Managed Third Stage and Rhesus Status - Advice Please!

[AliP]

Hi - just after some advice/experiences.
At my NCT class last night i was told that i was better not having a managed third stage if i was rhesus negative. Has anyone else heard this & can you give me any advice/point me to a good web site. None of the books i have have said anything about this.
I have already had my first Anti-D injection so not sure what the problem is.

any thoughts any fellow mumsnetters! PS this is baby no 1!

I haven't heard anything about the third stage bit but with my 1st labour i wasn't given the anti-d.Told they would wait until baby born and check his blood depending on his group as to weather or not they would give it to me.Never had it with him. Had it given with the second as i had bleeding throughout pregnancy due to placenta previa.

not much help am i sorry

AliP - I have my sister with me as I type (!) who is Rhesus negative and mother of 4 aged between 11 and 1. She had anti-D after each delivery, and the injection for a managed third stage. Was never warned not to, and the outcomes were good in each case. She says follow your doctor's advice is best. For my own part, I had a retained placenta with one and its not a pleasant experience so on balance would recommend a managed 3rd stage. HIH

I'm Rh- and had a managed third stage. I was given anti-D a couple of days later, after they had checked ds's blood group. I have never heard anything about not having a managed 3rd stage if you are Rh-. The idea of the anti-D is that it destroys any of the baby's Rh+ cells that get into your bloodstream, before your own immune system has a chance to make antibodies. The anti-D has to be given within a certain number of days. I can't see why having a natural third stage should make any difference to this (and I used to be an immunologist, but very rusty now).

HTH

The theory is that a managed third stage encourages a larger fetal maternal transfusion ( mixing of mother and baby's blood) as the placenta separates because the placenta is more engorged with blood and is forced to separate earlier because of the oxytocic drug given to shorten the third stage. A physiological third stage means that the separation takes place when the cord has stopped pulsating naturally and therefore the placenta is not so engorged with blood therefore reducing the amount of blood able to enter the mother's circulation.
This is a theoretical risk. As you are not opposed to having anti-D this is not so much of a problem. After delivery, as well as the baby's blood group being checked from the cord blood, a sample is sent from the mum for a Kleihauer test to be done. That measures the amount of fetal cells that may have crossed into the maternal blood stream. If it is greater than 0.4ml then the dose of anti-D given is increased to make sure that no antibodies can be produced.
A physiological third stage is absolutely fine if you have a labour with no interventions. If however, you need to be induced or have an epidural or assisted delivery such as forceps or ventouse then a managed third stage is recommended, rhesus negative or not. Hope you can follow my ramblings - have just finished a night shift and am heading off to bed.

I'm Rh- and had a managed third stage with an Anti D injection a few days later when they found out what blood group ds was (B+). It was never mentioned to me not to have a managed third stage. Thanks Mears for explaining the whys and wherefores.

Yes thanks Mears. I'm RH neg too and both times have had a managed third stage.

I am RH - : had a first labour with syntocynon at the end so had to have a managed third stage. However baby is RH +
and with second baby: labour "au naturel" and so physiological 3rd stage... again Rh + baby...
so never given anti-D

To Gilli - did you know the chances of a retained placenta are increased with a managed third stage? If the placenta is not delivered within the time taken for the Syntometrine to take full effect it may become trapped inside as the cervix contracts back.

I nearly had a retained placenta with ds2. It took over an hour to emerge, despite the Syntometrine, and I had by far the worst contractions of my labour in the third stage. Only because I was at home with a very confident midwife, was I allowed so long to deliver it. She was actually picking up the phone to ring for an ambulance when I got a huge contraction and out it came. Next time (if there is one) I would definately try for a physiological third stage.

Sorry - I never heard anything about being Rhesus neg and its implications for the third stage.

Khara - Yes I have heard that: I was told that the risk is only increased if the injection is given too promptly, and anyone concerned about this should ask the midwife to delay the injection slightly. In my case I had a retained placenta with ds2 because the cord snapped . With both dd3 and dd4 I was therefore advised to opt for a managed 3rd stage but with midwife manipulation of my tummy rather than pressure on the cord. Im sorry, I realise this probably leaves AliP more confused than ever!

AliP - Mears advice earlier looks like informed opinion to me - hope it helps!

Thanks everyone - i'm going to plan to have a managed third stage, but its great to hear how many of you have had no problems and how many of us 'odd-ball' blood group people are out there!

I'm seeing my midwife tomorrow so will talk to her.

Just a quickie pupuce - why no anti-D if you're RH Neg, and baby RH pos?

Leese - I don't know... you tell me
oops just realised as I type... NO I AM WRONG
They are Rh-.... of course...... silly me!

Ali P - why do you want a managed third stage? Why not see how the labour goes... you may not have a choice anyway as Mears said... and if you have a problem/drug free labour, why give your body some drug (artificial hormones) at the last minute?
Just trying to understand why you feel this way?
Thanks

pupuce - PHEW! - was trying to think how I may tell you gently your case had been mismanaged!

Just out of interest I have a question on the rhesus blood group, if you are rhesus negative do they give you the anti D injection just incase the baby is RH+ or is there any way they can know before the baby is born? I know this is a really dumb question but I always forgot to ask my midwife when I was pregnant a few years back now. I am RH- and assume I was given the anti d injection after the birth of my dd although it was all a bit of a haze, but that's another story. And do they test the baby after birth to see what RH type the baby is?
Thanks

Linnet, during my pregnancy blood samples were taken from me and tested for the presence of antibodies to the Rh+ protein. So although the foetal blood group was not known at that stage, they were checking to see if I was mounting an immune response to the foetus. If there is any concern about the antibody levels, treatment is by giving anti-D or by intrauterine blood transfusion (in extreme cases). I would imagine it is possible to ascertain the foetal blood group however, just that it is rather invasive so not usually done.

Mears' post below describes what happens after birth. If you need anti-D then it is given up to 72 hours after the birth. It would not usually be given immediately after the birth because it takes some time to check whether or not you need it.

You may not have received anti-D because you may not have needed it (e.g. if your dd is also Rh- you would not need it).

However, having said all this, practices may vary throughout the country and also may have changed in recent years because of concern over administering a biological (i.e. a product made from a human source) where it is not strictly indicated.

thanks for your comments gingernut. I don't remember getting any injections after dd was born, I thought they may have done it in theatre and things are a bit hazy from then so I wouldn't remember if they had.
I have vague recollections of a midwife telling me my dd blood group but I don't remember exactly what she said. That was when she was about 1 or 2 days old.
I've spoken to my GP about having another baby and mentioned being RH- and she did tell me that their policy has now changed and when I'm pregnant I'll get an anti d injection at 28 weeks and 34 weeks, they apparently do this as a precaution now. Not sure if this is nationwide but that is what they do here.

Linnet - the precautions you mention are new national guidelines of giving all rhesus negative women anti-D at 28 weeks and 34 weeks (NICE guidelines).
The Royal College of Midwives has grave concerns over this and as a midwife, so do I.
The reason it is being done is to try and prevent women developing antibodies and therefore preventing life threatening complications for the baby. However, there are very few rhesus negative women who do develop problems and of them, many would not have developed a problem had the existing guidelines been followed in the first place such as the administartion of anti-D after miscarriage, bleeding during pregnancy, any invasive procedure such as amniocentesis, abdominal pain, and ofcourse post delivery if the baby is Rh Positive. Also the kleihauer test must be performed to ensure a big ehough dose of anti-D is given post delivery. There are still some places that do not do that.
The health risk of being given a blood product has been claimed to be negligible because of the safety in it's preparation. However, I think it is outragious that all Rh Neg women will be given a blood product that may have some, as yet undetected virus or other in it as has happened in the past. I have concerns that women will not be given all the information to make an informed choice as to whether they want it or not "just in case". I worry that this will just be given automatically and women will think that it is something they must have.
If I was pregnant again for the first time I would be finding out my partner's blood group. If he is Rh negative then there is no need to have anti-D at all (that is actually mentioned in the guideline but there is a worry that women will not want to admit that their baby is not their partner's).
The subject is very close to my heart because I myself have got rhesus antibodies and my last baby needed 3 exchange blood transfusions. However, I developed antibodies at 37 weeks in my second pregnancy. I actually had had an episode of abdominal pain at 34 weeks which lasted for a couple of hours then passed. I saw my GP the next day who said it was probably my 'lower segment forming'. I accepted that ( me a midwife too!!). Once I developed antibodies I realised that the pain had probably been a small abruption which is a bit of bleeding behing the placenta. That would have resulted in some of the baby's blood entering my bloodstream.
On the one hand you could say that prophylactic anti-D would have prevented that. On the other I believe it would have been prevented by anti-D being given as it should have been to a Rhesus negative woman with abdominal pain. Awareness raising would have been a better tactic to me than blind administraion of anti-D to everyone. It will be interesting to hear what information rhesus negative women are getting from the professionals.

Thank you for that mears, it is very interesting. Do you know when the NICE guideline came out? I think they it be available on the web so I shall go Googling. I mentioned the 28 and 34 week anti-D injections to my GP when I was pregnant (i.e. did I need them?) and was told no, I would be monitored as I described (this was in 2001) and I was pleased that I would not be given anti-D unnecessarily. I hope that we shall have another child and would hope to receive the same monitoring (although I did have to be vigilant and make sure they took the sample for testing, and chase up the results later - just a warning to others!) rather than routine anti-D.

Linnet, I have had anti-D twice (once after m/c and once after birth of ds) and both times was given the jab in my bottom! I guess you would remember this . It is supposed to be given into a muscle so I suppose could be given elsewhere though.

PS: mears - do you know how anti-D is sourced? I guess from Rh- women who have rhesus antibodies?

Mears with my first pregnancy I was given a leaflet which didn't really explain much at all (in fact i've learned more this morning reading your thread).However they did not offer the anti-d until ds was born in which case i did not need it.
My second time around i had placenta previa and had 7 bleeds (3 very large) and was given lots of anti-d.So the system worked for me.Except for the fact I now have pnd and every period i get taken back to that time.That's another story.

Gingernut - anti-D is sourced from blood donors who have antibodies themselves who can be men or women. It is bought from donors from the USA beause they do not have variant CJD. I was going to donate my plasma because of my antiboies but plasma is no longer collected in the UK because of 'mad cow disease'.

The guideline was issued in May 2002.

It is called 'Guidance on the use of routine antenatal anti-D prophylaxis for RhD-negative women'.

You will be able to see it at www.nice.org.uk

They

Sorry about that misplaced 'they'.

By the way the most evvective place for it to be administered is in the deltoid muscle of the arm. However, more often than not it is in the bottom or leg where absorption is less effective. Is it any wonder that sometimes women develop antibodies in the first place?

Also the guideline does say if you want more info visit the NHD Direct website

www.nhsdirect.nhs.uk

I can guarantee it will not contain my sentiments

I had routine anti-D injections during my pregnancy in 1996. After her birth, DD's blood was tested and she is Rh- so I didn't need the injections anyway.

It was about 3 or 4 years before I found out that anti-D was a blood product - how naive I was. I was very worried, not just for myself but also because I am a blood donor and had donated a few pints in the intervening time. Although I was always questioned on all sorts of things, having had anti-D wasn't one of them.

I asked the Blood Donor Centre who told me that it wasn't a problem and allowed me to donate again.