Sunday, December 23, 2012

Christmas greetings

Thanks to Bec for the pic.
Loving greetings
from our home to yours
“Let us now go to Bethlehem, and see this thing that has taken place, which the Lord has made known to us.”
Luke 2:15

As we once again come together to celebrate our Saviour’s birth, we have chosen this lovely image of a precious young child, who is experiencing the Christmas celebration with eyes wide open, learning the stories, and singing the songs of our faith. 
The second reflection that I (Joy) would like to share from this picture is that time-honoured theme of mother and child, a theme that occupies my professional and personal life, and brings me a great deal of wonder.
Noel and I have come through 2012 with a wonderful sense of thanksgiving for life and love.
We pray that God will bless you in the coming year, and that you will know peace and strength in all of life’s challenges.
With love,
Joy and Noel

Saturday, December 15, 2012

hospital policy in the spotlight

Today as I write I have in mind a young midwife who is employed by a busy private hospital in Melbourne.  I hope that midwife comes to my blog, and reflects on the incident that I witnessed recently, and which I will briefly describe here.

The labouring woman had written a brief birth plan; the sort of plan that I call "Plan A".
Something like this:

I am intending to give birth under my own power, and will do all I can to achieve the best outcomes for myself and my baby.  At the time of birth, my baby’s cord should not be clamped or cut, and my baby must not be separated from me, except for clear medical reasons, and with my consent.  
I do not want any drugs to be administered to me or my baby without my consent. ...

"Yes, we do 'skin to skin', we do 'delayed cord clamping', and we keep babies with their mothers."
"But we can't do physiological third stage."
"The problem is," the young midwife said, "It's hospital policy that you have syntometrine.  I have checked with my manager, and we have to give you syntometrine for the placenta.  It's hospital policy."

The mother was labouring, wasn't saying much, so nothing was resolved.  The midwife brought the tray containing ampoules of the oxytocics into the room.

... fast forward  ...

A healthy baby made his grand entrance, and no drugs were used.  The woman birthed her placenta spontaneously about 30 minutes after the birth, with minimal blood loss.


I am recording this brief account because I want to comment on it.

  • A midwife became the pusher and enforcer of a hospital policy to administer a particular drug preparation.  This is not midwifery.  There was no professional discussion offered as to the implications of the use of this drug for mother or baby.  The midwife simply acted as an agent of her employer, demanding compliance with this policy.  
  • A midwife failed to recognise or uphold a woman's right to informed decision making, and ultimately her right of refusal.

I feel very concerned for this midwife, who is at the beginning of her career.   It seemed clear to me that the midwife considered it her job to enforce the policy.  The midwife gave no indication of any understanding of or interest in the physiology of birth.  Rather, she seemed set on carrying out a series of tasks that were, apparently, the essence of her professional practice. 

The midwife appeared to be ready to ignore a written statement by the woman, that she intended to give birth spontaneously, without drugs.  There seemed to be an assumption by the midwife that the woman's choice of working in harmony with physiological processes and avoiding unnecessary medications was a choice that could carry no weight in that particular hospital.   There was no discussion of the potential benefits or risks of either course of action.  'Hospital policy' was the big flashing light that apparently barred the woman from attempting her plan of action.

The prophylactic use of oxytocics in the third stage of labour, 'active management of third stage', is a process of routine intervention that comes under the banner of the 'evidence based practice' movement.  The uncritical adoption of active management by most hospitals, with the belief that it reduces blood loss and thereby reduces maternal morbidity, is rarely questioned.

In this birth, the mother was ideally suited to unmedicated, safe, physiological third stage because the following requirements had been met:
  • a woman in good health
  • at term
  • spontaneous onset of labour
  • good progress in labour
  • uncomplicated, unmedicated first and second stages of labour.

In contrast, there are good reasons why one might seek to avoid use of Syntometrine. 
Syntometrine is a preparation that combines synthetic oxytocin with ergometrine.
Syntometrine is an S4 drug - restricted to prescription by a doctor or an authorised midwife prescriber.  The idea that a hospital would make policy requiring the use of a restricted medicine is in itself suggestive of a breach of the basic rules of prescribing. 

Follow the link above to read consumer information about Syntometrine.  One small sentence stands out:  
Tell your doctor if you plan to breast-feed after being given Syntometrine. One of the ingredients in this medicine secretes into breast milk. Your doctor will discuss the potential risks and benefits involved.  (http://www.mydr.com.au/medicines/cmis/syntometrine-solution-for-injection )

Breastfeeding is an intrinsic part of physiological birth.
 
Further information on the use of Syntometrine in lactation comes from MIMS, the widely used medicines reference resource:
Use in lactation Of the two components, only ergometrine is known to pass into breast milk. The use of Syntometrine during lactation is not generally recommended.
Ergometrine is secreted into milk and the inhibitory effect of ergometrine on prolactin can cause a reduction in milk secretion. Syntometrine has the potential to cause serious adverse drug reactions in breastfed newborns/ infants. Postpartum women receiving Syntometrine should avoid breastfeeding at least 12 hours after the administration. Milk secreted during this period should be discarded. 
...
How many mothers are given this information prior to administration of Syntometrine?  Very few, I think.

I hope readers see the point I am making.  Today we are advocating a return to spontaneous breech birth, returing to the woman and her baby their right to unmedicated physiological birth.   Perhaps we also need a group of intelligent, well motivated consumers, to become activists for umnedicated, uninterrupted birth, from the onset of labour to the completion of the expulsion of the placenta and membranes and cessation of bleeding.


Your comments are welcome

Thursday, December 06, 2012

why breech births are important

I had a moment of clarity just the other day: Women who have breech babies, and for whom spontaneous vaginal breech birth (vbb) is an option, need MIDWIVES who are willing to be on call, and work with them to the full extent of midwifery as primary maternity care providers in their births.

But, I hear someone say, midwives have been deskilled in VBB,  Most breech babies in the past 20 years have been delivered by caesarean.  So how can a midwife consider herself competent?

And, I hear someone else say, surely the hospitals won't allow a midwife to 'manage' a breech birth.  Surely the senior obstetricians will take control?

Yes, these are valid points, but there's one other point - the point of my recent epiphany - that needs to be considered.  No matter how deskilled midwives and doctors are, the woman's body is, in many cases, ABLE to do the work.  Spontaneous birth, regardless of which pole is presenting, is just that: SPONTANEOUS.  Spontaneous means that the progress happens under the powers that are within the woman's body.

I don't want to sound ignorant or naive here, because I know there are specific complications with breech births that increase risk of neonatal morbidity.  An arm can impede progress: a midwife can manipulate the baby to free that arm.   A baby can be born with low Apgar scores: a midwife is able to provide resuscitation.   The knowledge that upright vbb works well has been circulated in midwifery circles for as long as I can remember.  I don't know when I first heard the old adages, "let the breech hang" and "hands off the breech".  One of the main questions in the exam I took in 1973, when I became a midwife, was all about breech births.  Yet the obstetric textbooks teach the lithotomy position; and the warmed towel to support the baby's body while the various manoeuvres which have the names of obstetricians (eg Lovesett, Mauriceau Smellie Veit ... - I haven't checked the spelling) are performed.

Since the publication of the Hannah (2001) Term Breech Trial, which had the almost immediate effect of channeling almost all breech babies to the operating theatre, midwives in my part of the world have had little experience with vbb.  Breech presentations occur at Term in about 4-5 of 100 births.  In my practice I have seen one or two most years, which is consistent with that rate.  I have followed the current best practice guidelines and sought out external cephalic version, which in at least half of the cases has done the trick.  I would be foolish to claim any special expertise in vbb.  Yet, with the information and drive I now have, I would now be prepared to discuss the option of spontaneous vbb at home in my care, or hospital, with any woman at Term with a breech baby on board. 

There are just a few birthing situations today that potentially challenge the skill, knowledge, and courage of a midwife.  These may be unanticipated.  They may occur with little warning.  And they require the midwife present at the time to act decisively in interests of safety of the mother and/or her baby.


A breech birth can be a big surprise.  The midwife can either act in harmony with the natural processes, and support uncomplicated birth of a healthy baby, or interrupt the processes and mechanisms of birth due to ignorance and fear.

Spontaneous birthing is the terrain in which midwives work best.  We watch and wait, and hold a cocoon of safety around the woman-child unit.  We know the subtle behaviours that indicate progress, and we know how to minimise adrenaline and other fear-related hormones.  We know how to leave well alone; how not to fiddle.  We know how to stay quietly with the woman, physically and emotionally, as she progresses on the pathway to bringing her child into this world.

Spontaneous birthing for vbb must be upheld and protected by midwives and women in all communities.  Sure, some of the big teaching hospitals need to set up breech clinics and have specialists strutting their stuff.  But the reality of childbearing is that women in small towns, and in outer suburbs, and on farms, will also occasionally need to give birth to breech babies.  Many won't have the $15,000 needed for a private hospital booking with the heavily booked breech doctor.  Many won't be within the catchment of the public hospital breech clinic.  They will need a midwife in their community who can work in harmony with a spontaneous and life giving process, and who has the skill to recognise complications in a timely manner and manage referral and transfer of care when it is indicated.

Does anyone out there see what I have seen?

Does anyone else feel deep sorrow for all the breech births for which we have not provided the option of midwifery care?

Midwives who are willing, we need to provide breech education for other midwives, and get the word out in women's groups that breech births can be great births. 

And, btw, we know that the promotion of spontaneous birth for breech babies will not necessarily be easy.  Midwives may need to provide arguments about women making informed choices in professional conduct hearings.   This is the world in which we live.



For more consumer-focused breech information, go to BBANZ


Saturday, December 01, 2012

Dueling Experts

This week, at the MIPP blog, I have recorded some of the questions asked in the course of a formal hearing into the conduct of a midwife.  The scene was a room in the County Court in Melbourne: formal, foreboding, and unfamiliar territory to the midwife whose actions in two particular cases were allegedly unprofessional.  The panel appointed to hear the case did not have anyone who could be called a peer.  Those three women also appeared to be in very unfamiliar territory.

Although formal hearings are open to the public, I have not identified the midwife or the witnesses who spoke for the Board or in the midwife's defense.  The name of the person who made the notifications (complaints) is suppressed by law, and the names of the women who received care from the midwife, leading to the complaints are also not allowed to be published.

In his opening address the lawyer acting for the Board ( Nursing and Midwifery Board of Australia ) commented that this case will probably come down to 'dueling experts'.  The second time he used that phrase it sounded more like 'drooling experts'!  Whether it was intended as a joke or not, it's difficult to see the funny side when a colleague is having to undergo such grueling questions about births that took place more than 6 years ago.

There were two experts called to answer the questions put to them by the two lawyers.  Both experts are Professors of midwifery: highly respected women who have impressive academic credentials.   The arguments become polarised between risk and the woman's choice.

Expert 1 told the panel hearing the case that the risk of a twin birth, or a postmature birth, was too great to be managed in the woman's home by midwives. 'Risk' and 'safety' appeared to be synonymous.
 
Expert 2 told the panel that safety can only be achieved when the woman's right to choose is upheld and supported - even if the woman is giving birth to twins, or the pregnancy is postmature.




Have you ever listened to dueling banjos?  Take a moment to listen to this one from Youtube, played by John O'Connell with James Meall.

That's the image that came to me when the barrister said we faced dueling experts.
They start out slowly, deliberately.
One makes a statement.
The second answers.
Another statement, slightly more complicated.
Another answer.
And it continues until they are in full swing, and I think one or both must surely be lost.  I do not understand how one or the other 'wins' the duel - I think banjo players must have some rules about that. 

And so it is for midwives.

Is a midwife *allowed* to agree to homebirth when one or more risk factors have been identified?
Is a woman *allowed* to plan homebirth when one or more risk factors have been identified?

This is the question, ultimately, that this panel are required to answer.  The NMBA has a two-fold statutory role, to protect the public and to guide the profession.  The protection of the public, in this case, is about putting limits on midwives, and thereby putting limits on the women who engage our professional services.  The guidance of the profession is, in this case, about attempting to define the boundaries of a midwife's practice.

I have come away from this episode of dueling experts without any solution.
I agree with the second expert, who strongly asserted that safety can only be achieved when a mother's right to informed decision making is protected and upheld.
Yet I know well that midwives will continue to be challenged if they agree to operate 'on the fringe'.

Monday, November 26, 2012

TWO YEARS LATER

It's two years since November 2010, when the Australian government announced sweeping maternity reforms that promised to give women a better deal in their maternity care.  The Report of the Maternity Services Review acknowledged that:
"... in light of current evidence and consumer preference, there is a case to expand the range of models of maternity care."

There are several posts on this site addressing the 2008 Review, and the subsequent recommendations and legislative reform.  For example, go to March 2010 Maternity Reform Hijacked, parts 1, 2, and 3; and the September 2010 one on Medicare funding: carrot or poisoned chalice.

Many midwives around this country have accepted the challenge, jumped through all the hoops, and achieved notation as Medicare eligible.  Our invoices for antenatal and postnatal midwifery services include the Medicare item numbers, and women are able to obtain Medicare rebate.  Some midwives are offering certain services at the Medicare bulk bill rate, which involves the swipe of a Medicare card in a little EFTPOS machine; the entry of a few details using the numbers on the machine, and the bulk bill payment shows up in the midwife's nominated bank account the next day.

The other major change that was brought about by the reform package was the ability of midwives to prescribe certain scheduled drugs: drugs that at present only a doctor can prescribe.  The first group of students in the Graduate Diploma of Midwifery from Flinders University are soon to receive their final scores for the Pharmacology exam paper, which we sat last Thursday, and which accounts for 50% of the mark.  For my journal as a student, go to this and subsequent entries.

On the positive side of the 2-year report of the 'reform' process we can record Medicare.  For example, Item number 82115, with a scheduled fee of $313.05 is
Professional attendance by a participating midwife, lasting at least 90 minutes, for assessment and preparation of a maternity care plan for a patient whose pregnancy has progressed beyond 20 weeks,...
]
The Medicare statistics website reveals that, in the 12 months October 2011 to October 2012, a total of $325,005 was paid out by Medicare for Item #82115.
The breakdown of amounts is (in order of magnitude):
Queensland $114,010
Victoria $63,944
South Australia $55,081
NSW $44,308
WA $40,720
ACT $3,241
Tas $2,912
NT $788
This is only one item number.  Other reports can be generated at the Medicare Item Reports site.


On the negative side of the leger, there are several points to note.  This list is my personal one, made from my experience.


  1. Medicare Collaboration:
    It is becoming increasingly difficult in some areas to obtain collaborative arrangements that meet the requirements for midwives to provide Medicare rebates for women.
  2. Access to practising in public hospitals: Despite expert multi-disciplinary committees and meetings and reports, it's clear that public hospitals do not welcome the idea of midwives practising privately within their confines.
  3.  Access to practising in private hospitals: Are you kidding?
  4. The homebirth problem: Midwives attending homebirth are doing so without indemnity insurance.  Surely the time of birth, regardless of place, is the very time when insurance may be useful. 
  5. The future of private midwifery practice: I believe it is becoming more difficult over time to sustain private midwifery practice.  I believe some (probably well meaning) captains of the industry have an agenda to rid our society of homebirth.
Two years on, and the private midwifery profession is more restricted than it was previously.  There has been no expansion of the "range of models of maternity care" - the stated purpose of the maternity reforms.

*****

In conclusion, today I sat in a court room in Melbourne, as the case of complaints into the professional practice of a colleague was commenced by AHPRA.  The law under which the complaints are being heard prevents publication of the name of the complainant, and in this case the names of the women who employed the midwife have also been suppressed.

The legal inquiries and arguments will proceed over the coming days, and the midwife will eventually be told what findings have been made against her, and what conditions may be placed on her ability to practise her profession. [see MidwivesVictoria]

The issue that will, I believe, be at the centre of the case is whether a midwife is *allowed* to attend birth at home for a woman who has recognised risk factors.  The other side of that same coin is whether a woman who has risk factors, such as post maturity, previous caesarean, or twins, is *allowed* to give birth at home.  I have written *allowed* this way to highlight the statutory process that is being employed here, using the regulation of the profession to either permit or prevent certain activities, that are seen - rightly or wrongly - as 'operating on the fringe'.

I am not able in a blog to explore these issues fully.  I would like to make a clear statement that I consider the duty of care of the midwife who agrees to provide primary care for any woman, regardless of the risk status of that woman, to include the promotion of the wellbeing of mother and child, and where reasonable, the protection of spontaneous natural life processes.  The woman is the one who has the final choice on accepting or refusing any intervention.

The midwife practising privately brings skill and knowledge that may not be accessible or reliable in the hospital, where ad-hoc staffing issues often take precedence over the interests of the individual woman.

What progress have we made in the two years since the Maternity reform package was enacted?  Very little.  The only place most midwives are able to practise is the home.  The only way a woman can rely on a midwife is if she plans home birth.


Monday, November 12, 2012

rare birthing footage

http://youtu.be/8NLyORwJCOk

This youtube link is really worth watching. 


Sunday, November 04, 2012

BREECH

When I think about breech births the pictures that come to mind are women who I have attended for breech vaginal births, as well as a few other stories that have been preserved in my memory.

There's Sally, who gave birth unassisted to her 'feet first' baby one night in an ambulance.  I had palpated her abdomen that afternoon: head down, very mobile.  When she went to bed she felt a huge movement, and knew that baby had done a forward roll into a breech presentation.  She got up, went to the toilet, and as she sat down her waters broke, a foot and some umbilical cord presented.  Sally kept a cool head, gently put the loop of pulsing cord back into her vagina (to keep it warm), explained what had happened to her husband, who called the ambulance and me.  Sally's first baby had been born by emergency caesarean after finding that he was presenting breech.  Her second baby had been born (cephalic) at home in my care.  This was the third.

The paramedics arrived quickly, and they assisted Sally as she walked to the vehicle, pausing as she laboured strongly.  Sally told me later in detail how she waited for the head to be born, and supported her baby as he took his early breaths.  By the time I connected with them Sally and baby were resting at the nearby hospital emergency room.  After birthing the placenta, we went home again and had a cup of tea, with vegemite toast.

A few others of these mothers have already been written about in this blog.  [Thanks here to the blogger search function!]


In 2007 I wrote generally about vaginal breech birth, and the deskilling of midwives and obstetricians.  I noted that:
 The very real situation that presents itself today is the deskilling of midwives, and of obstetricians, in breech birth. A baby may be harmed or die simply because the midwife or doctor did not know what a more skilled person could have done to achieve the best outcomes.
In 2008 I wrote about The 'B'-Word, and told two breech birth stories, about one whose baby was born at home after ECV, and another mother whose baby developed a serious spastic brain injury from hypoxia, after abruption of the placenta some minutes before the birth.

In 2009 I wrote 'Thinking about vaginal breech births' in the leadup to the screening of a video 'breech in the system'.

In 2011 I wrote about normal birth for a breech baby, reflecting on the work of colleagues in bringing vaginal breech birth to the attention of the maternity professions and public.

In (March) 2012, reflecting on twin and breech births, I wrote about safer and better systems of care:

I am very distressed when women with twin pregnancies, or babies presenting breech, and their midwives, are so unable to trust hospital care that they see home as the only option. Home or hospital, spontaneous, managed, or surgical, there are no guarantees. The mother's choice of home or hospital for the birth of her babies is her choice, and she will face different challenges with each pathway.

“... We must stop blaming individuals and put much greater effort into making our systems of care safer and better” (ACSQHC National Action Plan, 2001).


Another memorable breech (first twin) birth took place in 2009, and has been noted in the post titled 'Why bother coming here if you won't let us manage you the way we think is best?' 
and the follow-up post 'Drive-through birthing'.


The purpose of today's essay is not just to collect stories, but to assert my belief that we can change, and put effort into making "our systems of care safer and better".  By "our systems of care", I include all aspects of professional maternity care, from the 'village midwife' primary carer, and the bush hospitals, to the big tertiary maternity units.

I believe this is happening.  Women's Healthcare Australasia and the University of New South Wales, Sydney have advertised a program 'Hands off the breech'[click here for speaker' profiles] to be held 30 November and 1 December.  Several of these speakers will be presenting their talks in Melbourne and Warrnambool in Victoria, also in early December - click here for program.  I plan to attend the session hosted by Monash Medical Centre - one of the 'big 3' maternity hospitals in Melbourne, and a strategic place to get the discussion about vaginal breech birth happening.

Social media is active in this regard, and many messages are being posted on a facebook site linked to the Breech Birth ANZ site.

For some, the changes are too little, too late.  Mothers have told me that they agreed to caesarean births for their breech babies because they were afraid.  Fear works against the protective intuitive forces in spontaneous birth.

Mothers have said to me, "Are you willing to attend breech births at home?"  That is a question that I can not give an immediate answer to.  I am committed to doing all in my power to protect the wellbeing and safety of mother and baby.  There are times when a breech birth (or twin) at home could come into that scope.  Other times there will be discussion and the decision may be made to go to hospital.

That's enough from me for today.  Thankyou for your comments.

PS
The following comment was left today (14 Nov 2012) on an earlier post about breech birthing.  I have included it here as it is relevant to the discussion:


motherwho (http://motherwho.wordpress.com/) has left a new comment on your post "THE ‘B’ WORD Breech. A woman today whose baby is...":

Hi Joy, thanks for writing this post! I enjoy reading your blog although this is my first comment.

My second baby was born last month (in Melbourne). My midwife first detected she was presenting breech at 29 weeks which was not a concern at the time, but as the weeks went on she stayed in the same position. At 36 and a bit weeks after much stress, acupuncture, moxibustion, massage, swimming, hypno-tracks, spinning babies.com, etc, etc, the little bub was still breech.

The hospital I had a [back up] booking at were most likely only giving me the option of an 'elective' caesarean (not really elective when it is the only option you are given?), so we went to another hospital and had a successful ECV. I went into labour spontaneously and had my baby girl at home last month.

I feel so lucky to have escaped the knife and terrified that it seemed to be the only option, had my baby remained breech, as we had decided we would prefer not to go ahead with our plan for a homebirth if she stayed in that position.

I still feel confused about the system we had to navigate and realise that if we had have been less educated we would not have questioned it. I can only imagine my recovery and the distress I would have felt now with a 5 week old baby and a toddler running around had things have been different.

My youngest sister is now a graduate midwife and I don't think she has ever seen a vaginal breech birth, nor has she been taught how to support a woman/baby should one arise under her care.

Definitely cause for great concern, in my opinion. 


Thankyou 'motherwho' for sharing your journey.


Friday, October 26, 2012

an observation of a placenta's healing property

Those who have been reading my blogs over the years probably realise that a great deal of what I write comes out of reflection on actual recent experiences in my midwifery practice.  Today I want to write about a placenta.

As I sit down at the computer I am conscious of my weariness, overlaid with the 'buzz' of good cup of coffee that I have just consumed.  I was called out at midnight last night; the baby was born at about 2:30; and I returned to my bed for a few hours at about 6:30.  I accept this weariness and irregular sleep pattern that comes with the territory, and my heart is content and thankful to God the creator of life, because once again I have witnessed the awesome yet unremarkable event of a healthy woman giving birth to a healthy baby.

I have headed this post 'an observation of a placenta's healing property'.  That's what I think I observed, and will try to document here.

Last week I attended another spontaneous birth at home.  Uncomplicated; great 'outcomes'.  But there was one unusual feature that set my reflective mind in action: a considerable amount of fresh bleeding during the labour.  I have estimated 50-100ml in total, which is considerably more than a bloody show.  It would be classed an antepartum haemorrhage (APH).  The show usually comes from the cervix, while this APH must have come from the placenta. 

Anyone who is familiar with my midwifery practice will probably ask, how did this baby come to be born at home?  If the woman was having an abnormal blood loss, is that not an indication for transfer to hospital, continuous electronic fetal monitoring, and closely managed obstetric care?

Yes.  That is what would usually happen. 

The realisation of what had just happened only settled in on my mind after the baby had been born, when I went to the bathroom and saw a collection of blood-stained toilet paper not yet flushed away.  When I spoke with the mother about it she confirmed that there had been a significant amount of bleeding through the labour.  By the time I arrived, and she was ready to get into the birth pool, already feeling a strong urge to push, there was no bleeding; the fetal heart sounds were good; so we proceeded with the birth.

The second realisation that I had in this case was when I took the placenta to the kitchen sink, and checked it under the bright light (rather than the dull light of the birthing area). 

The placenta was complete, with no unusual features.  However the membranes were clearly torn into the placenta at one edge.  The interesting observation I made was that the torn edges of the membranes, for 2-3 cm from the edge of the placenta, appeared to have shrunk slightly as though an astringent had caused them to pucker.  [I wish I had taken a photo of this, but I didn't, so words will have to suffice].

Ummm.  Interesting, I thought, and completed my check of the placenta, placed it in the bowl provided by the mother, and went on with my work.

I had not previously observed this phenomenon that I have described as astringent, or drawing together of the tissue.  But as I turned it over in my mind, this is what I have wondered.  The bleeding obviously came from the point at the placental edge where the membranes had torn.  The bleeding did not compromise either mother or baby's condition.  There appears to have been something that had an astringent effect on the torn part of the placenta and membrane, that worked to heal the tear and reduce blood flow.  That is what I mean by the placenta's healing property.