Anti D: routine intervention debate

A medicine that offers a life line for a small minority has drifted into being used on a much wider population “just in case”.

If a medicine is good for a minority, then surely it’s even better to use it preventively on others? In this case, it appears that the logic doesn’t hold.

Our blood types are commonly understood – “O” “AB” etc. – and in addition we all have an Rh factor, which is the “positive” or “negative” aspect of our blood type. In the 1960s Anti-D was developed to help combat problems for Rh negative women with Rh positive babies, because an immune reaction to the baby’s blood can cause serious health problems in babies.

The people that this drug potentially benefits are:

  • Rh negative women with an Rh positive father of their child
  • Of these women, those who have experienced a trauma such as a car crash or interventions such as a C section during the birth

Originally, the drug was used in the 72 hours following a trauma or following birth interventions to stop an immune reaction in a future pregnancy. However, because studies found that women weren’t being offered the drug after trauma, in 1997 a consensus conference led to a recommendation to give the drug routinely rather than wait for a trauma to occur.

As with other birth culture issues we’ve covered, this is an area with large gaps in the research and a big lobbying pharmaceutical sector to deal with. National expert Sara Wickham has written about it in detail, well worth reading if you want to know more.

If you’re trying to make an informed choice on this intervention, one of the problems is that most of the literature available is produced or funded by the drug companies, rather than being independent. There is a US blog that offers some thoughts to help you (although from an activist not a medically qualified person).

The NHS page on this topic sadly doesn’t cover all the concerns raised by Sara Wickham. For example, if you are Rh negative but your baby’s father is too, then there’s no benefit from the drug, and it says that “it is likely small amounts of blood from your baby will pass into your blood during this time” which Sara points out is a contested point of view.

Rhesus disease can be serious for babies, and Anti-D may well be the best thing for those situations, but routine use of it on Rh negative women means passing the possible side effects onto mother and child without the benefits of preventing Rhesus disease to justify them. Sara points to some evidence suggesting it may even cause the disease in some babies by introducing the antibodies where they didn’t previously exist.

Dreaming and Practice: Notes from Midwifery Today Conference 2014, Bury St Edmunds, UK,

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Midwifery Today Conference May 2014, Bury St Edmunds

These are some notes taken at the conference but they are really only a small representative sample of the practical workshops, seminars and main sessions attended. Most of all I met strong, inspiring courageous midwives, working sometimes against the odds , for good birth.

The strongest memory: Outside in the dark watching an amazing fire eating display by a midwife.

Quote of the conference: ‘I’ll give myself a treat and go and have a pee.’ Sara Wickham: “Having a pee is not a treat!!”


Jan Tritten and Robbie Davis-Floyd – International Activism

Jan Tritten’s Introduction:

Quote Harriet Tubman ( the anti slavery activist):

“Every great dream has a dreamer”

Barriers to YOUR dream include: Fear – the antidote to this is Faith

Answer the call – stories of women around the world who have felt a call to midwfery and have had health and other problems until they answered the call.

  • Lies and myths are rampant
  • But we have dreams and callings to follow
  • Birth is sacred ground
  • We are called to a calling to change childbirth and to the benefit of both women and communities
  • What is YOUR dream/vision?
  • Don’t share dreams with negative people
  • Take first step then next step – implement your dream one step at a time
  • Dare to dream and dare to do it.

Participants in the workshop shared their stories:

NZ Chair of Council of Midwives shared their work in Bangladesh setting up midwifery led birth practices with good effect.

Midwife in Philippines told her story of being called by the local Bishop to set up a clinic in the Church because of his concern for the health and wellbeing of local women ( the hospital care was not good enough)

She talked of the importance in her practice of trusting the Higher One she also said that ‘what you believe can be done’

Robbie Davis-Floyd talked about the IMBCI and the 10 steps for implementation of mother/baby human rights.

She talked about the 4 demonstration sites about the world. the full stories can be found on the IMBCI website

One is in Brazil, in a hospital which has now become a ‘high risk’ hospital for high risk women in the region. Even so their CS rate is 25%. Every woman there has a doula.

Then the amazing story of Mercy Mission in the Philippines with their birth centre in a poor district ( recently flooded they piled the beds up on top of each other so women could birth out of water and midwives wading in the water – coz women still coming to birth!)

They set up a maternity clinic in the disaster zone last year, in tents, with no water, no electricity and no sanitation, women traumatised and lacking food and essentials – but still implementing the IMBCI 10 steps.  they maintained their 2% CS rate even within this situation. Amazing work – worth looking up.


Fear in Midwifery and Birth Workshop by Eneyada Spradlin-Ramos and Elena Piantino

Fear is not necessarily a bad thing – it can be a signal that a change is taking place, a call to pay attention, of the balance being changed. Fear is not necessarily a bad thing

Richard Davidson of Harvard re mindfulness – be aware of changes within yourself and room.

@ finding homeostasis for the brain
Homeostasis is the brain in equilibrium/balance. A perceived threat or stressor upset s homeostasis our balance – there is a response eg- fight or flight or fear. Then there can be a process of adaption to a new homeostasis.

In some contexts, the adaptive process makes midwives immune to situations (eg in a medical hospital context on large busy labour ward) that can upset or hurt women – midwives can act without compassion because they have adapted to their context and no longer feel the stressors and fear.

Fear alters our perception of risk and danger and it numbs empathetic responses
eg. homebirth – perceiving risk where evidence does not
decision making effected by emotional stress

Antonio Damasio, Neuroscientist found that brain damaged brains that cannot feel emotion also cannot make a decision.  He said: ‘Every decision is made with a cognitive balancing and tipped by an emotional factor.’

Fear affects labour – blood for fight or flight goes to arms and legs but not for thinking.  No blood to womb so contractions go off, fear tension pain cycle.

Coping with fear/uncomfortable emotions –

Short term coping mechanisms are:

Keeping busy, withdrawal, distraction and parties, letting off steam on other people (shouting and intolerance), expecting and working for the worst, abuse of substances etc.

Positive coping mechanisms:

Recognise triggers, know difference bet feelings and reality
Be aware re feelings/fear: is it history and memory ( what happened last time), is the fear coming from another person in the room, or what someone has brought into the room from elsewhere?
Emotions – is fear coming from in me, of from outside
Express/feel emotions, acknowledge and accept them – not block or repress them.

Other coping mechanisms: journalling, art therapy, red tent sessions ( safe spaces to share feelings without judgement or advice).

Red Tent specific experience:- talking stick. With stick – talk not interrupted. People can and do cry – but nothing said, no advice just accepted.


Twins  – with Jane Evans

Notes pick up when Jane is talking about nutrition:

Everything is the same more but more!

Tweak the diet because pregnancy is not the time to completely change diet all at once.

Mums need plenty of protein for growth; Vit B and Vit C – via whole grains and meat.  Complex carbs via beans and pulses.

Problems in pregnancy is often to do with liver problems – 2 babies twice the stress on the liver. So beans and pulses needed. If Mum not into lentils – suggest brown rice once a week as ‘medicine’, also soya, quinoa etc. As an aside: This is why students survive for years on beans on toast – cheap and nutritious. all there to support liver.  Mums need to drink plenty of water.

Salt is important: good sea salt. Himalayan pink salt. Can test if woman low is slat ( sodium?) give her glass of water with half, the teaspoon of salt – if she not taste a glass of water with salt in it then she is low on sodium. Also if woman eating crisps and chips etc. say they are needing salt so instead of eating crisps and chips and processed food add salt to their food instead. found that having enough salt in diet/body reduces swelling odeoma and incidence of pre-eclampsia.

Make sure eating iron. if not meat eating make sure getting it anyway.

Nutritionist in group said: they have worked out woman needs 300 calories extra over normal diet when pregnant, breastfeeding need 500 calories extra. It will be more for twins – up to double? Tweak diet and change it gradually.

Keeping woman safe and healthy through the pregnancy:

Not just check haemoglobin. also look at mcb, hcb .  Reason Eg. You can have normal haemoglobin but low ferotin and have problems mcb 70-99 normal so don’t iron supplement. If symptomatic then check ferotin. to supplement, avoid pharmaceutical iron which has bad side effects and not easily absorbed – try spatone ( favoured) also floradix.   Food and nettle tea also suggested.

Tweaking diet gradually:  Eg.ple feel better after eating veg so encourage to eat more veg. This starts a good habit for feeding themselves and their children in the future.

32-34 weeks is the crunch point – at this point need to make a big issue of food. There is less room for food but need to be constantly eating – feeding the babies. If you can get through the 32-34 crunch time to get calories into woman and babies, then the pressure is off after and then they can eat back at normal pregnancy rate. If this is done then pregnancy normally goes to the natural term – whatever that might be.  Normal term is usually the length of pregnancy for her previous (singleton) baby. (One example:1st baby 40+12, twins 40+11 days)

Concern: Induction of twins at 37 weeks – why do this when infant mortality risk of twins is at 37 weeks – so why induce at this dangerous time. why not wait until babies are ready to come out?

Obstetric practice. Concern re serial scanning. Research show that the thing that scans do is restrict the growth of the baby – so routine scanning is not good for the babies’ growth rate.

Palpating is good. then scanning when it is needed – scanning: need it when need it but not for routine. Midwife should palapate regularly: you are saying hello to the babies so they know you & you know them. Ask mum what she is feeling. Check differing sizes and think if differences are normal or pathological eg could it be boy/girl differing physiology. If you have concern offer scan to check.

Position of Babies for Birth. ‘Twin babies dance all over the place’ – 2 babies move about more than 1 baby. For birth the most stable is head down head down – but they can move as birthing. Eg. first baby head down for birth, when 1st come out then other baby will change position to birth –  unless lying on back(obstetric method)then movement is restricted.

Leaving cord attached after birth of first. As contractions start for the second the cord starts closing down so cut cord and give baby to dad.

Timing between each baby – does it matter? Listen to the heartbeat if all OK – wait. For mum contractions usually restart after half and if baby ok why rush it? Heartrate (decelerations) can drop very low. if baby ok before prob ok – keep listening and if a continuing problem ( eg baby’s heart rate not pick up) then need to act. Between babies, cervix can pull in – eg to 5 cm but dilation is fast.

Placenta. Some women want to push out placentas.
Remember there is alot of placenta: ‘two handfuls of placenta’. Jane holds to cord of first baby ( which has been cut) as bearing down. Very satisfying to have one big one out. But often placentas will abut as one placenta can support the other. Placentas coming out separately not like as not know which one is which.

Remaining upright during births is what works – this point repeated several times.
About 25% of her twins babies have to have a cs despite their care.


The following notes are from an unscheduled session so I do not have name of the speaker, however, the following was too interesting to omit!

Quote from Grandma Beatrice, South Dakota who told twins birth story. She said she washed her hands then moved baby so baby born safely. Asked how she knew what to do, she replied:
‘Mother knows how to give birth, woman knows how to help’

Working in a remote area in Afghanistan setting up maternity services
Talked about how women generally treated – photo of a man with a whip fighting women back trying to get food.
Early marriage – photo of woman who aged 15 got married to 70 year old man had 10 children, he now dead.
She went with French NGO, decided to work with traditional midwives as they are always there – ngos will leave
But then Afghan Government adopted US/CMU programme to get rid of traditional midwives and train new set of midwives. They worry: it will be white uniforms and hosp care and this not work in poor remote areas.
Talks about looking at US aid programme and traditional midwifery program and how we bring them together. Lack of life choices: Choice for these women is having access to ANY care or none

‘We want local women and mothers to be the experts not us. We are wary of coming in and telling them what to do and what is happening.

Inuit in Northern Canada. How to preserve the tradition.  Women not telling their story because they do not speak/write in English or other mainstream language.

Photo: This how women Inuit traditionally give birth, isolated in their own little hut/igloo. With fire in there. Very hot in there and steamy .
The amazing story of the Inuit people. Harrowing story of oppression and suffering. Then one community took birth back for themselves, replaced the medical man with a strong Anouk woman. Made decision not to continue the medical practice of taking the women away from their communities for 6 weeks around birth, to boarding houses by hospitals thousands of miles away. They knew that some women might die if they not travelled to city hospital for 6 weeks – but the disruption and damage to family and community life so great that the community decided to take that risk. However, outcomes vindicated their decision: although no immediate access to cs – 8 hours (until recently, now 2 hours) – their outcomes have improved anyway. The old prescriptive hospital model did not work for outcomes either!


Sara Wickham – Homebirth Emergencies in Perspective

Sara Wickham’s session was excellent and way over my head as a lay person.  Midwives please do not use my notes as an alternative to spending time with Sara the expert!  Find her website here and book a session with her:

The more we deal in physiology the less likely we are to see an emergency. Also find that there are fewer emergencies the longer you are in practice Experience and normal physiology support safety.

Piece of recent research: proportion of cord prolapse associated with ARM
(2013) Results:  risk of cord prolapse at home is vastly reduced because the key reasons for cord prolapse above are not done in home/physiological practice. Research showed that as practitioners got better at supporting physiological 3rd stage then incidence of pph reduced. There is alos the question of measuring blood loss/defining pph.

Cases of ‘Safety Labour’ – women have a very long slow labour, eg. one case 40 hours because short cord and needed long labour to descend safely (and gave birth choosing lateral lie and leg up). Another example: slight heart defect and so need a long gentle labour – fast one would be too much.

Necessary Prep for Home emergencies:  which included making sure you had good backup, looking after yourself and making sure you had the right equipment checklist and rountines.

Other tips included, working with people you trust, dont’t fear fear doing the dummy run! Oh yes and be ready to ask for help or check stuff when you need to!

Why aren’t all emergencies equal.

Sarah’s Top ten tips for emergencies

Sarah then went through the research showing the incidence and circumstances of emergencies. Basing it on a homebirth caseload of 25 per year. Some of the emergencies on this baisis would be about once every 63 years! I was not able to get all the figures down but they were extremely interesting.

Eg. Incidence of pph in home environment based on 25 HB’s per year = 2-4 years; serious one every 5 years. This reduces with practitioner skill.

After looking at the incidence of main obstetric emergencies pertinent to the home environment, Sara said there were just three skill sets most needed regularly! So make sure you have these skills most practiced and uptodate
Other emergencies will happen between once in 20 and once in 50 years.

Sarah finally talked about her pph emergency kit which included the partner!