lungs where the oxygen is no, right? You know that lung tissue?

The oxygen comes from the capillaries to the spaces.

Oh, okay. It's not a respiratory thing. No, this is not for the first breath. Oh, okay. Yep. Okay, so we're that we're talking about before the first breath.

If a baby has a delay in initiating the first breath, you want to make sure that that placenta is still giving oxygen. Okay, you want to make sure that that that, that the capillaries surrounding it looks like a web around every single. After you have large space, there's 250 million alveolar spaces in your lungs, and in a neonatal furl term baby, there's 50 million 50 million lung cells. And all of those lung cells are filled with a sticky surfactant fluid a lot. Let me just go back to prenatally and throughout the birth, the lungs only receive a percent of the full cardiac output. So the the fetuses heart is beating and sending blood to the essential parts to the brain to the kidneys to the liver to the lungs, but they're bypassed. The placenta is the baby's kidneys. The placenta is the baby's lungs. The placenta is the baby's GYN. So all of those things in the fetus are not filled with blood there. And so especially in the lungs, that low arterial pressure creates a high pulmonary resistance. That means that nothing can go inside. Nothing can get in, no bacteria can get in No, and even Mykonian can't get in until and that's a whole nother area. That's a whole nother podcast. Okay, this, what you're just saying right now, Barbara is so important for people to understand that that neonatal transitional physiology that people really don't have a good understanding of is so critical and so much is happening in that moment. So incredibly much is happening that transition is massive for a baby. So when a baby when a baby is born, and we are in there, vigorously, rubbing them, shaking them, spanking them, hanging them upside down. How can this poor body of a brand new baby go through this incredible transition that it has to make smoothly when there's so much disruption, this is the most important most critical period and every human beings life.

Number Number one is fill the lungs, the lung capillaries with blood, and fat doesn't happen until the chanson the heart clothes let's go backwards. Why poses like closest the chanson the heart, I talked about it in in 100.

The nitrogen receptors in the baby's cheeks like nitrogen receptors so bad happens when the the baby hits the air. A breech baby and a water baby. Don't do that. The airborne Virtex baby head down baby does that right away. And so the water baby and the breech baby are delayed in filling those capillaries. So therefore, you must not up the cord at all until that transition happens. So second reason, the stem cells and the T cells. We want to give the placenta blood. Okay, a premature baby at the time of birth has one half of its whole cardiac blood flow in the placenta. A full term. Ork app term baby at the time of birth has 1/3 of its blood in the placenta. That could be up to 100 milliliters of blood. They don't take 100 milliliters of your Blood for blood donation, you would probably die. Surely don't take a third. No, they don't take a third of your blood. No. So number two is that placental blood is rich in stem cells and T cells and ferritin iron. There isn't enough iron just in the placental blood just in that already 200 milliliters of blood sustain a baby from birth to its full first year.

That's an argument for delaying cord clamping. But is it an argument for keeping the cord intact after the cord has stopped pulsating until the placenta is out? Giving care? That's interesting because by now the baby has the blood. So there's more to it

if I did have the blood, but not all of the blood, okay. Okay. Every time I if I want to have a blood sample for type and crossmatch where do I get it? Where do I get it? I get it out of the placenta. I don't take it from the baby. I don't take it from the court. I take it from the placenta because even as the placenta delivers and it envelopes and it is pushing that last bolus of blood into the baby. It is like squeezing the last drops and I want that baby to receive every T cell every stem cell every single cell of blood that has iron in it. Okay, why did why did they tell us in Florence dressers book feminine Alhaji a guide for womankind. She was an MD and and she said in there, absolutely. Do not cut the cord until the placenta delivers. Because also you're cutting the cord and then you're not going to get the retro placenta clots, this is the third reason it's going to be baggy, it's not going to get rid of all the blood that's supposed to go into the baby, and you're going to have a heavier placenta. And it's going to have an it's going to take longer for those uterine vessels to close off, and you're going to get more clots behind there, you're gonna get more hemorrhage.

Because that is another mechanism in the placenta separating from the uterine wall is the draining of the placenta, the emptying of the placenta. Exactly. Nobody talks about that.

Exactly.

Barbara, you had told us about a woman whose placenta took a very long time to come out --

-- this will curl a provider's hair. It was six hours,

I had one client for whom it took five. So there was no urgent medical situation at hand, which I think is the first thing we all have to appreciate because they're rushing women. Now they're just pressuring them and rushing them and tugging and giving them fondle massage. And but you mentioned earlier in the episode, there are reasons the vessels might not close off. Do you feel you covered all those reasons in the episode? Or did we leave me that you didn't get entire to your dress attire to your dress? I hypovolemia. So, which might be some bleeding during the second stage, but also, when a mother is dehydrated, if she's in a state of acidosis, and the baby's in a state of acidosis, it's all the medical complications. If she's had Pitocin, to start a labor, the vessels aren't going to close as easily.

So it's safer. We've learned from Rachel reed to have Pitocin. And the third stage of labor, if it isn't medicalized birth of any kind Pitocin epidural, and it is safer not too if you had a physiologic birth.

There you go.

So you agree with that

same research? Totally 100%.

There is one thing I feel I have to ask you and get your opinion on. In the years that I've been teaching, which is 16 years now. I see trends, of course, like the rest of us, and I have been personally horrified at how many women tell us they are experiencing manual extraction of the placenta. I can't I can't believe any woman indoors such a thing. And it's starting to become quite commonplace. From what I'm from what I'm sensing. Can you comment on that? I'm horrified by Can you tell me when it ever makes sense to do that? Because I don't I don't have that. Like, does it ever make sense and when sounds like a nightmare to experience? Personally, it's very painful. It's, it's excruciating.

Why does anyone do this to women? Why is this I saw it, I saw it. I remember my my first my first birth in nursing school that I observed was 52 years ago. Okay, I know, I don't look that old. But I'm 71. And I. Yeah. And it was par for the course to do manual removals. Because every woman had a spinal block. And it was it was such medical management. It was it was incredible medical management. When I worked in Russia, it was all that it's happening now, Barbara, it's a trend happening now. It's becoming I really think commonplace. And I fear looking at past trends in the recent years. I fear it's becoming routine in some places. So is there ever an argument for doing it should a woman there's no, okay. No. So, Sunday is taking forever to come out.

I have seen midwives do that. In the case of a post a severe postpartum hemorrhage. You want to do that in a delivery for them with with some sort of sterility? Do it under controlled circumstances?

Why would that help the hemorrhage? Why would going in there and removing the placenta, especially if those vessels haven't fully closed? And now you're exposing more of them because they were attached? Why would that possibly help a hemorrhage?

If it's a placenta? accreta? If it's if it's something that that has to be medically managed, and there are situations when that would happen.

But okay, so in rare instances, then in very rare, very rare, okay, we're not gonna say never, we're going to say very rare, very rare, very rare, the, you know, the panic hormones set in on the provider side. And this is this is one of the things that you're taught to go in and manually extract the placenta to control a postpartum hemorrhage.

I was taught it, I was taught to, I think your point about the provider fear kicking in is really important because providers do the same thing when a baby appears to be stuck at the shoulders. rather than waiting for the body to make the adjustments, were in there rotating, moving, pulling, extracting. And I think it's very similar with the placenta, if there's concern that it's partially separated, the woman's bleeding, there could be massive clots forming behind it, they want to get in there and do something to expedite the process. But we're saying that that isn't necessarily the right thing to do.

The biggest concern of providers is my reputation, livelihood is so wrapped in having a healthy live birth and a healthy baby and a healthy mother.

Can you comment on how during a C section, the placenta has to be manually extracted right away before the body is ready? Is that why is that why there's an increased risk of hemorrhage with C section? Or do you have any other salutely?

Absolutely. But it doesn't, it doesn't. You could, you could wait. You could have

to just leave the mom open and you'd have to allow all the blood to transfer and that's something they could potentially do.

Well, they have started delayed cord clamping for four. Yes, they have. And skin to skin. Everybody's fear factor comes in again.

And everyone's in a big damn hurry. That's a big part of it. That's why this nonsense about well, we like to give the cord 30 seconds oh, we like to no more than 60 seconds. It's so ridiculous to think that anything is is ideal. When you think about how we've evolved to this processor shows Trisha said it before, when we talked about cutting the cord and the baby gets separated. That separation where either we're either moving towards connection and that brain growth or we're moving towards separation. And I've had a few doctors who've had life changes, like Dr. R Bell, in the Tanya at Laniado Hospital in Israel, she came to me with tears and said You changed my life Barbara, you changed my life. When you said it was okay to wait for the placenta when you said it was okay to to wait for the baby's shoulders when you said it was okay to deliver this baby in the water to to have a hands off birth. It changed everything. And that's when practices change. People would ask me what do you do? Well, I'm a I'm a traditional home birth midwife, but I get paid to go tell doctors what not to do.

That's a dream job.

Dream job. And with that, it's people like you who are using the technology to to the best advantage. And and while I'm cooking I listen to podcasts and I always listen to yours. I really love the speakers that come on and the experts that come on I go back and and I think everybody should sign up for your Patreon to get the full meal deal. It's it's just it's one of the best places to get information. All of my students I say you have to listen to Cynthia Overgard Trisha and be a down to birth follower.

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