Unchanging Protocols
Midwives and other childbirth attendants must understand the mechanism of blood loss in the birth process and observe the amount critically. A gush of blood is one of the signs of placental separation and should not be a cause for alarm. If continued bleeding occurs, assess the position of the placenta. To stop blood loss after birth but before placental delivery, the placenta must be removed. Only when the placenta is out can the muscle fibers of the uterus contract firmly around the spiral arteries and cut off the flow from maternal circulation, acting in concert with the clotting system of the body. Removal of the placenta can be achieved through maternal effort, controlled cord traction or manual removal, depending on the situation.
To stop blood loss after placental delivery, assess the source. It could be coming from a laceration instead of the uterine blood vessels, necessitating repair. Is the uterus empty? Clots in the uterus can prevent firm contraction of the muscle, as can retained fragments of placenta or membranes. Blood loss is stopped by contraction of the uterus and by normal clotting of the blood in the placental site, which shrinks from the size of the intact placenta to just a few centimeters across as the empty uterus contracts. Shepherd's purse and red raspberry leaf are natural aids to this process. Angelica can help the uterus expel retained fragments.
Direct pressure will stop bleeding in the short term while natural clotting mechanisms are beginning to act. Never hesitate to use external or internal bimanual compression to stop the loss of blood. Remember that by the time blood loss reaches 1,000 milliliters, the woman has lost about one sixth of all the blood in her cardiovascular system.
Don't fall victim to the following all-too-common scenario: The placenta may or may not be delivered. A trickle of blood persists; the attendants can't get it to stop. They watch and wait. The blood pressure is good. She seems to be tolerating the blood loss. "She's a strong woman," they assure themselves.
But the body has many mechanisms to protect itself from shock. The pulse is actually a more sensitive indicator of impending danger than blood pressure, and a steadily rising pulse rate may warn us that it is time to act. If blood loss persists, the mechanisms will fail, and the woman will rapidly go into shock.
An emergency transfer occurs. In the hospital, the woman's condition is found to be so critical that blood transfusion must be given before she is stable enough to undergo procedures to stop her hemorrhaging. Even getting intravenous access is difficult when shock has occurred. Also, if the placenta is still in, she faces additional blood loss with placental delivery. Don't put a woman into the dangerous position of already being seriously depleted of blood with the placenta still inside! Learn to assess blood loss and observe for it critically at every birth.
One way to learn to evaluate blood loss is to weigh the blood lost at a few births during your training period. One milliliter of blood weighs one gram, so if you know the weight of the pads or towels you are using to soak up the blood, you can weigh the bloody pads on a gram scale and subtract the weight of the pad. You will soon develop an eye for normal blood loss as opposed to postpartum hemorrhage. Do not dispose of anything that contains maternal blood until the woman's condition is clearly stable. When estimating blood loss, remember that blood lost at the time of birth may be diluted with amniotic fluid.
These basic protocols can prevent serious problems for childbearing women. Accessing the emergency medical system at the right point is an art and a science for the midwife. Being transferred to the emergency room simply to have clots expressed is an expensive mistake, but not as costly as being kept at home until shock occurs.
— Marion Toepke McLean
excerpted from "Unchanging Protocols,"
Midwifery Today Issue 73, Spring 2005
Midwifery Today Issue 73
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Research to Remember
The New York Times reported on research by Cochrane review, which found that women who use a hands and knees position during labor may experience less pain, particularly back pain. This will not come as any news to midwives.
Their research did not support the proposition that hands and knees made the baby go into the proper position faster, however. The researchers used three previous studies, which involved a total of 2700 women, to arrive at their conclusions.
— New York Times, 16 Oct 2007
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Web Site Update
Learn about the new book coming from Midwifery Today's new department, Motherbaby Press: Survivor Moms: Women's Stories of Birthing, Mothering and Healing after Sexual Abuse
Read this article excerpt of the 4th in a series on bullying:
Finding Better Solutions to End Bullying—What a Midwife Can Do
by Marinah Valenzuela Farrell
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Question of the Week
Q: I need some help for a friend of mine who is due with her second baby any day now. She very much wants a homebirth and has a birthing pool set up. Her first birth was in a birthing center and was without any problems. Her second baby has been transverse and breech for a while and her midwife easily turned the baby head down twice in the last two weeks, but the baby goes back to breech position. The midwife thought there must be some reason why the baby keeps turning head up, so she and my friend decided to get a sonogram. The sonogram showed the baby in a footling breech position with the cord wrapped twice around the neck. The doctor said the cord is short. The midwife herself was a footling breech birth and she is willing to go ahead with the homebirth if my friend is sure that she wants to do so. The husband does not want to risk a homebirth, so she is feeling some tension and distance as she doesn't feel that he is supporting her.
The mom is willing to try natural techniques like acupuncture, homeopathic pulsatilla, playing music at the cervix, swimming and getting in inverted positions. She visited the doctor who was at her first birth and he tried moving the baby a bit and checking its heart beat to see how tight the cord was wrapped. He said the heart showed no signs of distress, so moving the baby can be tried. This doctor is the head of the birthing center that is in the Roosevelt Hospital in Manhattan and he hasn't "delivered" a breech baby in five years.
I keep reminding this woman that the baby can turn head down at any moment, even during labor. Any thoughts or advice for her?
— Anonymous
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Question of the Week Responses
Q: I have had two homebirths and two hospital births; I will be having my third homebirth in January. With my last three children my body starts pushing when I am dilated to 8 cm. I can't seem to get my brain to function at this point to prevent any pushing at all until I fully dilate. My other problem is that with that pushing at 8 cm, I always have a cervical lip, which has to be massaged back in order for the head to get past the cervix. This is very painful, and probably needed to be done with my first child, but instead I was made to push for two hours. Any recommendations for me and my midwife?
— Peggy
A: As a labor and delivery RN, when I have a patient with a stubborn cervical lip, I encourage the mother to turn to the side that the lip is on. So if it's thicker on the left, mom lies or shifts to the left. Within a few contractions, it usually resolves itself.
— Cindy Covill, RN, BSN
A: It sounds like you know what your body wants and how you react in labor. That is wonderful. One suggestion I have is when you feel at 8 cm that you want to push, try other things like rolling on the birth ball, sitting on the toilet or standing and movement, belly dance, etc. These can help shift the pressure and allow you to move without actively pushing.
Another technique would be to say, "My body will release my baby, when it is time," and relax. In my experience relaxing and easing up on yourself can really help.
Good luck and talk to your provider and support people about these concerns.
— Demetria
A: Usually it helps to sit upright. So sit on a birth chair or a skippy ball. You have to lean backwards against your partner; in that position the lip most of the time slips away.
— Jolande Schmitz-Brom
A: In response to a pushing urge at only 8 cm, homeopathic remedy Arnica in conjunction with Sepia, alternating doses every 10–15 minutes, works very well.
— Bonne Dunham
Responses to any Question of the Week may be sent to E-News at any time. Write to mtensubmit@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.
Think about It
Perhaps we should be teaching middle school and high school students about Harry Harlow's experiments in the 1950s in which baby rhesus monkeys, when given a choice between a wire mother with a bottle and a warm cloth mother without one, clung to the cloth mothers. They preferred comfort over food. The monkeys raised with only a wire mother became emotionally disturbed and as adults did not know how to parent.
— Cheryl K. Smith
excerpted from "What Babies Need," The Birthkit Issue 56, Winter 2007
Feedback
As a young woman and consumer of midwifery services, I really wanted to encourage midwives to get their advertising online. A friendly photograph and some information about the midwife's philosophies and services is very helpful for prospective clients, as well as being available to answer a few questions via e-mail.
Readily available information helps prospective clients narrow the field. One local midwife advertised a fee for "false labor visits" in addition to the standard package fee - since I knew I had lots of false labor in my two previous pregnancies, I immediately realized this was not the midwife for me.
— Angelia Mercer
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