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Wednesday, October 19, 2011

third stage

i managed the third stage at the birth i was at the other night. in other words, i helped to deliver the placenta.

i love the this part. i'm still trying to figure it out mind you.

the whole communicating with people thing.

it's not as easy as you may think.

i need to work on articulating what i want, what i need a mother to do, in a kind loving supportive and informative way.

of course after looking at the photo in william's obstetrics a few days ago, i have trepidation about cord traction and prolapsed uterus. maternal demise. sorry. not on my watch. and definitely not because i pulled it out of her.

i knew the placenta had separated. i knew it was hanging out in her introitus. but she was in that bath tub. awkward space. baby was still attached. she was in a semi-reclining position and i didn't have the gusto to really pull that placenta down and out through the curve of carus (the curve created by the sacrum).

my midwife i think was getting impatient with my efforts. she came back right when i was going to get the woman into a squat. we freed the baby and got the mother squatting. the placenta immediately came out.

golden right.

no. not really. ideally you want to twist the placenta once released if there are trailing membranes.

well like the baby, the placenta pretty much was ejected as soon as she got into an upright position in the bath tub.

in retrospect i should have gotten her out of the tub, onto a chux. yes much more convenient for me. better access, better to estimate blood loss. no funkatated posititioning....but NO! i didn't want to interrupt the third stage. i didn't want to make her to move so much.. i doubt she would have cared. and really i should have just gotten her out of the tub in the first place. she wasn't attached to keeping the baby attached to the placenta before it was delivered...that was something we placed on her in the moment.

so placenta delivers and there are trailing membranes. really. trailing membranes. like the whole amniotic sac was still in there. it was a shultz delivery.. i.e. fetal side first.

but because of positioning when i twisted the placenta it pretty much just tore away from the membranes leaving them inside her introitus/birth canal/uterus....who knows really how far up they went.

she wasn't hemorrhaging. she lost a less than average amount. so no one was immediately concerned.

i told my midwife that there were trailing membranes, but it wasn't until i inspected the placenta and there were really no membranes left that i realized how much were still inside. to be honest. i don't think it did occur to me how much were still inside and the implications. it should have occurred to me.  it wasn't until the exam of her bottom and when my midwife began to remove the trailing membranes, that after a bit of a rub of her fundus and a handful of membranes were released that i knew really how much was still in there.

my midwife asked if i had thought it was that much...i said not until i examined the placenta...but really i don't think i understood.

she said this is information she would have liked to know. i did tell her there were trailing membranes immediately, but like i said there was no immediate concern. i wasn't comfortable leaving it that long. but i'm just learning. i should have maybe expressed my concern more, but it's hard to do that in front of a family. i don't want to put my inexperienced concerns on a new family, when it may be nothing. was there really that much still remaining?

again i need to learn to communicate.

this profession.. it's going to drag it out of me some how.

i am such a recluse and introvert. i find it so hard to verbally communicate and interact with people. funny that i chose to be a midwife.. ha. not really funny like that. ironic.

i'll learn. i'll be challenged. i'll grow. i'll become more experienced, knowledgeable, confident.

this will happen. at least i'm confident in that.


Saturday, October 15, 2011

complications of labour and birth

study study study


amniotic fluid embolism

following references into old obstetric textbooks with pictures of prolapsed uterus with placentas still attached.

knowledge is power.

i've heard that this class is what makes many student midwives terrified at everything that can go wrong. it may have even broke a few faint of heart.

i think that this is having a different effect for me.

i'm fascinated by it all. most of this we will never see. maybe if i were to travel overseas.

i'm grateful that we have access to advanced medical services in north america and that there are doctors trained in these obstetric emergencies.


i also feel that i may be conservative in my practice - specifically in this moment - retained placenta.

is it prudent to internally explore a uterus to identify if it has accreted when it hasn't detached?

should i attempt a manual removal?
risk haemorrhage? infection?

it's all so interesting.

knowledge truly is power.

i love it.