Valerie Gommon Midwife’s Blog

Archive for the ‘Third stage of labour’ Category

Pregnancy

“The condition of having a developing embryo or fetus in the body.”
“The process by which a human female carries a live offspring from conception until childbirth.”

Pregnancy is referred to as a gestation period – the time between conception and birth. Approximately 40 weeks (280 days). Measured from the first day of the last menstrual period. For women who use a procedure that allows them to know the exact date of conception (such as in-vitro fertilisation IVF, or artificial insemination) the gestation period is 38 weeks (266 days) from conception.

Pregnancy is divided into three stages – called trimesters, each lasting about 3 months.

An embryo is a multicellular diploid (has two sets of chromosomes) eukaryote (an organism whose cells contain complex structures enclosed within membranes) in its earliest stage of development; from the time of first cell division until birth. In humans, it is called an embryo until about eight weeks after fertilization (i.e. ten weeks after the last menstrual period or LMP), and from then it is instead called a fetus.
Embryo is the term used to describe the developing baby in the first 8 weeks and the term Fetus is the term used after 8 weeks until birth (when all the structure of the baby and systems of the body such as the digestive and nervous systems have developed).

Facts at 24 weeks
24 weeks is the legal cut off gestational age for a legal abortion (although abortions or terminations can be carried out later in the pregnancy on medical grounds).

COMPLICATIONS OF PREMATURE BIRTH
Babies born after 34 weeks have a low risk of problems although they are sometime slower to feed.
A baby born before 33 weeks will have more serious problems such as immature lungs.
Very premature babies (born under 28 weeks) need to be delivered in a hospital with a neonatal intensive care unit.
Doctors have been able to improve dramatically the survival hopes for babies born as early as 22 or 23 weeks.
However, very premature babies face a huge battle at the start of life. They are at risk of serious conditions including:
* Hypothermia, due to lower levels of fat
* Low blood glucose, which can lead to brain damage
* Respiratory distress syndrome – which can cause blindness
* Brain haemorrhage
Long-term they may have cerebral palsy and have sight and hearing problems.
They are also more likely to have motor impairments and co-ordination and concentration problems.

Birth
Occurs at around 38 weeks after fertilization, so 40 weeks pregnant. Term is considered to be 37 – 42 weeks gestation. The fetus has developed enough to survive easily outside its mother’s body. Babies are usually born head first but occasionally are born breech.

http://www.babycentre.co.uk/v1027487/inside-pregnancy-weeks-28-37

There are a variety of birthing methods; the majority of babies are born by a natural vaginal birth but some labours might need help such as
Ventouse, Forceps, Caesarean section.

The process of natural birth involves what is known as “labour” the baby passing from the mother’s abdomen through the vaginal passage and into the world. There are three stages of labour:

Stage 1: The cervix has to open and stretch around the baby’s head until it is 10cm open.

Stage 2: The baby has to come out, either by the expulsive efforts of the uterus and the mother breathing the baby out, or by her actively pushing the baby out.

Stage 3: The placenta or afterbirth has to be expelled.

Linked blog posts:

https://midwifevalerie.wordpress.com/2008/12/07/so-you-are-pregnant-preparing-for-the-birth/
https://midwifevalerie.wordpress.com/2008/12/19/the-big-day-the-birth/

Another guest blog by Sarah Ward … thanks Sarah.

The placenta is the fetal life support system, but can also become more than this, and is a powerful symbol that many believe deserves some respect when it has fulfilled its main aim. 

A new TV programme on Channel 4 called ‘How to be a Good Mum’ made me decide to do a topic on placentas. I tend to hate programs like this because they always portray what can be reasonably sensible well thought out ideas, throw them all together and turn them into a program designed to shock and mock anything mildly different from the perceived ‘norm’.

The first episode showed a lady making a print from her placenta in quite gory horror style detail. Each to their own maybe, but here are some ideas I found on the internet!

1. Plant It! 

The most obvious and common thing to do with a placenta (after throwing it out that is) is to plant it in the garden or a pot.  Sometimes this is done as part of a ceremony, naming day, with friends, family or just a personal thing done without announcement, just to show respect to the thing that nourished and fed your unborn baby for all those months.  Maybe to throw it out seems in some way disrespectful after all its hard work?

2. Print From It!

This is easier than it sounds.  It can be frozen for some time, defrosted, washed, dried and the side closest to the baby including the cord can be inked and printed to look like a tree, with all the veins looking like branches.  They can be quite beautiful.  They can also be printed from soon after birth using the blood left within it to make the print.

3.  Encapsulate It!

There are many practitioners that will encapsulate your placenta for you.  This basically involves mulching it up, drying it out and turning it into a powder form that’s put into tablet capsules for you to take.  The benefits are said to be that it can balance your hormones in the weeks and months after birth, increase your milk supply and quality, and increase energy.  Its been reported to decrease the risks of developing post natal depression also. In fact it’s not a new idea, its been a traditional Chinese medicine practise for centuries.  This needs to be done within 48 hours after birth.

4.  Ingest It!

Ok, I mean Eat IT! The benefits are the same as above but you could do this yourself at home and not need anyone to help you. I think most people are generally aghast at this idea, but it’s not so uncommon in other parts of the world. In fact there are many rituals and ceremonies that involve this, and are a way of welcoming the new baby into the community and celebrating its safe arrival. If you google this subject you can find many recipes and ideas from simple smoothies to bolognaise!

In fact MOST mammals eat their own placenta and the benefits are said to be that it encourages milk production, and encourages the uterus to shrink down after birth. 

5.  Burn it!

Some cultures burn the placenta in a clay pot and then bury the ashes.

6. Make a Teddy!

Artist Alex Green set off a media storm after his Placenta Bear went on display at the ‘Doing it for the Kids’ exhibition.  He explained:

“The goal of the exhibition is to inspire designers, educators and parents to be more critical of the toys that shape a child’s values and the impact toy making has on the environment.”

7. Other Cultures Do This!

In Yemen the placenta is placed on the family’s roof for the birds to eat, in the hope that it will guarantee the love between the parents.

In Malaysia the placenta is seen as the child’s older sibling and thought that the two are reunited at death. The midwife carefully washes the placenta, cord and membranes and wraps them in a white cloth to be buried.

In Nepal, the placenta is given the name ‘bucha-co-satthi’ – meaning ‘baby’s friend’

The Tanala people of Madagascar observe strict silence throughout the labour and birth and as the placenta is being delivered. When the placenta comes, everyone present claps and shouts “Vita! Vita!” – meaning ‘finished’.

Philipino women often bury their placentas with books with the hope that this will ensure an intellectual child!

To Conclude:

Whether you choose to eat it, paint with it, throw it out or whatever, there’s no denying that the placenta is a beautiful thing. It is the connection between mother and child and can be a very spiritual symbol. Whatever we decide we should not judge other people’s choices even if they appear alien to us. Being different is what makes the world an interesting place.

This is a guest blog written by Sarah Ward.

 Homebirth & PPH

Women often worry about what would happen if a woman bled heavily after a home birth. Throughout history, severe blood loss has been one of the main causes of women dying in childbirth, and it remains the most common cause of maternal death in the world [WHO, 1994].

Efficient management of postpartum haemorrhage is one of the wonders of modern obstetrics. The key is the availability of oxytocic drugs, which make the uterus contract down and normally stop bleeding.

You can choose to have either a ‘managed’ or a ‘physiological’ third stage, at home or in hospital. A ‘managed’ third stage means you have an injection of syntometrine as a precautionary measure. A ‘physiological’ third stage means you take a ‘wait and see’ approach to the delivery of the placenta, and only have drugs if you are worried about bleeding or if the placenta is taking longer than you want to wait for it to turn up

Sometimes one hears of doctors trying to dissuade women from home birth because of the risk of postpartum haemorrhage yet in fact severe bleeding after a home birth in the UK is rare, and postpartum haemorrhage is usually managed at home or by transfer to hospital. Despite the fears of some doctors, you would be very unlikely to bleed to death after a planned home birth in a developed country.

A famous review of quality studies of home birth (Olsen, 1997) looked at outcomes for over 24,000 women and found no maternal deaths. The National Birthday Trust Fund study looked at around 6,000 planned home births in the UK, and found no maternal deaths.

Where treatment for postpartum haemorrhage is needed, there are two elements. Emergency treatment focuses on stopping the bleeding, and in severe cases, keeping blood volume up while the bleeding is stopped. The other element of treatment is helping you to recover from blood loss, by administering a blood transfusion or iron supplements, this usually occurs several days after the bleed after blood tests have been performed.

What can a midwife do about heavy bleeding at a home birth?

Your midwife would follow exactly the same steps that she would take in hospital. Oxytocic drugs to manage blood loss are part of the basic kit that midwives take to every home birth.

If these did not bring the situation under control quickly then an ambulance would be called, and the midwife would take other steps if necessary, such as manually compressing your womb to stop bleeding.

In the UK most midwives can put an intravenous drip in at home while they are waiting for an ambulance to arrive.

What if the midwife isn’t there?

In the rare circumstances that a baby is born so quickly the midwife has not arrived yet, or the bleed has occurred after the midwife has left (also extremely rare), then you can do the following:-

  • ·       Call 999 if you can’t get hold of your midwife immediately
  • ·       Massage the uterus firmly – this often stops the bleeding immediately
  • ·       Pass urine
  • ·       Bi-manual compression – only if bleeding is extreme – involves someone continually massaging uterus externally and internally until help arrives

When the midwife arrives…

  • ·       She considers what we call the 4 T’s: Tone, Trauma, Tissue and Thrombin (clotting) factors.
  • ·       She can make sure the woman has passed urine and does not have a full bladder.
  • ·       She can use massage of the uterus, syntometrine or ergometrine medication to try stem bleeding. These medications induce a sustained uterine contraction. The massage of the uterus will sometimes expel any tissue obstructing good uterine clamp-down.
  • ·       The midwife can check for a tear, sometimes we can tear internally and it be less obvious
  • ·       Bi-manual compression will be used and transfer to hospital will happen as soon as an ambulance arrives if bleeding is not slowing.
  • ·       If bleeding has been easily stopped and woman feels fine then she may end up declining transfer to hospital. However in hospital they can offer a number of extra helpful interventions for anyone who has experienced or is experiencing a life-threatening PPH.

Placental Problems

  • ·       Occasionally the placenta doesn’t separate properly and obstructs, the midwife can manually remove it allowing the uterus to contract down and stem the bleeding

Can more be done in hospital than at home?

  • ·       The answer is yes, but only because there are more staff on hand, however the chances of having a life threatening PPH are far far greater in a hospital than at home in the first place.
  • ·       The most common reason for PPH is to do with atonic uterus, where the womb fails to contract down properly. At home, this is dealt with in the same way and with mostly the same drugs that would be used in hospital.
  • ·       It’s important to mention that PPH at home is reasonably rare, by the very nature of the fact that the major risk factors for PPH are things which only happen in hospital (instrumental deliveries, long hours on syntocinon drips, caesarean section etc).
  • ·       The last confidential enquiry into maternal deaths listed approx 5 deaths from PPH, all of which were in hospital, four of them were following instrumental deliveries and one following caesarean.

 How likely is post-partum haemorrhage after a home birth?

  • ·       PPH is significantly less likely to happen after a home birth than after a hospital birth.. This is probably because home birth reduces the risk of interventions which can contribute to PPH
  • ·       For more info, see the National Birthday Trust Fund study in the first instance, but numerous other studies have also found a reduced PPH rate in planned home births.
  • ·       Part of the reason for higher rates of blood loss after hospital birth is that PPH is statistically more likely to occur after intervention such as caesarean section, assisted delivery (forceps or ventouse), or medical induction or augmentation of labour (having a drip to speed labour up). None of these things will be happening at home. If you were to have any of these interventions, you would already be in hospital.
  • ·       There are some ways in which planning a home birth actually reduces your chances of having a PPH. Simply planning a home birth significantly reduces your chances of ending up with a caesarean or an assisted delivery – labour just seems to progress more smoothly at home, leading to less call for intervention. As these interventions increase the risk of PPH, by reducing the risk of the intervention, you are reducing the risk of PPH.

Can you have a home birth after having had a PPH with a previous baby?

  • ·       To try to work out the chances of a PPH recurring, and whether this is ‘safe’ for a home birth, you’d need to know why the PPH occurred, and if the same circumstances were likely to recur.
  • ·       Much depends on how you felt after the PPH.  Some women feel great even after losing a considerable amount of blood whereas others may feel terrible only losing 300ml.
  • ·       Its often hard to accurately measure the amount of blood loss. In the UK we call a loss of 500ml a PPH, but Europe don’t record a PPH unless over 1000ml.
  • ·       What were the circumstances the PPH occurred in? Were there known risk factors for PPH which would not apply this time? For instance, PPH is more common after assisted deliveries, first babies, large babies, induction or augmentation of labour.

o      If she needed an assisted delivery this time she would transfer to hospital, so that shouldn’t affect her status as regards home birth.

o      Likewise, her labour is not going to be induced with prostaglandins or augmented with syntocinon.

  • ·       Was the PPH a ‘true’ PPH in terms of being blood loss from her uterus, or was it associated with perineal tearing or episiotomy? Blood from both sources ends up in the same measuring jug, but the difference is significant.
  • ·       Did she have a retained placenta, or did the bleeding occur after the placenta was delivered – some ‘uterine atony’ involved?

Conclusion

All in all the risks of a PPH are lower in a planned homebirth than in a planned hospital birth.

However if one should occur, there are many ways it can be treated successfully at home, or by transfer to hospital.

It’s also important to realise that a negative outcome from a PPH can also occur in a hospital situation as well as at home.

Having experienced a PPH following a birth is not an automatic barrier to home birth in the future, it would depend on the reasons why it occurred. In fact planning a home birth may significantly reduce the chances of having a PPH in the future.

 

I have just returned from an Association of Radical Midwives (ARM) meeting.  It was great to meet up with other midwives who feel passionate about normal birth.  Tonight we viewed a film about the “Lotus Birth” of twins, in a birthpool, at home in Australia; the film is available from http://www.birthinternational.com/product/video/dvd010.html

 

A Lotus Birth is when the umbilical cord is not cut after the birth of the baby, instead the baby remains attached to the cord and placenta until the cord naturally detaches at the baby’s umbilicus.

 

The placenta is usually salted and treated with herbs to preserve the placenta until it separates.  The cord dries quickly and shrinks in diameter and detaches within a few days after the birth.

 

http://www.birthinternational.com/product/book/bk663.html

 

http://www.lotusfertility.com/Lotus_Birth_Q/Lotus_Birth_QA.html

 

http://www.withwoman.co.uk/contents/info/lotus.html

 

There may be many reasons why families choose this unusual method of managing the ultimate separation of the baby from the placenta; they may have personal or spiritual beliefs about the significance of the placenta, but also it is true that the baby extra blood, via placental transfusion, which contains iron, red cells, stem cells and other nutrients if the cord is either left intact or left until the pulsating ceases.  Additionally advocates of Lotus birth are aware that the mother and baby are more likely to be left to “bond” and establish breastfeeding with the placenta remaining attached to the baby.

 

This raises other questions: that of when to cut the umbilical cord, and also the question of stem cell harvesting.  In the vast majority of births within the UK the mother is given an injection of an Oxytocic to speed up the delivery of the placenta as it is believed that this lessens the risk of post-partum haemorrhage (NICE, Intrapartum Care September 2007).  http://www.nice.org.uk/guidance/index.jsp?action=byID&r=true&o=11623 This national guidance is questioned by some midwives and also Association for Improvements in Maternity Services (AIMS) (Delivering Your Placenta, The Third Stage 1999) http://www.aims.org.uk/

 

Routine stem cell collection is not recommended by the Royal College of Obstetricians and Gynaecologists or the Royal College of Midwives however it is a question midwives are often asked about.  In a routine hospital environment the cord is quickly clamped and cut after birth, however in a physiologically managed third stage the baby receives the extra blood supply and also the stem cells.

 

On a separate and sad note, I acknowledge the death of Hope Williams one of the conjoined twins.

 


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