Saturday, October 13, 2012

And what is this?.....placenta?!?....

So, as I work at an out of hospital setting, it is logical to assume that I believe in natural, physiologic birth.  I believe strongly, that most of the time, if well supported a woman and her baby will safely navigate the birth process together.  However, sometimes this is not the case.  If you are a reader of this blog, you will have already read some of my stories that discuss less than optimal situations.  Fortunately, by the grace of the divine, my learned skill, years of training, the amazing nurses,  our healthy low risk population and a sprinkling of luck I have not had a "bad outcome".  I also know that, if one works in this realm long enough, it is more and more likely to happen.  My reasons for sharing this story are complex and I have thought long and hard about whether or not to do so.  In the end, I have decided to share it.  Not to tout the "crazy" things that may happen in an out of hospital setting. But to highlight that even in an out of hospital setting, when a trained and skilled provider is present, many unexpected high risk scenarios can be handled safely and well.

 At our center, we do not require that Mama's get any ultrasounds.  We believe that ultrasound is a tool, to be utilized thoughtfully.  I will say that a majority of our clients do get one ultrasound, the traditional 20 week anatomy scan, but it is optional.  If something comes up during the course of a clients care, for example: bleeding, her fundal height measuring too big or too small, we will request that she get an ultrasound.  Other clients may get an early ultrasound to establish a due date if we don't have accurate menstrual or ovulation information.  And if a Mama goes into her 41st week we will use the ultrasound to get an AFI (amniotic fluid index) level. ***I do realize that there is controversy around the use of AFI to assess fetal and placental status, but in our community it is the standard of care so we include it our assessment.*** Recently, I attended a birth that caused me to seriously question my stance on ultrasound...

Sue and her husband are open, intelligent people with a beautiful family.  She is very involved in the local birth community as a doula and educator. They are preparing to welcome a new child to their family.  She has been rumbly for a day or so and we decide to have her come in and check things out.  She arrives with her husband, children and a friend/doula.  She is in labor, but it is still a little early.  My student checks her cervix and finds it to be about 3cm.  We all decide that Sue and her family will go home and return when her labor has picked up.  My student goes home to sleep and I go lay down in our midwife sleep room.  About two hours later my phone rings and it is Sue's husband, I can hear Sue in the background and tell him that they should just head in.

When they arrive, it is clear that Sue is ready to begin pushing.  The family gets settled and I listen to the baby's heartbeat, a strong and steady 140bpm.  Many times when a multiparous woman starts to push, I will not check her cervix, however, this time I felt that I should.  Sue layed down on the bed and I checked her cervix, which was completely dilated and effaced, the baby head was at 0 station.  However, there was also something else presenting, a soft, spongy, "tissuey" something from about 12 o'clock to 3 o'clock.  It takes me a moment to realize what this is that I am feeling.....placenta!!!!  Everything that happened next seemed to take forever, but in reality happened extremely quickly.  I looked at Sue and calmly (hopefully) told her the situation and that she would need to pull out her inner Mama Bear and birth her babe quickly.  I called for help and then set up one of our birth stools.  I had calculated in my head the time it would take to get Sue to the hospital v. how long it would take her as a multip to just push out her babe and decided it would be quicker to just do it. (Had she been a primip I never would have attempted this!)

Sue got on the birth stool with her husband behind her, I will never forget the look on her face.  She was preparing to fight for her baby and would not accept anything other than winning.  It was powerful and exactly what we needed.  With the next contraction, she pushed the babe to +2, the waters broke and the baby had a low heart rate.  We all breathed, gathered our focus and prepared for the next contraction.  Thankfully, it came quickly and with one more mighty push the babe was born!  She was beautiful and still, had a good heart rate but needed some resuscitation.  I worked on her, Mama and Daddy talked to her and she came around to join us in the world.  The placenta was birthed very soon after that, with a chunk sheared off but still attached to the membranes, and otherwise normal.  I helped Sue, her husband and the new babe get into bed and settled.  Then my help arrived! Basically, as soon as I saw my nurses I left the room and collapsed in the hallway, my legs just buckled out under me and I started to cry.  I remember repeating over and over again that they were both well and thanking the creator.

During the course of her prenatal care, Sue had declined any ultrasounds.  Her pregnancy had progressed normally and was a healthy one.  She never had any signs, like vaginal bleeding, that would suggest she had a partial placental previa.  In the initial days after this birth, I felt strongly that as a center, we needed to change our policy on ultrasound and begin requiring them.  Then, through talking with other midwives, processing the birth and visiting with Sue and her family, I began to slowly shift back to my original thinking.  Birth work will continually keep you on your toes, will cause you to question your beliefs and require that you are always learning and adapting.  Each birth will give you new insights into the process...information to gain and information to discard.


  1. I understand how in the moment a situation like this would make any midwife question her stance on ultrasound. Not having encountered this in my midwifery journey yet, I can't really say how it would affect my thinking. As of now, I still think that since the long term effects of ultrasound on a developing baby are unstudied, it's better to use them as little as possible.

  2. If you're going to require any interventions--even ultrasound, which long-term effects are still unknown--you're depriving women of choice. It's also illegal to force anyone to have a procedure they don't want.

    Also, if that's your mentality, why are you working in a birth center with other midwives? Why don't you work with OB/GYNs and deliver in hospitals, where women are expected to have their choices discarded?

  3. Anonymous,
    Wow, it may be that I am tired from being up all night with a Mama, but your tone seems a little rude. If you read the post carefully, you will note that our center did not, and conintues to not require ultrasounds. I was simply walking through my thoughts and feelings after this particular birth. If difficult situations and outcomes are not cause for some thought and introspection, then there should be concern. As midwives, we need to be continually examining, reflecting and adapting to new informaion and experience. We need to be very mindful of not becoming "set in our ways". Ultrasound is a tool, one that must be used judiciously and with care, but a tool none the less.
    To answer your last questions. I am, first and foremost a midwife. My mentality is one of being with woman, to support and empower women on this journey. But also to monitor the health and safety of women and their babies. I work in a birth center because I am passionate about out of hospital birth. I believe that my words throughout this entire blog clearly convey my convictions and mentality. Please read further before you jump to judge me. Additionally, I am blessed to work in a community where we have two excellent hospitals with caring, compassionate care providers from CNM's to perinatologists who respect a woman and her right to accept or decline interventions. Perhaps, you are in a community where you do not have this type of consulting care available, and so have had bitter experiences. I too, have had tough interaction with hospital staff, in our community we also have some hospitals that are not as open to collaboration. Which is why we need to work to build relationships based on mutual respect and trust, not negativity.

  4. As a mother and a birth professional, my view on ultrasound has evolved over the years, but like Aubre, I see it as a tool to be used judiciously, as with so many other tools we have available to us during pregnancy, birth, and postpartum. After this birth, I will never again have another baby without a quick mid-pregnancy scan. It would take a (standard obstetric) scan longer than two hours to equal the amount of ultrasound exposure received from a ten-second heart tone check with a doppler, and for me, I now feel that the benefits outweigh the risks. Other women may feel differently, and I respect their informed decisions.

    Thank you, Aubre, for your clear thinking in the moment, your skill, and your compassion. You are amazing, and I'm so grateful that you were with me when I needed you.

  5. Sue, your words truly warm my heart and hold deep meaning for me. Thank You!