MWs... how long do you wait for placenta? - Page 2

[MidwifeErika]

I think that some midwives base this decision on the laws in the area. Here in WI if the placenta isn't out in an hour, the midwife has to call a doctor or CNM to consult on it. So, if I was to the point of being primary, I would feel totally comfortable waiting an hour (without bleeding), but after that hour I would need to consult with someone else and they may or may not be comfortable with a woman waiting for longer than that at home.

[pamamidwife]

Originally Posted by bionicsquirrel

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.

I'm so surprised that there wasn't one midwife that would be ok just observing for excessive blood loss, etc., in lieu of directly managing third stage. I'm glad she had a peaceful birth without rigid rules - especially when she has a history of longer third stage.

Even if the placenta is truly retained - and by that I mean placenta accreta - there is no blood loss. And, of course, we're likely to see a higher incidence of accreta simply because cesarean sections increase this risk and that mode of birth is on the rise...

But if you do not have anything more than a separation gush, no excessive blood loss and mom (on her own time when she is ready) changes positions, empties her bladder and performs her own cord traction...is there really a sudden danger?

The only issue I would have is with a partial separation. This incidence would be a true emergency and there's no way I'd wait around for that (of course).

I recently had a client who experienced what I thought was a partial separation after the birth. Careful review with another midwife revealed that it wasn't likely a partial separation at all (we would have lost way more blood), but more a matter of a placenta likely released from the uterine wall, but still hanging right inside the cervix. We saw pretty steady blood loss about half hour to 45 minutes after the initial separation gush. However, looking it all over, if it was a partial separation then we would have likely seen more constant blood loss after that initial separation, which we didn't. What we ended up dealing with was a boggy uterus and a placenta tucked inside the 'corner' of the uterus. Anyway, the placenta eventually was released with Pitocin and some further cord traction.

I think that placentas usually release really soon after birth or sometime close to 45 minutes or an hour. That's typically what we see in my practice. And just because there's a seperation gush doesn't mean that we need to go in and get it. We offer moms some position ideas, cord traction (or they do it themselves) or a trip to the bathroom to get those placentas out. Otherwise, we wait.

(And yes, there are very selfish times when I feel like three hours postpartum is enough. That's just me, my selfish side, etc. I usually want to go home after births...but if a woman said that she wanted to wait, I'd be right there waiting with her. If I was really worried about accreta, over time a decision would need to be made...but an accreta isn't something that is going to cause a major catastrophe if action is delayed hours.

[pamamidwife]

Originally Posted by 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.

can you tell me more about the manual removal? I've gone in two times to see if a placenta was still attached, but the placentas were sitting right inside the uterus. I'm not sure if I could have really done a manual removal at home...especially since I practice in an urban setting, the opportunity for transport to a safe facility is simple.

what happened that prompted the manual removal? what would have caused you alarm during that removal? did you end up actually removing the placenta from the uterus during that instance? were you concerned about excessive blood loss if there was a true placenta accreta and the placenta could not be wholly removed?

I hope it doesn't seem like I'm criticizing - I'm genuinely interested. I've gone up twice to retrieve placentas that were just sitting inside the uterus (that didn't budge with cord traction). However, going up I had no idea what I'd find. I'm not sure that my gut would have really let me feel ok about a manual removal at home. Once you start shearing off that placenta, you'd better be darn sure that it's all going to come off...or you're in trouble. At least, that's my thinking and that's what I've always learned.

In school we always talked about "Zimbabwe midwifery" - meaning that if you had NO OTHER CHOICES and life was of the essence, these are mechanisms that could save a mother or baby. A "safe" manual removal of the placenta was one of the things that we learned. I remember technique and procedure, but I'm not sure that I'd be ok doing it in my neck o'the woods.

oh - wanted to add: I'd definitely attempt a manual removal with a true partial separation. With Emerg Response called, removing the placenta is the only way to deal with a partial separation. I'd rather attempt a manual removal with Pitocin on board than to just wait for transport response. Just so you know that there's one reason why I'd attempt it.

[MsBlack]

Thanks for that, Pam--

I want to say that the main reason I urged transport for my one, 5hr placenta is that I was tired and wanted to go home! It had been a very long day starting at 4am, no naps, was then midnight. Mom was doing great tho, very minimal blood loss w/birth and since then, fundus very firm and low--we were sure placenta was separated and I think in her case the cervix did close up on it. And if there had been anyone else to come and sit with her, continue observing her while she got some sleep, I would have been ok with supporting her and dad's wish to stay home and trust. As it was, I told them it worried me to consider leaving them with placenta in, and no one at all on hand to help mom if bleeding did begin (and I lived nearly 3hrs from them--no way I'd be any use once I left). As I did not carry pit, I didn't want to try the rough fundal massage that was what got that thing out in short order at the hospital (followed up by a shot of IM pit).

It is only realistic, not so selfish, I don't think, for a mw to have limits in this way. I kinda wished, in that situation, that I had felt comfortable waiting--now that I've heard some 12-24hr 'normal' placenta stories But, I do have to consider 'the rest of my life' along with safety and I definitely had to have some sleep as well as deal with my kids soon. In that situation, I wasn't really afraid per se--very healthy mom, all signs good. I was just done, and just concerned enough that I could not see leaving her without some awake backup. I don't know...maybe now, having heard some of those very long placenta delivery stories, I would just go to sleep right there (as I would during a long labor anyway), close enough to help maybe if things went bad.

And of course--the family in this case certainly retained the right to refuse. It was just one of the very rare situations in my practice where I used a lot of persuasion to influence their decision!

[bionicsquirrel]

Originally Posted by pamamidwife

I'm so surprised that there wasn't one midwife that would be ok just observing for excessive blood loss, etc., in lieu of directly managing third stage.


The only issue I would have is with a partial separation. This incidence would be a true emergency and there's no way I'd wait around for that (of course).

I recently had a client who experienced what I thought was a partial separation after the birth. Careful review with another midwife revealed that it wasn't likely a partial separation at all (we would have lost way more blood), but more a matter of a placenta likely released from the uterine wall, but still hanging right inside the cervix. We saw pretty steady blood loss about half hour to 45 minutes after the initial separation gush. However, looking it all over, if it was a partial separation then we would have likely seen more constant blood loss after that initial separation, which we didn't. What we ended up dealing with was a boggy uterus and a placenta tucked inside the 'corner' of the uterus. Anyway, the placenta eventually was released with Pitocin and some further cord traction.

I think that placentas usually release really soon after birth or sometime close to 45 minutes or an hour. That's typically what we see in my practice. And just because there's a seperation gush doesn't mean that we need to go in and get it. We offer moms some position ideas, cord traction (or they do it themselves) or a trip to the bathroom to get those placentas out. Otherwise, we wait.

.

Considering there are only 3 midwives in Wichita, she didn't have very many options.

I have seen what you describe where the placenta was seperated, but we were still a little unsure. There was just a steady trickle of blood and a placenta that wouldn't budge. Finally mom just pushed with all her might and it literall flopped out, but with a big splatter of blood behind it. This was one of those incidents where my preceptor was very nervous.

[scifimom]

Finally attempted it because mom really wanted me to, she couldn't relax with it still there and was long past ready for bed at that point. We tried her doing traction, a few trips in the bathroom, blowing in the bottle, blowing in a balloon even with regular doses of placenta out, etc. It was an urban setting and she was feeling good besides being tired, it had been a very easy birth. She decided she would rather me try it and transfer if anything didn't feel right, than to have to go to the emergency, we are in an alegal state, it can be bad for everyone involved to transfer. And luckily it went well, came off easily with very little bleeding. If it had not been so easy I of course would have had her moved. her cervix had closed a bit but it was still very stretchy like. If she hadn't been a long time friend I might not have tried either. It was ready. Hard to explain all the things that make you decide what you do lol. It also was a quite small placenta. I'm still not sure I'd do it again, one of those hard decisions.

[Happyucmama]

I am not a midwife yet...I wish to be someday. I just wanted to add a few things. Pam, I am the friend Bianca was referring to. Thanks to you I had the confidence to have my uc and got my peaceful birth I had always wanted. The birth previous to that one ended in a uterine inversion. My caregiver was bothered by the 30 minutes my placenta was taking and went in to examine what the situation was, she thought I had an accreta. As she removed her hand, my uterus came out behind it. I was in massive pain and literally wanted to either die or have them knock me out. It took me quite a while to physically and emotionally heal from it. I have huge issues with cord traction to this day with my doula clients and actually have to leave the room if it is done. Please keep in mind that no matter your state as a caregiver your choices are effecting someone else's life forever.
With my uc I waited about 2 hours before my placenta came out but had membranes attached and dangling for over 24 hours. I could feel my body working hard to get them out and my blood loss was very minimal so I just trusted it to finish the job. I took lots of vitamin c and watched for fever. It came after a day or so and the after pains/cramping/contractions stopped immediately. I'm not sure what I will do when it is my time to help make decisions about other birthing women as their midwife. I do know that out of 3 birth, all of my placentas have taken their own time, and I make sure to honor that.

[mwherbs]

first let me say that it all depends each birth and situation is different- but I see a trend that most placentas are out within 15 minutes- there is an obvious separation bleed and mom is uncomfortable and the placenta comes out. Average longer wait with no separation bleed- and the fundus is not enlarging(sigh of hidden bleed- checking for this is a technique in-itself- too rough can make a problem) 45 min -3 hrs
longest wait 24 hrs
my view is that there is no reason destabilize a healthy woman-- if the placenta is firmly attached and there is no occult or obvious bleeding then the placenta will come out in it's own time-- that being said midwives do not practice in a vacuume - there is the beliefs and sensibilities of the parents and extended family, the medical place you may have to transfer to, the political climate and legal standing of the midwife distance from a hospital... to name a few things besides just purely the health of a woman. we transfered one mom to a very busy trauma hospital and with some seeping blood loss- small trickle the placenta was in place for about 8 hrs postpartum before they had an opportunity to remove it--
manual removal is a LIFE risk- risk of hemorrhage, hysterectomy , infection, torn cervix or uterus... just to name a few

a completely attached placenta is far less risk- possible infection missed hemorrhage or delayed hemorrhage
where to look in the lit is at European conservative management of accreta they are moving more toward the American style but in the past just a wait and see approach was done- with abx coverage to prevent infection--