Do you deliver placentas in the water?

[momileigh]

Thought I'd take a short minute out of my studying-like-crazy-for-the-NARM-madness to ask something I've been wondering about for a while.

I was trained to do water births as follows:

1. Baby comes out
2. Make sure baby is breathing, etc.
3. Two or three minutes of oohing and ahhing
4. Cut the cord
5. Give baby to dad (or whoever)
6. Get mom out of tub and onto bed to deliver placenta.

Now, I don't really care for this way of doing things. I'd much prefer to let the mom stay in the water until she wants to get out. (I was "allowed" to stay in the water until I was ready to leave, but if my placenta had started separating, they probably would have rushed me out.) But at the same time, I've had it drilled into me that you must measure blood loss during 3rd stage/just after. If you don't measure it, you could be mistaken about how much she has lost, and she could have a serious hemorrhage and you wouldn't even know. I don't think I could reliably tell 1 cup from 2 cups from 4 cups of blood if dispersed in a tub full of water in a dim room, or even a brightly lit room. (I am pretty good at eyeing blood in a bedpan, and decent at it on a chux, but in water? Nope.)

So, do you do 3rd stage in the tub? How do you know if she is hemorrhaging or not? Is it (forgive me) kinda gross, like she's sitting in a tub full of nothing but blood? (I think that would freak me out if it were me in the tub.)

[Jane]

Done a couple. Don't really like it. It's really nice if it's a plumbed in tub, cause you can pull the drain plug so mama doesn't have to get out, but there isn't so much water in the tub.
The rule of thumb I use; If you can't see her legs, it's too much bleeding. If the water is still translucent, it's okay. Boy that's scientific, isn't it?

[nashvillemidwife]

I don't have a problem delivering them in the water though for some reason my moms usually want to get out before the placenta delivers.

Estimating blood loss is one reason why I push the La Bassines I have available for my clients (all others being I just love those pools). It's easier to estimate blood loss when you're making comparisons in the same tub.

Make yourself up some fake blood and practice estimating. There are a lot of recipes out there, one that I've heard that's good for mimicking the consistency of actual blood is to mix up raspberry Jello substituting Hershey's syrup for half the amount of water called for in the recipe. Fill up the tub and add the blood to the water 100cc at a time. You can refrigerate it to make clots (black cherry flavor makes better clot colors). You can also put a white towel in the bottom of the tub to help you gauge the color of the water. Learn to estimate how much water is in the tub, then extrapolate what color the towel should be based on how much water is in the tub.

[sevenkids]

I was taught to get mom out for the placenta, but I don't. Unless she wants to get out, like the placenta is taking a while and the water gets cold, or she's getting uncomfortable and wants to get dry and warm.

Measuring blood loss in a tub is a learned skill, just like measuring BL on a chux. Watch for the seperation gush, watch the water for how dark it gets, watch how fast the water turns dark.

I like the placenta being delivered in the water, it seems mom bleeds less. I don't like making a mom move so soon after the birth either, I don't like to see dizzy moms climb out of the tub. I think women feel better and more like themselves after the placenta is out.

[MsBlack]

Recently helped at a waterbirth that was my first in which mom wanted to push out placenta while she was still in the tub. Yes, I was a bit concerned about being able to est. blood loss--tho I"d heard that rule of thumb from another mw about 'if you can't see Mom's legs anymore, get her out of the tub'. What I did was keep an eye on the water color/translucency, and an occasional hand on her fundus to double-check that it was indeed remaining firm and low. This particular mom bled not at all w/baby, then only a small separation gush followed by a *very* minor trickle (which was easy to see at first, but not so easy once water generally darkened some). Took placenta about 25min, and the water did darken somewhat--but as mom was alert and perky, fundus was firm and she kept reporting contrax, and I never lost sight of her legs through the water, I didn't worry.

And I agree--I'd rather have Mom move after placenta is out unless she herself initiates getting out. Interestingly, while I've had several moms prepare for a waterbirth, only a few actually wanted to give birth in the water when that time came (and a few who didn't like the water at all, not even for labor). Anyway, of these few waterbirthers, most wanted to hang out in the water for a bit--maybe 10-15min--then wanted out, dry, and to deal w/placenta on dry ground.

Without clear sign of some sort, I'm not going to interfere with mom's wishes in the matter. I generally try to avoid routines of any kind, but to remain alert in the moment and following mom's/baby's lead until signs show me that something 'managerial' is actually needed (seldom!).

I like nashvillemw's thoughts on learning to estimate through practice....thanks

[mendomidwife]

I did a waterbirth last week and the women wanted to deliver the placenta in the water - it wasn't a problem. I usually try to get an idea ahead of time what they think they want to happen. It doesn't matter to me and I try to estimate blood loss best I can.

Carla

[Jane]

I think it is prudent to plan for problems - for example, a woman giving birth in a tiny bathtub with those sliding glass doors, in a tiny room where only half your supplies fit, and it's been a long pushing stage after a long labor and she's heavier than I can pick up might be more likely to be encouraged to deliver the placenta out of the tub.
In a birth center with a big, easy to reach tub, large birthin' room, a few good lifters standing around, few risk factors for bleeding, etc...different story.

It's really good if this comes up early or in the interview. I am not ashamed to say that I ask women to do things that are for my own preference and comfort level. Of course, I try to keep that to a minimum - she's the laboring woman, after all, but I am not a machine. If that's gonna be a problem, I want to know. It's also good to know what's really important to a client.

[momileigh]

I really should have done that blood estimation thing at the birth center with actual blood, since I had so much access to it. Mixing up fake blood seems like a lot of trouble, but I suppose its worth it.

That's interesting about most women not wanting to do the placenta in the water. I didn't. After about 15 minutes after the birth, I was like, "OK, let's get the rest of this over with," and I got out.

Also interesting MsBlack about most of your clients not ending up with a water birth. I heard almost the exact same thing from a midwife I almost used who works in rural Minnesota. She had never attended a water birth. She said most women "instinctually" got out of the water right before the birth (if they were laboring in water). I asked here on MDC about having a midwife who'd never done a water birth, and the consensus was that she must be one controlling, old-fashioned, managerial midwife never to have done a water birth. That didn't strike me as true at the time. Very interesting that your experience is somewhat similar, and I believe you are working in the same general geographic type of area as she with perhaps a similar sort of clientele.

[MsBlack]

That IS interesting, momileigh....

My clientele is actually quite mixed, from urban yuppie or hippie to rural conservative Plain of various stripes. I consider myself to be just about as "unmanagerial" as it gets! And I think my clients (the ones who've used other mws or docs) tend to agree.

I should add that waterbirth did not emerge in my practice--only because no one asked for it--until my return to practice about 2yrs ago after an 8yr break. I think in the meantime, waterbirth simply 'got on the birth map' so to speak. So, I have not seen all that many 'intended waterbirths' in the first place....I'll just have to see how it goes from here on out. Most women do really like the water for laboring, and some who intended to birth in the water just happened to be taking a break from the tub when transition hit--they then just didn't want to move anywhere! Only 2 felt that the water was no help with labor at all.

Apricot--

I definitely think that there are times when safety and practicality allows that a mw is within her rights to 'impose' her prefs. THe scenario you mention is just such a one (bathtub w/slider glass doors) I too have dealt with. This is the sort of thing I mention as birth day nears, and try to work out to everyone's satisfaction beforehand. I've never had anyone object to what I propose, once they understand my reasoning behind it. First of all, they see all along how much I do work with THEIR prefs and values; and secondly, the reason they hired me after all was for safety's sake and to receive input as called for, safety-wise. So, if I point out a need to adjust things for safety's and comfort's sake, even if it means in the end that we erred on the side of caution and it turned out to be unnecessary, well no one objects to that as long as the Big Picture was good by the family's lights. In the case of a waterbirth, I am not only conscious of possible placental issues, but also of such things as SD, anything that might mean helping mom to change position. I definitely don't want to be in circumstances where helping mom move could mean destroying my back because of tight quarters and the impossibility of utilizing good body mechanics! Or to have a harder time helping in any way, because of the physical circumstances.

[mendomidwife]

I have found that most women I attend (especially primips) want to get out of the tub for pushing. Having their feet planted on mother earth helps. It always reminds me of the book "The Red Tent." The midwives carried bricks to place in the sand and the women would place her feet on the bricks for pushing and squatting.

Carla

[nashvillemidwife]

Interesting, I've only had one mom ever want to get out of the pool (she was afraid of pooping). I've done a lot of water births.

Those shower doors are very easy to remove.

[sevenkids]

At the 36 week home visit, I check out the room and tub they plan to birth in, sliding glass doors can be removed by Dad before hand, and if the bathroom is too small then I can express my concerns about not having room to manouvre in, and make a Waterbirth Plan B.
Of course, if there's a problem or concern, I'll ask mom to get out, and the possiblity of the birth not happening in the water is always discussed prenatally.

I'd guess about 80% or more births I attend are waterbirths, I've had a few who HATED being in the tub/pool when actually in labour, but most stay and love it and most express no desire to get out for the placenta. I wonder if we'd find a difference in preference among coast dwellers and folks who live inland? Just a thought.....

I've had 2 S/D's in water births, both were spontaneously resolved when mom lifted her leg WAAAAAY up high to get out of the pool. One I did end up jumping in to help her get out.

[SublimeBirthGirl]

Both times I got out when I wanted to, and both times the placenta came out after I was out of the water. I have been present at a birth when the placenta came in the water. I'm not sure it really matters one way or the other. Once mine are born I want out pretty quick.

[Charmie981]

I prefer not to cut the cord until after the placenta comes, water or not. It's how I was trained and how the birth of my DS2 was done (in water) as well.

As we wait for the placenta, you'll see me picking up handfuls of water to check the amount of blood in it, to check for that mom's bleeding *and* for future reference. I was always taught that if the water looks more like blood than water, you've got a problem. And that's been my experience, too.

I've had one mom bleed too much in the water. Usually when mom has a separation gush in the water, she's sitting in a dark circle of water and everything else is clear, then the placenta comes and there's more blood, but the water is still reddish-clear to the bottom of the pool (you can see an example in this picture where the apprentice is clamping the cord after my DS was born). In my client's case, the bottom of the pool was covered in dark and the top was still clear, then after a minute, all of the water was cloudy-red (as opposed to the clear-red I'm used to). I had her get out and it was clear she was bleeding too much when she stood up. Still, we didn't cut the cord for her to get out..a friend held baby next to her while her DH helped her to bed (long cord, short distance to bed...I can see where this might not have worked too).

[nashvillemidwife]

Might want to make that photo public if you want us to see it.