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.
Showing posts with label bleeding. Show all posts
Showing posts with label bleeding. Show all posts
Friday, October 26, 2012
Saturday, October 13, 2012
bleeding after birth
Today I am reflecting on experiences I have had with post partum haemorrhage, linking those clinical scenarios to my body of knowledge, reading reliable references that relate to appropriate interventions and drugs to treat bleeding, and applying learning to my practice.
The real test of primary maternity care is FIRST the safety and wellbeing of the mother, and SECOND the baby (even though the baby's birth usually comes first).
The aweful possibility of sudden dramatic bleeding after the birth, and what that can mean in terms of loss of life, is the spectre that hovers in the mind of many public health decision makers. The burden of such loss, particularly in resource-poor parts of the world, has led to many initiatives that seek to make changes that will protect life and reduce harm. An example is the Joint Statements on Prevention of Postpartum Hemorrhage, released in 2011 by the international peak bodies for midwifery (ICM) and obstetrics (FIGO). The key recommendation, active management of third stage of labour, is explained in the joint statement released in 2003.
Midwives (and I am one) have learnt, over the past few decades, to value our knowledge of working in harmony with natural physiological processes. The third stage of labour is one of the key challenges that a midwife faces when attending a birth. I do not fear the third stage. If that were the case I would not be suitable to continue in the work that I do.
The discussion that I have around third stage with my clients in preparing for birth always includes consideration of our plan for the management (or non-management) of the third stage. The clinical decisions that I will make in the minutes and hours immediately after the birth include my assessment of the need, or not, for drugs at that time.
Midwives around the world work this way. This is alluded to in a statement on physiological management of third stage released by ICM in 2008 and reviewed in 2011.
The midwife's skill and competency resides in protecting the woman and her baby in healthy natural birth (PLAN A), and in recognising situations and conditions that may require medical interventions such as active management of third stage (PLAN B).
At a very practical level, I understand that the physiological separation and expulsion of the placenta without excess bleeding is a process so finely tuned that it can easily be interrupted. Today's birthing community in my world has introduced all sorts of extraneous and potentially disruptive elements - clocks, bright lights, telephones, cameras, text messaging, men, children, other invited onlookers, ...
Women giving birth are not a uniform, pristine group whose bodies all function at optimal levels. Women may have internal uterine abnormalities from fibroids or procedures or terminations of pregnancy. Women may have poor abdominal muscle strength, allowing their wombs to sag excessively, and putting unusual pressure on other supportive structures. Women may be overweight, or poorly nourished. Women may be emotionally drained or have specific painful deep memories that are triggered by labour and birth. ... and so on!
So, you may ask, what's the problem? What causes uterine atony in an otherwise uncomplicated situation? Why does a woman bleed after a normal, unmedicated birth of a healthy baby (or babies)?
I won't attempt to give a text book answer here. I would encourage students who are reading this post to review your text books, while reflecting on your own experience of haemorrhage, and seeking to learn from each situation. You will need to decide, in practice, whether you follow the current recommendation of universal active management, which is not without risk, or if you are able to work competently with a woman who is intentional about natural, unmedicated birth.
I have looked through my birth register. In the past few years several of the women who I have attended have had post partum haemorrhage of in excess of 500 mls. I remember these women, and the setting of birth. I remember the (thankfully rare) instances in which we called the ambulance and transferred to hospital.
The challenge that I return to, having reflected critically on my own practice and my experiences of bleeding after birth, is to continue to practise and learn my role in protecting the natural process.
The real test of primary maternity care is FIRST the safety and wellbeing of the mother, and SECOND the baby (even though the baby's birth usually comes first).
The aweful possibility of sudden dramatic bleeding after the birth, and what that can mean in terms of loss of life, is the spectre that hovers in the mind of many public health decision makers. The burden of such loss, particularly in resource-poor parts of the world, has led to many initiatives that seek to make changes that will protect life and reduce harm. An example is the Joint Statements on Prevention of Postpartum Hemorrhage, released in 2011 by the international peak bodies for midwifery (ICM) and obstetrics (FIGO). The key recommendation, active management of third stage of labour, is explained in the joint statement released in 2003.
Active management of the third stage of labour should be offered to women since it reduces the incidence of post-partum haemorrhage due to uterine atony.Recently released 3 Centres Guidelines, confirm the practice:
Active management of the third stage of labour is recommended practice worldwide, with an anticipated completion period of 30 minutes.
Midwives (and I am one) have learnt, over the past few decades, to value our knowledge of working in harmony with natural physiological processes. The third stage of labour is one of the key challenges that a midwife faces when attending a birth. I do not fear the third stage. If that were the case I would not be suitable to continue in the work that I do.
The discussion that I have around third stage with my clients in preparing for birth always includes consideration of our plan for the management (or non-management) of the third stage. The clinical decisions that I will make in the minutes and hours immediately after the birth include my assessment of the need, or not, for drugs at that time.
Midwives around the world work this way. This is alluded to in a statement on physiological management of third stage released by ICM in 2008 and reviewed in 2011.
The midwife's skill and competency resides in protecting the woman and her baby in healthy natural birth (PLAN A), and in recognising situations and conditions that may require medical interventions such as active management of third stage (PLAN B).
At a very practical level, I understand that the physiological separation and expulsion of the placenta without excess bleeding is a process so finely tuned that it can easily be interrupted. Today's birthing community in my world has introduced all sorts of extraneous and potentially disruptive elements - clocks, bright lights, telephones, cameras, text messaging, men, children, other invited onlookers, ...
Women giving birth are not a uniform, pristine group whose bodies all function at optimal levels. Women may have internal uterine abnormalities from fibroids or procedures or terminations of pregnancy. Women may have poor abdominal muscle strength, allowing their wombs to sag excessively, and putting unusual pressure on other supportive structures. Women may be overweight, or poorly nourished. Women may be emotionally drained or have specific painful deep memories that are triggered by labour and birth. ... and so on!
So, you may ask, what's the problem? What causes uterine atony in an otherwise uncomplicated situation? Why does a woman bleed after a normal, unmedicated birth of a healthy baby (or babies)?
I won't attempt to give a text book answer here. I would encourage students who are reading this post to review your text books, while reflecting on your own experience of haemorrhage, and seeking to learn from each situation. You will need to decide, in practice, whether you follow the current recommendation of universal active management, which is not without risk, or if you are able to work competently with a woman who is intentional about natural, unmedicated birth.
I have looked through my birth register. In the past few years several of the women who I have attended have had post partum haemorrhage of in excess of 500 mls. I remember these women, and the setting of birth. I remember the (thankfully rare) instances in which we called the ambulance and transferred to hospital.
The challenge that I return to, having reflected critically on my own practice and my experiences of bleeding after birth, is to continue to practise and learn my role in protecting the natural process.
"Western practices neither facilitate the production of a mother’s own oxytocin nor direct attention to reducing catecholamine levels in the minutes after birth, both of which can be expected to physiologically improve the new mother’s contractions and therefore reduce her blood loss."
Subscribe to:
Posts (Atom)