What are the signs of placental seperation?

1. Uterine contraction.
2. The fundus of the uterus rises in the abdomen, when the placenta moves from the upper segment of the uterus to the lower segment and vagina.
3. Lengthening of the umbilical cord. This sign is most easily seen if the cord is clamped with forceps at the vulva. Any lengthening of the umbilical cord above the forceps is then easily noticed.
4. An amount of blood suddenly escapes from the vagina.

Separation of the placenta can now be confirmed by applying suprapubic pressure. The placenta has definitely separated if the umbilical cord does not shorten when the uterus is pushed up (no cord retraction).

Information from this website: Ebwhealthcare.com

Cord Presentation and Cord Prolapse

What is the difference ?

1. With a cord presentation, the umbilical cord lies in front of the presenting part with the membranes still intact.
2. With a cord prolapse, the cord lies in front of the presenting part and the membranes have ruptured. The loose cord may lie between the presenting part of the fetus and the cervix, in the vagina or outside the vagina.

Why is prolapse of the umbilical cord a serious complication ? 

Because the flow of blood between the fetus and placenta is severely reduced and may stop completely, causing fetal distress and possibly fetal death.

Information found on this website:
Ebwhealthcare.com

When Should You hurry and cut the cord ?

In the delivery of multiple births.

I found this information from this website very helpful. Ebwhealthcare.com

It also states that You Should Not hurry to cut the cord if the mother is Rh Neg. I Am Rh Negative so this was helpful to know.  Here is what the link says.

1. "The umbilical cord must not be allowed to bleed after the delivery of the first infant in a multiple pregnancy. In identical twins with a single placenta (monochorionic placenta), the undelivered second twin may bleed to death if the umbilical cord of the firstborn infant is allowed to bleed.
2. The umbilical cord should be allowed to bleed if the patient’s blood group is Rhesus negative (Rh negative) with a single fetus. This will reduce the risk of fetal blood crossing the placenta to the mother’s circulation and, thereby, sensitising the patient. Nevertheless, anti-D immunoglobulin must always be given to these patients.
3. Allowing the umbilical cord to bleed during the third stage of labour reduces the placental volume and, thereby, speeds up the separation of the placenta. As a general rule, the umbilical cord should be allowed to bleed once a multiple pregnancy has been excluded."

How to cut the umbilical cord ?

Cutting The Cord Video

In this video, it appears it is cut after the cord has stopped pulsing but before the delivery of the placenta. 


Information from this website: About.com

Here's How:

1. Be sure the cord has stopped pulsing for most births.
2. Ensure that there are two clamps on the cord.
3. Hold the section of cord to be cut with a piece of gauze under it.
4. Using sterile scissors cut between the two clamps.
5. Dab excess blood.
6. Place scissors away.

Tips:

1. The gauze keeps excess blood from splattering.
2. Remind everyone that mom and baby can't feel the cord being cut.
3. The cord is thicker and harder to cut, more like meat gristle. Don't be surprised.

How to examine the placenta after birth ?

Below information found at this website: Ebwhealthcare.com


Every placenta must be examined for:

1. Completeness.
   Make sure that both the placenta and the membranes are complete after the delivery of the placenta:
   
   • The membranes are examined for completeness by holding the placenta up by the umbilical cord so that the membranes hang down. You will see the round hole through which the infant was delivered. Examine the membranes carefully to determine whether they are complete.
   • The placenta is now held in both hands and the maternal surface is inspected after the membranes are folded away. A missing part of the placenta, or cotyledon, is thus easily noticed.
2. Abnormalities.
   • Cloudy membranes, or a placenta that smells offensive, suggests the presence of chorioamnionitis.
   • Clots of blood which adhere to the maternal surface suggest that abruptio placentae has occurred.
3. Size.
   The weight of the placenta increases with gestational age and is usually 1/6 the weight of the infant, i.e. 450–650 g at term.
   If the placenta is abnormally large, the following possibilities must be considered:
   
   • A heavy, oedematous placenta is suggestive of congenital syphilis.
   • A heavy, pale placenta is suggestive of Rhesus haemolytic disease.
   • A placenta which is heavier than would be expected for the weight of the infant, but with a normal appearance, is suggestive of maternal diabetes.
   • A placenta which is lighter than would be expected for the weight of the infant, is suggestive of fetal intra-uterine growth restriction (IUGR).
4. Umbilical cord.
   Two arteries and a vein should be seen on the cut end of the umbilical cord. If only one umbilical artery is present, the infant must be carefully examined for other congenital abnormalities.
   

Infarcts can be recognized as firm, pale areas on the maternal surface of the placenta. Calcification on the maternal surface is normal.

All placentas must be carefully examined for completeness and abnormalities after delivery.

More Links

Placenta Pics 

Placental Exam

Gross Examination 

You Are So Fat !

Let me tell ya these are the words that every pregnant woman wants t hear. :-) Ha ! When I was pregnant with my 3rd here in Tanzania this is what I was told. Believe it or not, in Tanzania this is a compliment. Being on the bigger side of the weight scale is a good thing. I guess it means that you have enough money to eat well enough to gain weight. Also it is custom for women to ask for cooking oil as a present after they have the baby. They want to eat lots of fried foods to Keep their "baby weight." They want to stay "fat." Even though many pregnant women are proud of their extra pounds they cover themselves up with cloth wraps. They don't try to "show off" their weight gain. I know in America it is even hard to find a maternity shirt that isn't very low cut, because most pregnant women want to show off their extra weight gain in their chest. For the most part, especially compared to America, their dress is very modest.

The Case Against Newborn Suctioning

In research of when and how to suction, I came across this document. It basically states that newborns do not need to be suctioned and states why.

Here is the link

The Case Against Newborn Suctioning

Resuscitation - Newborn Life Support

I found this Awesome information in regards to the resuscitation of a newborn and newborn life support. The thought of having to do this to my own baby completely freaks me out, but knowing the information helps me feel more confident. I have done CPR on adults in the hospital before but to a newborn it is much different. It made me fell a little more comfortable when it was stating that most babies at term will not need this. It also reassured me by basically saying that in most cases a few puffs of air to open the lungs is all that you need.

Here is the link.
(I had to save it to Google Docs, so that I could post it, since it is in Pdf. format)

Resuscitation, Newborn Life Support Document

Suction

I keep reading articles that state that suctioning at birth is unnecessary. When my first was born the nurses quickly cut the cord, and swept her away for deep suctioning. I thought something might be wrong but they said that it was their normal hospital policy. 

She had a severe reflux problem for the first year of life and I later want to study if it had somethign to do with them suctioning like that after birth. It seems more and more babies that I know are having the reflux problem and I have to wonder if they were deep suctioned after birth.

If having your baby in the hospital you may consider thinking about this.


I will have a bulb syringe and a DeLee Mucus trap for deeper suction if necessary. I was told by a midwife that you only use the Mucus trap if there is meconium present And the baby is having trouble breathing.

Oxygen Levels Slowly Rise After Birth

I had recently read another blog post stating that some babies slowly transition to breath, (within a few minutes) and that a mother, or health care professional, should not panic, cut the cord and wisk the baby off for suction and oxygen. I remember with my first, they quickly cut the cord, and did the hospital policly of deep suction, with a tube down her nose.

I just read this article about a babies oxygen level. I don't understand all of it completely but from what I do understand is that a babies oxygen level slowly rises within the first 15 min. of birth. And to me again, another reason to wait to cut the umbilical cord. Here is the full article. Oxygen Level After Birth

Resuscitation and Premature Cord Cutting

Here was a great blog entry that I found on a midwifes website. She reinforces the need to delay cord clamping and gives some helpful suggestions as what to do if the baby first has trouble breathing.

One good thing that I learned is that some babies make a slower transition to breath. She states,
"Their colour change may be the only obvious indication that they are making the transition. The cord pulses at the same rate as the baby’s heart, so feeling (or watching) it will reassure you that all is well."

I think I am going to be more prone to freaking out, so this was helpful for me to read.

If there is a problem she suggest milking the cord firmly toward the baby... to initiate breathing. I definitely would not have thought to do that on my own.

Her other suggestions include :

Suggestions

• Try and ensure that the baby does not arrive compromised by minimising unnecessary interventions.
• Do not clamp or cut the cord.
• Give the baby time to transition – if the cord is pulsing the placenta is providing oxygen… relax and reassure the mother if she needs reassurance.
• Do not clamp or cut the cord.
• If the baby requires assistance, start small – gentle stimulation, talking, blowing in his face (all can be done by a parent).
• Do not clamp or cut the cord.
• Milk the cord firmly towards the baby. This shunt of blood into baby is often enough to initiate breathing.
• Do not clamp or cut the cord.
• If further measures are needed, take the resuscitation equipment to the baby and resuscitate him in his mother’s arms.
• Did I mention – Do not clamp or cut the cord.

Note: Routine suctioning of the baby is totally unnecessary, invasive and could potentially create problems by stimulating a vagal response (a drop in the heart rate). "

The Website: Midwife Thinking Blog

Tips On Breathing During Labor

Another topic of my research is the best breathing techniques of labor. I have no idea why I didn't pay more attention to this with my other births. Here is a good link that gives some suggestions like...

1. With each contraction start with a slow cleansing breath
2. Begin slow breathing when contractions are intense enough that you can no longer walk or talk through them without pausing. Use slow breathing for as long as you find it helps you. Switch to another pattern if you become tense and can no longer relax during contractions.
3. Focus your attention
4. Slowly inhale through your nose and exhale through your mouth, allowing all the air to flow out with a sigh. Pause until the air seems to “want” to come in again.
5. With each exhale, focus on relaxing a different part of your body

During the Active Phase of Labor

The website give a suggestion on light accelerated breathing. I tried it and felt like I was hyperventilating. It gives another option which is the  “pant-pant-blow” or “hee-hee-who” breathing. It says that this type of breathing combines light shallow breathing with a periodic longer or more pronounced exhalation. I think that I like this better.

Breathing Patterns for Second Stage of Labor - The Pushing, it suggest...


1) Take an organizing breath—a big sigh as soon as the contraction begins. Release all tension (go limp all over—head to toe) as you breathe out.
2) Focus on the baby moving down and out, or on another positive image.
3) Breathe slowly, letting the contraction guide you in accelerating or lightening your breathing as necessary for comfort. When you cannot resist the urge to push (when it “demands” that you join in), take a big breath, tuck chin to chest, curl your body and lean forward. Then bear down, while holding your breath or slowly releasing air by grunting, moaning or other verbalizing. Most important of all, relax the pelvic floor. Help the baby come down by releasing any tension in the perineum.
4) After 5-6 seconds, release your breath and breathe in and out. When the urge to push takes over join in by bearing down. How hard you push is dictated by your sensation. You will continue in this way until the contraction subsides. The urge to push comes and goes in waves during the contraction. Use these breaks to breathe deeply providing oxygen to your blood & sufficient oxygen for the baby.
5) When the contraction ends, relax your body and take one or two calming breaths.

Here is the website: American Pregnancy Association

I will have to research more on the breathing during the pushing stage.

Danger of Oxygen During Labor ?

I am wanting to set up my bedroom like a hospital room, with all the necessary supplies. I am planning on going next week to the local hospital to find out where I can get an oxygen tank and oxygen. Even if I were to get an oxygen tank shipped from America to Tanzania, I might not be able to have a way to get it filled. Researching oxygen got me wondering when/if I should use it and are there any dangers/risk from over using it. From what I have seen is that if there is an obvious change in the babies heart rate, then you should give the mom some oxygen, and get her changing positions. But in America the practice of giving oxygen, just in case, is becoming more and more common. Some say that oxygen is just air and that it causes no danger, so why not? I am doing more research on this but this is one article stating their trial results on this topic. It states,

"The effect of maternal oxygen administration during the second stage of labor on umbilical cord blood gas values: a randomized controlled prospective trial

Article Abstract:

Administering oxygen for longer than 10 minutes during pushing appears to have an adverse effect on the fetus. Eighty-six women in normal labor with a healthy, term fetus were randomly assigned to receive oxygen via mask during the pushing phase of labor. A blood sample was taken from the umbilical vein after birth and analyzed. As the length of oxygen therapy increased beyond 10 minutes, the pH of the baby's blood declined. Low pH is a symptom of decreased oxygen, although no baby experienced fetal distress. Results may not be applicable to different situations, as, for example, when the baby already lacks oxygen. Several studies have shown that although oxygen is often administered liberally in labor to the mother to improve fetal oxygenation, its use can have this adverse effect. Laboratory studies have shown that umbilical and placental blood vessels constrict in the presence of abnormally high amounts of oxygen, which may be the cause of this phenomenon."

Read more: http://www.faqs.org/abstracts/Health/The-effect-of-maternal-oxygen-administration-during-the-second-stage-of-labor-on-umbilical-cord-bloo.html#ixzz1JfcGDBeg

Intermittent Fetal Monitoring or Continous Fetal Monitoring ?

I had never previously considered whether to have the "baby monitor" on all the time or just have it checked every now and then. I guess I figured the more monitoring the baby gets the better. With my previous births, in the hospital, this is just how it was. I was discouraged to take the monitor off, even though there was no complications. I do regret this decision now, looking back. Here is why.

*The continuous monitor limited my mobility.
* Limited mobility causes more pain during labor.
* Decreased mobility decreases circulation which decreases oxygen to the baby.  The decreased oxygen changes the heart rate of the baby, and the monitor detects the problem.

(It is ironic how the continuous monitor is the initial problem, and ends up detecting what problem it causes.)

Now I do have to say that if you have an epidural then I can understand being on a monitor because of all the risk and complications that an epidural can cause... your mobility Is going to definitely be limited, and you are adding More Risk to you and your baby and need to be monitored more closely.

* Another reason why I regret having previously been on a continuous monitor... (Not sure why) but I hated calling the nurse over and over to come "hook me back up."
I now see that if I was up and moving more then my labor would have gone a lot faster (with my first and third birth). My second was so fast, but I think it was because I was walking and sitting up until we got to the hospital and he was born.

Still more reasons...

* The doctors and nurses focus more on the monitor than the patient.
( I was a witness to this when I was in nursing school and did my labor and delivery rotation. )

Something new that I have learned...

According to new research (many websites are now saying)

Continuous monitoring Increases your chance of having and unnecessary C-Section. What ? Really ?
 

I was reading this one website that just casually mentions this in their article. It states.
(EFM stands for Electronic fetal monitoring)

"Besides the risk of an unnecessary cesarean section , other risks posed to the mother by EFM include her immobilization in bed. Immobilization simultaneously limits changing positions for comfort and causes changes in blood circulation, which decreases the oxygen supply to the fetus and can lead to abnormal changes in the FHR on the EFM that was applied to detect these changes. Another problem with the use of the EFM is that practitioners have a tendency to focus on it instead of the laboring woman. For these and other reasons, the United States Preventive Services Task Force states that there is some evidence that using EFM on low-risk women in labor might not be indicated. EFM, however, has become an accepted standard of care in many settings in the United States for management of labor. Interestingly, there has not been a reported reduction in perinatal morbidity in the United States with the use of EFM. There is a benefit to using EFM in women with complicated labors, such as those induced or augmented with oxytocin, prolonged labors, vaginal birth after having a cesarean section, abnormal presentation, and twin pregnancy. Link to website


I noticed that it basically said that even though the EFM seems to doing more harm than good, the practice in the U.S. is to still use it. ("has become accepted standard of care") 


So again I am just sharing this journey of research with you, as I learn what is best for me and my baby during pregnancy, labor, and delivery.  

How To Monitor FHR During Labor

A midwife recommended this website to me and his has been helpful in knowing how to monitor the FHR- fetal heart rate, during labor. I have a medical grade fetal Doppler that I use now to listen to the baby, but I was unsure when exactly that you use it with labor or birth. I wondered if you were to use it during a contraction or after a contraction. I knew that the babies heart rate was suppose to change with contractions but I didn't know the heart rate ranges. This website gives an in depth explanation, it gets sort of complicated, but if full of great information.


Intermittent Auscultation CCC

When and how to use oxygen during labor.

This is a question that I was asking myself. Basically I came to the conclusion that if there seems to be fetal distress, as detected by fetal heart rate monitoring, then the mother can receive oxygen along with interventions, such as changing positions. 

"Intra-uterine resuscitation is designed to immediately reduce the stress on the unborn baby by instructing the mother NOT to push, use of anti-gravity positions, lying left side, bolus of IV fluids, etc. 

Administration of maternal 02 due to fetal bradycardia should also be noted on the FHT graph. 

Maternal O2 at 8 liter via tight fitting mask is recommended for evidence of fetal hypoxia. 

Midwives need to anticipate that intrauterine resuscitation will be followed by the need to perform neonatal resuscitation. Oxygen supplies should be adequate to meet the needs of both procedures. In that regard, it is useful for the second call midwife to also make available her own cylinder of oxygen as a backup. "

College of Midwives Website 

IV Fluids - Why use IV fluids duing labor, and which ones do you use?

This was a question that I googled. This book seemed helpful. Basically I understood that you might use IVF during labor if there seems to be fetal distress or a significant change in the FHR. The book states that and IV bolus given to the laboring mother, can help expand blood volume and get more oxygen to the baby. It recommended 500-1000ml RL over 20 minutes. States 1,000 ml was better. It also cautioned Not to give glucose, like D5 or D5RL as this can cause more harm than good.

Here is the link where you can read some of the book Perinatal Nursing Book Preview

Waiting to Cut the Umbilical Cord

One thing that I had never considered before was waiting to cut the umbilical cord after birth. I have done a little research and it seems that it is a great benefit to the baby, for many reasons. If you wait until the cord stops pulsing before you cut it then more nutrients and oxygen gets delivered to the baby, along with other benefits. If waiting a short time to cut the cord is a benefit to your newborn, then I have to ask, Why Wouldn't You Wait?

Here are some links that give more information on the subject.
You can also just Google the topic to see for yourself.

Television News - Msnbc.com

In the Newspapers - The Telegraph

Science Daily

Thinking Outside of the Box

The older I get (even through I am just 30) the more I see how people just think "inside the box," especially when it comes to birth and babies. I see how the pressures of society really mold your thinking. If you don't do certain things then you are frowned upon. Weather it is your kids having to be in the best school, or you haveing to give birth in a hospital, etc. Whatever is the "norm" at that time. When we go back an visit America I watch commercials and see how they really use their selling techniques. They play on moms and give the sense that if you don't use certain products that you are exposing your family to danger. For ex. If you don't use certain cleaning products then everyone is going to get sick, because germs are Everywhere, oh no! Ex. Lysol spray. I guess my point is that I see where people should really stop and actually think for themselves. Ask yourself, why am I doing this and is it Really the best thing to do. People should truly study things for yourself. This can go along with religion, but since this blog is about birth and babies, I will stick to that. Now with the Lysol spray, okay why sure not, go ahead and kill some germs, but what about immunizations, birth in a hospital, which labor positions are really the best... And Why ! So why am I rambling about thinking outside the box ? I guess I am just frustrated because I was trained as a registered nurse and have given birth to 3 children in the hospital... and I am just now learning about birthing and the way your body really works. For ex. Sitting up/walking to progress labor !Birthing classes teach you the these things, but when you get to the hospital it is all thrown out the window. It is... lay down, strap in, hook up, and wait for the epidural. Completely against everything natural. Now when I think of "going natural" I think of a person that is all organic, hippy type.. no offense to anyone. But really I the more I study for myself, and learn from experience, the more I see a benefit in natural birthing techniques. I will try to post my previous birth stories with you in another post. In short, the first with an epidural, the second- very fast barely made it to the hospital. The third, Demeral/Phenergan a few hours before birth. The first time I even questioned an epidural was when I was working in the hospital, taking care of a postpartum mom. Long story short... she had a reaction to the epidural, she quit breathing, emergency c-section, and a previously healthy baby was not expected to live... because of the epidural. This fourth little one will be born here in Tanzania, and unless there is a severe emergency, will completely natural. Sooo keep coming back to read more post on how things turn out.

Bonnie in TZ

A Place For My Thoughts

I have started this blog today to give myself a place for my thoughts about giving birth here in Tanzania, Africa. I have three healthy children, Aubrie - age 5, Ayden - age 4, and Ryan - age 2. I am only 12 weeks away from my due date with baby number four. Yea four sounds like a lot to me also. :-) I have another blog about our life here in Tanzania, but I wanted to start a new one that family doesn't really know about. I want to be able to write and post freely about the realities here in Tanzania without them freaking out more than they already are. Sorry mom. I do hope to have some followers, so please subscribe and follow me along on the journey. I like talking about Tanzania, and life here, so if you are interested, Join me on this journey, and I will do my best to keep you as informed and updated as possible.


Bonnie in TZ