The third lesson about hemorrhage I learned from my mentor was how to properly
massage a uterus. Everyone has been trained to massage the fundus, but it is rarely
the fundus that bleeds! When the uterus pulls up on itself in labor, it becomes
very much more thickened than the walls, which then taper down, getting thinner
toward the cervix. So unless the placental implantation site is entirely in the
fundus, the bleeding site will be where the placenta was, on the thinner side
walls. This area has far less endometrial fibrous tissue with which to contract
down upon the vessels that supplied all that blood to the placenta. So it is not
the fundus that needs all the attention!
Massaging the fundus also creates more pain than focusing on the side walls,
may actually damage some of the supporting structures of the woman's uterus, could
push the fundus down into the uterine cavity if there is very low tone (causing
an inversion and/or prolapse) and could delay what you needed to do in the first
place: get it into firm tone. Massage the sides of the uterus! If you also lift
up just slightly on the uterus, this action will elicit a response from the stretch
receptors, and the uterus itself will help you. You can feel this happening under
The only value to even touching the fundus is to evaluate how elevated it is
in the pelvis as a landmark. Massage the sides, and please be aware of your touch.
We have all seen the tortuously painful uterine dominatrix, the one who turns
the woman pale with pain. This is plain cruelty! The massage should be firm but
- excerpted from "Some Thoughts on Postpartum Hemorrhage," by Lisa Goldstein,
CPM, CNM, Midwifery Today Issue 48
The third key to preventing postpartum hemorrhage is to not rush the delivery
of the placenta. Almost all postpartum hemorrhages are caused by being in a hurry
to deliver the placenta. In these cases, I believe hemorrhage is caused by the
intervillous spaces not having a chance to contract and help control the flow
of blood. Also, the overmanipulation of the uterus to facilitate placenta delivery
can cause lobes to be left on the uterine wall, which results in uneven contraction
of the uterus. These lobes must be manually removed to prevent postpartum hemorrhage
and infection--not fun for the mother or the midwife. A policy of hands off, unless
there is due cause, is the most important key to preventing postpartum hemorrhage.
- excerpted from "Three Keys to Avoiding Postpartum Hemorrhage," by
Margaret Scott, CPM, Midwifery Today Issue 48
The maternal vessels that nourished the pregnancy will not be able to contract
and control the bleeding until the placenta is out of the way. These vessels have
been wide open in the final weeks of pregnancy, with a pint of blood a minute
coming through the placenta. The crisscross muscle fibers of the uterus, which
have been called "living ligatures," tighten in around these vessels
to close them off; the vessels themselves draw in and close down where they were
severed with placental separation, and the blood coagulates, blocking further
If the placenta is retained without bleeding, evaluate carefully before making
attempts at delivery. Mark the top of the fundus and watch it to see if it is
rising, suggesting concealed blood loss. If it is not rising, and there are no
signs of blood loss, the situation is stable. Partially separating a placenta
that is abnormally adherent and then being unable to complete delivery means that
a site for bleeding has been opened up. The bleeding is unlikely to stop until
the placenta is completely delivered.
If hemorrhage occurs with the placenta out, direct pressure by external or internal
bimanual compression of the uterus will stop the flow of blood while other measures
are being taken to help the mother's system work. These may be fluid replacement,
herbs or medicines, or simply getting the baby to nurse to encourage uterine contraction.
It is best to use manual methods to prevent further loss while a second attendant
gives Pitocin or shepherd's purse. Expressing clots may be necessary to stop the
bleeding.. They can mechanically prevent the uterus from contracting effectively,
same as the retained placenta, causing continued blood loss.
- excerpted from "Hemorrhage during Pregnancy and Childbirth," by Marion
Toepke McLean, Midwifery Today Issue 48
MIDWIFERY TODAY ISSUE
48 is a veritable manual about hemorrhage.
PATHS TO BECOMING A MIDWIFE -- UPDATE
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Question of the Week Responses
Q: Has anyone developed her own system for newborn
gestational age assessment? The New Ballard Scale seems more elaborate to me than
is necessary for term babies who are born at home. I know that experienced midwives
can quickly look over a baby and estimate the gestational age, but for now I would like to find a concise format to document characteristics for EGA.
- Amy Kieffer, student midwife
A: Many things are unnecessary and actually a little cruel or disturbing
to a sound baby and tend to check only simple things like creases, ear coil, breast
buds, lanugo, vernix. I, however, stay away from the scarf sign, leg lifts, wrist
bending, etc. Today I needed to add a five-day-old baby's gestational age to his
birth certificate. I gave him a 38-week gestational age, yet in retrospect believe
he was a 40-weeker. I used all the text info, and did most of those disturbing
things to reach this guestimate. I do think that after a homebirth, why muck it
up with statistical info? I'd rather stick to noninvasive measures. But I won't
make a mom or a baby upset after a great, nonintrusive homebirth.
Please let us know if anyone has drawn up a better plan for those of us who
feel the Ballard scale is too much.
- Heather Zanon, midwife
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Re acupressure [Issue 3:45]:
When I delivered my first baby, a midwife pressed my little toe to encourage
contractions. Every time she did this the contraction was enormous, so much so
that I kicked her away and I think I may have even sworn at her (just a little).
It did do the trick though. That was at Princess Royal Hospital, Haywards Heath,
West Sussex, England.
- Anna Reeve, student midwife
I went to 42 weeks pregnancy and my OB threatened induction, so I tried everything
(eating curry, sex, nipple stimulation, etc.). My mother suggested she do some
reflexology (she is qualified). She told me that parts of my feet represent my
body and the squidgy inner parts represent my uterus, which is why it looked swollen.
I remember she touched my toes, too. Most of it was stroking movements. The next
morning my waters broke!
Halfway through labour my contractions stopped and once again I was threatened
to be induced the next day. My mother came over again and did some special reflexology
tricks and labour started again later that night, although the hospital had told
me labour had completely stopped because I was having only about one contraction
an hour. I gave birth that night, with only gas and air. I also had no injection
for the placenta, which I delivered about 5 minutes after.
She suggested to my partner that as contractions happen, push against the tight
part of my foot. This didn't remove the pain but balanced it out a bit.
My mother also mentioned that it is possible to cause more harm than good if you
don't know what you are doing, so get training first!
The big toe is an acupressure point for the pituitary. In theory, stimulating
this point would release oxytocin and facilitate the separation of the placenta.
- Lynda Comerate, RN, BSN, LCCE, HBCE
What value do fetal heart tones have in pregnancy besides reassurance to the
mother and midwife that the fetus is alive and well, which we can easily ascertain
by fetal movement? Any ideas? Any known research?
- Jennifer Moore, traditional midwife
Re painful postpartum cervix [Issue 3:45]: I used a homeopathic remedy following
the birth of my second daughter that is commonly prescribed for "pelvic trauma."
I had an anterior cervical lip that my midwife slipped off the baby's head just
before she crowned. After the lochia flow stopped I noticed an ache in my cervix
and a burning discharge. My homeopath suggested Bellis Perinis, which worked wonders
for me. I am not qualified to offer suggestions on dosage but if your client can
find a homeopath, she might begin there.
- Samantha Sering
I have two children, the youngest 16 months old and his sister 27 months older.
I'm having issue with the vertical muscle in my abdominals that separates from
sternum downward to accommodate pregnancy. Both of my midwives assured me that
it would heal if only I concentrated on doing some sit-ups every day. I'm not
overweight or unhealthy and I do exercise, but it hurts to work that part of my
stomach because it's split so far open. It never healed between my two pregnancies
and it's yet to even close up a little bit since my son's birth (if I sit up a
little from lying down, I can get three-plus fingers in the gap.) It hurts and
I have a hard time lifting. My mother seems to have the same problem. Does anyone
have any idea what I'm talking about and/or what could be wrong? Will this be
a problem for me if I get pregnant again?
I am a first-year student midwife studying in England. I read an article in
a "baby magazine" aimed at mothers (not midwives) about a technique
of nipple piercing which enabled a mother with inverted nipples to breastfeed
(with the piercing in place) because it held the nipple outward. Has anyone heard
of this technique? A literature search and questions to my tutors have revealed
no further info and I've lost the article.
- Anna Reeve
I was greatly heartened to read Ms. Bjorkland's response [Issue 3:44 & 45].
I shared many of the experiences of both the sister-in-law and the laid-back woman.
I went into my fourth pregnancy with great joy and since I had already had two
very easy pregnancies and births (less than two hours of labor, unmedicated).
I felt I had nothing to fear. Imagine my surprise at 27 weeks as I developed nephritis.
I stayed sick for the rest of my pregnancy. I clinically developed nephritis three
additional times. At about 34 weeks I began to sense something was not right and
began to question my OB. Finally just to humor me he ordered weekly nonstress
tests, which were inconclusive for two weeks and then at week 36 showed my baby
in significant distress. We attempted to be induced but ended with an emergency
c-section. My baby had the cord around his neck three times and my placenta had
several large areas of infarctions. My OB later told me that he was grateful that
I was as vocal as I was and that he had learned to listen to his patients.
Since my son's birth I have gone on to become a practicing labor and delivery
nurse, currently studying for my lactation consultant's exam. I am always so surprised
at my colleagues' reaction when I share this particular birth experience. At the
time there were no midwives practicing in my area but the midwives who are here
now in particular have tended to act like I brought that whole experience on myself.
A judgmental attitude closes doors of communication faster than just about anything.
I have found in my practice that the more I stand back and let the parents tell
me how they feel and what they sense about their baby, the more wisdom both they
and I develop.
To automatically assume that because a woman is tense or worked up about her
delivery and so deserves a difficult labor is wrong. How much better would it
be if we could reach out in compassion and say "What can I do to help?"
How blessed I was to have a doctor who listened to me, a partner who listened
to me, and two nurses who served as advocates for me. My son is now 16 and a true
- Karen Madsen, RN, lactation & childbirth educator
Many of us in the natural childbirth community (especially in the out-of-hospital
community) lack compassion for women making choices other than those we recommend.
Consciously or unconsciously, we look down on or judge women who desire high-tech
birth. Our attitude about their choices colors our interactions with them. How
can we expect a woman to believe in the beauty and safety of natural birth when
she's being treated in an unsafe, unloving way? How can we expect our choices
to be respected when we are disrespectful to the choices made by others?
When I talk to a woman planning a (by my standards) high-tech, high-intervention
birth or a woman allowing her provider to plan such a birth, I try to remember
that I am an advocate of informed *choice*. Each woman has a right to choose the
birth experience she wants/needs regardless of my opinion of the quality of information
she's basing that choice on and certainly regardless of my opinion of her choice.
If someone wants more or different information, I make it available. Otherwise
I try to act as a mirror: allow the woman to examine her choices by bouncing them
I am not a homebirth midwife because I believe every woman should have a homebirth.
I am a homebirth midwife because I want to make the option of homebirth and independent
midwifery care available to families who want this experience. I respect all families
and all choices.
Each of us--midwife, doula, MD, nurse, client, student--should strive to treat
everyone with respect and, if we can muster it, love.
- Melissa Jonas, licensed midwife
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