MWs... how long do you wait for placenta?

[sunnymw]

How long are you comfortable waiting for the placenta to come out, and when do you start worrying?

Why? What research or experience is behind you?

If the placenta is not out in X amount of time, what do you do to help it along? What do you ask the mother to do?



Answers would be very helpful as I just interviewed a MW and her answer on this was the ONLY one that didn't "feel" right.

Thank you SO much.

[momileigh]

Where I work the mw's flip if it takes longer than 20 minutes so I'd love to hear what others have to say.

[Carolinamidwife]

Well, I guess it depends on what is going on. I'm assuming you mean a placenta that is staying put but without any bleeding?

[sunnymw]

Right, just regular old "Hey, where is it?" placenta... no hemhorrage or anything.

[MsBlack]

The longest I ever waited was 5hrs--and only because fundus was firm and low, no bleeding, mom fine. We transported at that point--and OB was able to remove it by doing rougher fundal massage than I was willing to (and he followed up w/IM pit)

Usually, I see placentas within 15-60 min. Not common, but not real rare for it to be a bit longer. Have seen it take as long as 2hrs, fairly rarely. I don't worry if mom is doing well...tho after 60 min, I'm not exactly comfy either. Still, if mom's ok, then I'm ok with waiting longer.

Haven't seen any issues with this at all.

[Carolinamidwife]

Hmmm.... I'm a chicken so I think the longest I would be comfortable with is about 2 or 3 hours. I mean, if it ain't coming it ain't coming and waiting around isn't going to make it.

Most I have seen come in about 20 minutes, including my own. Some mw's I know get nervous after 30 minutes and might at that point want to give a tincture or have the mom try to urinate. As long as there is no bleeding and the fundus is low and firm there is no reason to panic but if it's been a few hours most likely it's adhering.

[sunnymw]

Okay, thanks. I guess I'm a little more comfortable, knowing that it doesn't take very long... my MW says she's changed her stance on it over the years and has waited less and less... she says she waits 30 minutes, but starts getting a little concerned about it starting at 15 minutes.

[transformed]

sorry to hikack but whats the "panic" part? "if" the placenta doesnt come? You go to the hospital for some kind of medical intervention?

[momileigh]

If the placenta doesn't come and you do go to the hospital, WHO KNOWS what you might be put through or how you may be treated for giving birth outside of a hospital with a midwife?

Theoretically speaking, that could be a reason to do a manual removal after 30 minutes. To avoid dealing w/ the hospital people.

Also, I know some midwives are just positive that the cervix is going to close down completely and not allow the placenta to be delivered if you wait too long.

[transformed]

Originally Posted by momileigh

Also, I know some midwives are just positive that the cervix is going to close down completely and not allow the placenta to be delivered if you wait too long.

Seems like the body would have some kind of defense against that.

:

It's pretty amazing what the human body can do-all by itself.

[momileigh]

Hey, I'm with you on that, transformed...

Part of the reason I'm so excited to graduate!

[wumanh]

I am ok waiting as long as mom is fine. The longest I waited was 4 hours. The mom was just not ready to deal with it. After she got it out she bled about 1 tablespoon, I swear. We were amazed.
Usually the moms are involved with their babies for at least 15-20 min. Then they start getting crampy or uncomfortable. Then it's time to deal with the placenta- that's why it is After birth.
I wait for the mom's cues that something is happening and keep an eye on bleeding and how she is doing. Alert, attending to the baby, good color?

[bionicsquirrel]

Can I jumpstart this thread again?

This is a big one for me in my apprenticeship. I definitely a up against a midwife who "panics" when the placenta is not out. She is often talking about the cervix closing down and/or the bleeding pooling up behind the placenta so you don't know if mom is hemorraging or not until the placenta is out.
I am of the thought that you wait until and it will come in good time, but I haven't seen enough births of both ways to know what is best yet.
Is there research behind the theory that the cervix will close up?

I know that the body works amazingly and I trust that, but aside from the trust thing, you know? What am I up against if choosing to wait on the placenta instead of more actively managing it like my preceptor does?

[Carolinamidwife]

I don't think you're up against anything, KWIM? Having a more relaxed attitude is a good thing as long as you're alert, which I'm sure you will be. You'll know in advance the risks associated with uterine atony and you'll be at the ready just in case.

The cervix can close up before the placenta delivers but it's not likely, it's pretty floppy for a while. Bleeding from a partially detached placenta is more likely but even it only occurs in roughly 4% of births and is more likely after surgical birth.

Has your preceptor had a bad outcome due to placental issues?

[transformed]

OMG, I was just talking to my mom about this-in case we have to do the birth alone, and she totally asked me "What do you do if the afterbirth doesnt come out?" Afterbirth is the yuckiest word I have ever heard.

[bionicsquirrel]

Originally Posted by Levatrice

Has your preceptor had a bad outcome due to placental issues?

I think my preceptor has seen a lot, partly because she assisted other midwives who are much more aggressive than she is, so things happened that would't normally have.
I think this is more a case of her learning that way, so that is how she does it.

[pamamidwife]

I feel ok waiting as long as there is no excessive blood loss. I have found that nearly all the time with a slow placenta, the placenta has detached but it's sitting right inside the "inner corner" of the uterus (on one side of the cervix). Due to position of the mother, or musculature of the lower segment, it may stay there for awhile.

The longest I've waited was 3 hours, but I did do unassisted birth support via phone for a woman who waited on her placenta for 24+ hours. No blood loss, some cramping but not alot, etc. It was her decision to wait (of course) and it went well.

I am still working on reframing some third stage issues. I'm excited about hearing Sarah Buckley speak on this topic at the Trust Birth conference in March.

[Carolinamidwife]

Originally Posted by bionicsquirrel

I think my preceptor has seen a lot, partly because she assisted other midwives who are much more aggressive than she is, so things happened that would't normally have.
I think this is more a case of her learning that way, so that is how she does it.

I can totally understand that. I went to several births with an aggressive manager and she wouldn't even wait 20 minutes, she got active right away, catheter, even going in and scooping it out. Yeowch.

[bionicsquirrel]

Originally Posted by pamamidwife

The longest I've waited was 3 hours, but I did do unassisted birth support via phone for a woman who waited on her placenta for 24+ hours. No blood loss, some cramping but not alot, etc. It was her decision to wait (of course) and it went well.

I am still working on reframing some third stage issues. I'm excited about hearing Sarah Buckley speak on this topic at the Trust Birth conference in March.

Pamela, you helped my good friend and doula back-up here is Wichita once. We talk a lot about her birth and postpartum because she typically goes at least an hour before the placenta comes and could not find a provider who would be okay with this fact...she ended up having a UC for many reasons, but this was one of them.

[scifimom]

I did a manual removal at 5.5 hours once and had another come out on it's own at 4 hours. i don't really have a policy if theres no bleeding and the fundus is hard and mom looks and feels ok.