topical thursday #2 - postpartum practices (placental procedures)

well since i'm in my postpartum period, seems like a good topic for chldbirth education. one thats often glossed over in live cbe.

i guess there are two componets to the postpartum period: mother care and baby care.

and i guess postpartum actually begins when? after baby is born? before the cord is cut? after? lets just start with the 3rd stage of labor, delivery of the placenta

gloria leamy recently posted an excelent article about the "30 minute third stage" http://www.glorialemay.com/blog/?p=161

heres a different take on third stage mqnagement from the aafp http://www.aafp.org/afp/20060315/1025.html

basically the delivery of the placenta is managed either physiologically or actively. in a physiologic third stage the birth attendant does nothing other than watch for some time. loria suggests 30 minutes. the aafp states that there is a ower incidnce of postpartum hemmorhage in an actively managed third stage though. active management includes "uterotonic medication", early cord clamping and cutting, and controlled cord traction.

this from the article from the aafp:

"A Cochrane systematic review6 identified five randomized controlled
trials (RCTs) comparing active and expectant management that included more than
6,400 women. Compared with expectant management, active management was
associated with: a shorter third stage (mean difference, -9.77 minutes); a
reduced risk of postpartum hemorrhage (number needed to treat [NNT] = 12) and
severe postpartum hemorrhage (NNT = 57); a reduced risk of anemia (NNT = 27); a
decreased need for blood transfusion (NNT = 65); and a decreased need for
additional uterotonic medications (NNT = 7).6 Active management also was
associated with an increased risk of maternal nausea (number needed to harm
[NNH] = 15), vomiting (NNH = 19), and elevated blood pressure (NNH = 99), likely
caused by the use of an intramuscular ergot alkaloid as the uterotonic
medication in four of the five studies in the systematic review. There were no
advantages or disadvantages for the baby with either approach."

BTW: let me explain nnt and nnh. actually heres a wiki on it http://en.wikipedia.org/wiki/Number_needed_to_treat

dr. sara j. buckley weighs in in favor of a physiologic third stage here http://www.birthresourcenetwork.org/the-news/68-leave-well-alone-a-natural-approach-to-the-third-stage-of-labor dr. buckley takes the reduction in blood transfer from the cord to the baby into account in her article.

"While the aim of active management is to reduce the risk of haemorrhage for the
mother, 'its widespread acceptance was not preceded by studies evaluating the
effects of depriving neonates [newborn babies] of a significant volume of
blood.'10
It is estimated that early clamping deprives the baby of 54 to 160
ml of blood,11 which represents up to half of a baby's total blood volume at
birth. "

and here is a very detailed look at the third stage from childbirth connection

http://www.childbirthconnection.org/pdf.asp?PDFDownload=gecpc3ch33

this is actually taken from the book A Guide to Effective Care in Pregnancy and Childbirth (Oxford University Press, 2000)

In all that i just read it seems to boil down to what the mother wants. the risk of post partum hemmorhage is about 4%. some women would want to do everything to eliminate even that risk whereas others would prefer to have that time of undisturbed bonding as a new family.

in my own case i would have strongly prefered a physiologic third stage. but i can see that active management is an evidence based option as well. it does reduce risk....i just don't feel that the risk is high enought to warrant all the fiddling.

of course there is a third option...... http://en.wikipedia.org/wiki/Lotus_birth

BIRTH STORYor why its been a month since i posted

originally posted on facebook
Saturday, August 8, 2009 at 8:14pm

so for the last few weeks of pregnancy my mom called every morning to make sure i was ok. which sounds nice but was actually annoying. she was worried i was going to go into labor and wait too late to call her and end up having the baby in the car.

little did she know.

i was getting impatient and started nipple stimulation tuesday. finally on tuesday night around say 7 i started to have some contractions that felt a little more intese than the braxton hicks i'd been having for months. they settled into a pattern of about 10 minutes apart and continued even evenn after a meal, a shower...soo around 9 or 10 we called mama.oddly enough cvs called right around then also to see how i was doing. i had been just about to call and tell them we were headed out. by the time she got there and we loaded everthing in the car it was around 11 when we headed out to savannah.

kurt had booked us a room at the courtyard at marriot on abercorn. we got their about 1 and had a late supper. krystals. deciided to just go on to bed, contractions petered out so i figured i just as well rest.

woke up early wednesday and had some snack-y things for breakfast. had some contractions. was waiting for them to get to be 5 minutes apart. ended up taking kellen to the pool but didn't stay in long cuz it started to storm. had contractions all day but never got to 5 minutes aoart, 1 minute long. had been continueing to stimulate the nipples and also walked the halls some. but eneded up going to bed again w/ no baby after a very long walk.

woke up thursday with not much to show for my walk except a sore back. was sick of clock watching and contracting timing and nipple stimulating. we decided to stay over even though it didn't seem like a whole lot was happening or at least not very quickly. but priceline wouldn't let us renew the same room a second time so we had to change hotel rooms. moved to the hyatt on river st.was focused on enjoying the extended vacation so we went out and had a nice seafood supper. blackened salmon for me, shrimp for the kids and raw oysters for the hubby. then a fabulous ice cream for desert.had some good contractions during supper but ignored them as much as possible.

later on in the evniong had more good contractions.started timing again around 12:30 am friday morning. definately stronger but not really a consistent pattern...averaged about 5 minutes apart and 1 minute long. took a hot bath to see if they would continue. they did. went back to timimng....was definately having to work with the contractions at this point. kurt was at the restaraunt/pub a couple of doors down so decided to call him because now they were like 2-3 minutes apart and getting more and more intense and averaging about a minute. called him and he was on his way out the door anyway. as soon as he got back we called the midwife. she said come on to the birth center.

i was so escited it was finally time to have this baby! i had honestly been pissed off earlier in the day for what i thought was a wasted trip to savannah. had been dissapointed with waiting and tired of being all keyed up for no reason. it was a big relief for something to finally be happening that was unmistakablely labor.

though i had read about prodromal labor and knew thats what was happening, the intellectual knowledge had not fuly prepared me for he emotional reality. it was so unexpected....even though i know every pregnancy, every labor and every birth is different my 1st 2 were such textbook cases. they were both born a day before their due date. both labors progressed in a typical manner.

of course i was induced with olivia so who knows how that would have gone had her labor and birth been undisturbed?

the kids were asleep and i knew my mama was tired so kurt and i took a taxi to the birth center. we got there right at 2:45 and withing seconds my midwife, jill, was there. she let us in and did an exam and i was 5 centimeters. she also put me on the fetal monitor for a little while, prolly about 20 minutes.

i hate enduring contractions flat on my back on a monitor. well i wasn't flat on my back she adjusted the exam table so i was itting up somewhat but just to be so imobilized was aweful. freedom of movement makes contractions so much easier to bear. but i tried my best to relax and breath through them.

another couple arrrived a little while after we did. which was kind of neat. and also gave us more time undisturbed.once she took me off the monitor (with perfect readings) we went on back to the birthing room. i wanted to get in the tub right away but she wanted me to wait until the nurse got there. she was afraid i would get in the tub and get relaxed and deliver before the nurse got there.

but i squatted and rocked my hips and leaned on various things and dealt just fine.every contraction made me feel like i needed to pee so i spent alot of time sitting on the potty too. it just felt good to squat like that but to still be supported. and kurt was ready to help however i needed him to but i wasn't feeling very verbal so i ended doing for myself somewhat. he was good for support to lean on and all though. and get my water and manage the fan and all the small things.

finally jill said i could get in the shower. it felt so good to blast hot water on my belly and especially my hips. i was feeling lots of pressure in my pelvis. i knew it would soon be time to push.once the nurse, amanda got there and they got the other couple settled in, i asked about getting in the tub and jill said she would have to break my waters to make sure wasn't any mec (meconium....1st baby poo) in the water 1st.

they don't let you do a water birth if there is b/c it can indicate fetal distress and if its aspirated it can cause a nasty infection too so they don't want any delay in case they need to suction or do any other resucitative actions. personally i think with light mec a waterbirth would be fine especially with good readings on the monitor but if they have protocols they have to follow, well thats ok. i would've prefered to have kept the bag intact but that close to delivery (and i knew i was close because i was getting that pusshy feeling with some of the contractions at this point) i was ok with it, especially if i wasn't getting in the tub w/o them doing it.so there was mec in the water. very light lime green mec.

i'm glad i hadn't had my heart set on a water birth. my main dissapointment was just knowing i wouln't have hot water as pain relief.i tried the birth stool for a little while. but ended up on the bed in a hands and knees position. it hurt really bad in my hips. a pain i had been anticipating because it had been such a suprise to me with kellen's birth.

they told me that it would feel better to push...they said to push past the pain. and that was kind of true.i could tell when she made her way into the birth canal. i felt very full down there. and i knew that within a few pushes we'd meet our baby! it didn't take but a few pushes and she was crowning. that was a very intense feeling. more painful than it was with kellen but ok. i had to really summon courage to keep pushing though. its funny how even knowing as much as i do, i still had that fearful feeling. of course there wasn't a whole lot to do but to push her on out.

kurt made me a little mad b/c he took my glasses off so he could wipe my face with a cold wash cloth. but it felt good once he did it and later i forgot they weren't on my face anyway.

jill suggested i stack a bunch of pillows in front of me to lean on. it gave me a more upright position. only a few pushes (and lots of encouragement!!!!) and she was out. that was at 5:01 am.they suctioned her just a bit. mostly snottyness i think not mec. then handed her to me and helped me lay down with her. she latched right on and nursed well.

and then the placental drama started.

i'd originally plannned to wait until the placenta was born to cut the cord but they needed to take some cord blood to see if i need to get rhogam b/c i'm rh negtive. i had it at about 32 weeks so it shouldn't be an issue but just in case we do have another one sometime i want to be sure.so we waited until the cord stopped pulsing and then i cut the cord. kind of neat. the ob cut olivias. kurt cut kellen's and now i've cut one.

w/in just afew minutes jill was ready for the placenta to come out. i really don't know why it was so urgent. especially since i had mentioned reading gloria lemays blog post on the 30 minute thrid stage and jill said she had shared it on her fb page.she kept saying that if it was right there at the cervix there wasn't any reason to wait.

she tugged on the cord very gently and waited a bit. encouraged me to try pushing. gave me some "placenta release tincture", finally ended up injecting some pit into the cord. (mind you i was nursing and they took B'Elanna away for some of this) (baby nursing is supirior to pit imho) she ended up basically going in and removing the placenta manully.

it was all completely unnecessary i think. not evidence based practice at all. i don't know, maybe there was some urgency she didn't fully communicate the reason for? she did say that it almost looked like there was a velatinous (sp?) insertion in the cord...a term i've heard but still don't really know exactly what it means. (i'll look it up and post a link.) anyways its not something i knew to mean urgency in placenta delivery.

i will say the placenta was the funniest looking placenta i've ever seen. she looked at it and had the other midwife double check and seemed like it did come out intact. haven't had any hemmorhage so i guess its ok.what makes me mad is that i had specifically asked about third stage management at a prenatal apt and was told (by the other midwife) that they practiced "watchful waiting"

after we had a chance to nurse a bit jill helped me get a quick shower and to pee.i had already peed in the bed all over the chux pads.at that point i said "i must not have torn much b/c it really didn't hurt to pee" ( you mamas know exactly what i'm talking about)she said she hadn't seen a tear and would look and see. barely a skidmark and it was on my episiotomy scar so if the tissue hadn't already been weakened i prolly wouln't have torn.

we stayed and nepped for a few hours. mama and the kids came around 12:30 and we all left around 2. we went straight to mcdonalds and then hheaded back to dublin. so nice to come straight home.i guess thats it. any questions.... feel free to ask!