week 3 - still birth daystillbirthday.com/wp-content/uploads/2011/08/chapter3training1.pdf · week...
TRANSCRIPT
1
Week 3
Hospital Admission through Discharge
This chapter discusses everything about medical options during the
birth. We will begin by looking at a full term live birth in a hospital
setting, and then look at stillbirth options, and medical options for second
and first trimester births.
Each intervention is evaluated by its necessity, any drawbacks to it, how
to avoid it, and how to work with it once it is implemented.
You will learn the difference between induction and augmentation, and
about the various medicinal forms of pain relief, the safest times for them
to be introduced, and again, what their benefits and drawbacks are.
Having an understanding of the mother’s unique situation: her cultural
and religious approach to birth, her husband’s cultural and religious
approach to birth, the details of this pregnancy including how many
children she has, how many live children she has, her efforts in obtaining
this pregnancy, and any diagnosis or expectation of this pregnancy all
can help you approach the medical involvement in her pregnancy and
birth with more respect.
From this chapter you will gain a better understanding of the motivations
behind medical suggestions presented to the mother during her
pregnancy or her birth experience. This provides the family with an
important service: knowing that they can turn to you to help explain what
is going on, why things are being suggested, if there is a safe non-
medical alternative, and how to manage any side effects.
Medical Involvement in Pregnancy
Medical Options (full term live birth)
Medical Options in Loss Medical Options when given
extra time (explored in greater detail in Chapter 5)
Medical Options in Subsequent Pregnancy
(Medical Terminology in regard to
complications and reasons for loss will NOT be discussed until Chapter 6)
2
Medical Involvement in Pregnancy Medical involvement may begin well before a pregnancy. The mother may already have an established
relationship with her primary care provider and her obstetrician/gynecologist. Her medical professionals
will, ideally, have established customized goals for her in regard to general health, optimized nutrition for
pre-conception including folic acid and prenatal vitamins, as well as clearing or controlling any important
health issues such as diabetes, lupus, depression, blood clotting disorders, HIV/AIDS or other important
health factors such as genetic testing.
The first prenatal visit is generally scheduled at 6-8 weeks pregnant (2-4 weeks after the first missed
menstrual period). During this visit, the doctor will complete a genetic background questionnaire, the
mother may have a vaginal exam, she will give a urine sample and her blood will be drawn. Her blood
sample will determine:
Her blood type
Rh antibodies
Infections such as syphilis, hepatitis, gonorrhea, HIV/AIDS
Varicella/chickenpox, rubeola/measles, rubella/German measles exposure
Cystic fibrosis
hCG level and PAPP-A level
Aspects unique to culture:
Mothers of African or Mediterranean descent may be tested for thalessemia
Mothers of Ashekenazi Jewish heritage may be tested for Tay-Sachs disease
Mothers of French Canadian descent may be tested for Tay-Sachs disease If a mother has experienced previous loss or if her doctor has heightened concern about her sustaining her
pregnancy, he may schedule a series of blood tests at any time before reaching 8 weeks pregnant. The
mother may have her blood drawn every two days for a series of three days, to ensure her hCG levels are
rising.
3
Ultrasounds might be performed in any trimester.
First trimester ultrasound scans may be performed with a transvaginal or standard ultrasound machine, and
can confirm:
Pregnancy
Heartbeat – if the baby is alive or has died
Crown-rump length to determine gestational age
Molar or ectopic pregnany
Fetal nuchal translucency (measures fluid at baby’s back of neck)
MaterniT21 is a blood test that may be an alternative to ultrasound
Second trimester ultrasound scans:
Diagnose an anomaly with the baby
Can assess potential Down’s syndrome characteristics at approximately 13 weeks, and congenital
malformations at approximately 18-20 weeks
Identify structural abnormalities and levels of amniotic fluid (Amniotic Fluid Index)
Confirm multiples pregnancy
Confirm dates and growth
Confirm the baby is alive or has died
Evaluate the baby’s well being
Third trimester ultrasound scans:
Identify location of placenta
Observe the baby’s position and activity
Identify pelvic or uterine abnormalities of the mother
Confirm the baby is alive or has died
Evaluate the baby’s well being
Pregnancy, by weeks, months and trimesters
Weeks 1-4 5-8 9-13 14-17 18-21 22-26 27-30 31-35 36-40
Months 1 2 3 4 5 6 7 8 9 Trimester 1 2 3
4
Prenatal Visits:
We’ll look in other chapters at ways you might provide support prenatally, that also mirror
support you might provide postpartum.
Every four weeks until the 28th week
Then every two weeks until the 36th week
Then every week until birth Weight, urine and blood pressure may be checked at each appointment to help assess possible
preeclampsia and gestational diabetes.
Preeclampsia (toxemia, pregnancy induced hypertension, PIH) is when the mother develops high blood
pressure and protein is found in her urine in the second half of pregnancy. PIH brings serious health
complications to both the mother and baby and close medical care is given, including early artificial
induction of the birth. While rare, PIH can lead to maternal death and fetal death.
Diabetes screening:
Performed at 12 weeks for mothers of higher risk of having gestational diabetes, including previous
baby weighing more than 9 pounds and/or family history of diabetes
Performed at 24-28 weeks for other mothers
Involves a glucose drink and a blood test
Triple Screen (2nd Trimester): Alpha-fetoprotein level in blood can help identify spina bifida or other neural tube defects in the baby (when
level is high) or Down syndrome or other chromosomal abnormalities (when level is low). This is called
MSAFP (Maternal Serum Alpha-Fetal Protein) and is read as a percentage of likelihood based on variables;
hGC and Estriol levels in blood can also help determine the possibility of abnormalities. Quadruple Screen / Quad Screen (2nd Trimester):
When testing for Inhibin-A is added to the second trimester screen, it is called a quad screen. These tests
combine factors such as the mother’s age to help determine the likelihood of the baby having Down
syndrome. Babies who have Down Syndrome
5
Results: the two Ps Prenatal blood testing provides the parents with preparation – if there is a statistical likelihood of a defect, it
allows the parents to ask questions, learn of special treatment or care options, helps them bond with their
baby as they learn more about the diagnosis, and helps them plan the birth. Blood testing also can assess
placental issues or other abnormalities which, when more closely monitored during the remainder of the
pregnancy, may prevent additional complications, including stillbirth.
Chorionic Villus Sampling (CVS) is a sampling of the villi, the genetic material that connects the amniotic
sac to the uterus. This is a more invasive testing, with a long tube inserted through the vagina and guided
by ultrasound into the uterine cavity to collect the material. This test is performed in the first trimester and
may be given for mothers whose babies are considered more likely to have Down’s syndrome or spina
bifida, including the age of the mother, among other factors. While considered safe, there is an increased
risk of miscarriage and preterm labor with this test.
Amniocentesis is a sampling of the amniotic fluid. This is a more invasive testing, with a long needle
being guided by ultrasound through the mother’s abdomen (umbilicus) into the amniotic sac. This test is
performed in the second trimester and may be given for mothers whose babies are considered more likely
to have Down’s syndrome or spina bifida, including the age of the mother, among other factors. While
considered safe, there is an increased risk of miscarriage and preterm labor with this test.
Amnioinfusion – through ultrasound guidance, a needle is inserted into the uterus and fluid is infused into
the amniotic sac. This may be done to help with lung development if fluids are extremely low, although if all
other tests return normal, low levels of amniotic fluid itself may not be reason for medical assistance. It can
also be used to help determine a leak in fluid, and may be used in labor if there is fetal distress and
meconium present.
3D and 4D Ultrasounds – may provide a better visual of the baby Non-Stress Test – monitors both the baby’s heart rate and any uterine contractions, just as we learned
about with the external fetal monitoring in chapter 2. The pink band has a UC Transducer and is placed
near her fundus to monitor her contractions. The blue band is placed lower than the pink band, and has a
USD Transducer which monitors the baby’s heartrate in relation to the contractions.
6
Contraction Stress Test – this is similar to the non-stress test, but with a small amount of Pitocin
intravenously given to the mother to create contractions, in an effort to monitor the baby’s reaction to them.
Group B Streptococcus (GBS) infection testing involves a swabbing sample from the vaginal and/or
rectal area. This test determines the presence of GBS. GBS is a normal, healthy part of a woman’s
vaginal flora, which may or may not be present during the time of testing. If GBS is present during the time
of testing, the mother is said to be colonized, and it is determined that there is a likelihood of the GBS being
present during birth. While GBS is normal, symptomless and harmless to the mother, it can pose a serious
danger to the baby, including death. If the mother tests positive for GBS, or if she enters labor with a live
baby prior to the test (unknown GBS status) she will be given antiobiotics, usually Penicillin, once every
four hours during the course of her labor. This has been proven to provide sufficient protection to the baby.
The baby’s temperature may also be supervised every couple of hours for the first few days of life. If the
mother is positive for GBS, she should limit vaginal exams including stripping the membranes, as this can
aid in the GBS travelling through the protective barrier of the mucous plug, entering through the amniotic
sac and reaching the baby.
Blood Pressure Medication may be given for mothers with PIH or HELLP, along with medications to help
prevent seizures.
Corticosteroid injections may be given to the mother to help speed up the development of the baby’s
lungs if the baby is deemed to have the potential to be born prematurely, particularly in cases of PIH or
HELLP. The protocol is generally two intramuscular injections 24 hours apart. However, some studies
indicate that only a single injection is necessary, and that additional lung support offered in any subsequent
dosage is not only less effective, but comes with elevated risks of maternal infection, cerebral palsy and
other complications for the baby.
7
Additional Information Additional medical support in births of any trimester may include:
Medical Help during Pregnancy:
Antiretroviral medication – given if the mother or partner has
HIV/AIDS to reduce the risk of transmission to the baby
Nausea medication – may be given at the mother’s request. Any Care for Any Condition – pregnancy can bring on unique
conditions or can exacerbate any existing ones.
Medical Help in Sustaining the Pregnancy – this will be discussed in chapter 6, including reading
medical information. Here are some things:
progesterone
avoid NSAIDs
cervical cerclage
treatment for things such as blood clotting disorders
Medications to stop labor such as:
calcium channel blockers (nifediprine)
prostaglandin synthetase inhibitors (indomethacin, ketorolac, sulindac)
magnesium sulfate
beta-mimetics (terbutaline, ritodrine) Medical Help during Birth:
Antibiotics – may be given in labor; full term live birth if the mother has tested positive for GBS or if her
GBS status is uncertain (having labor begin before testing, particularly if her water broke before 37 weeks).
Rhogam – if the mother has an Rh-negative blood type, a shot of Rhogam can offer certain protections in subsequent pregnancies. The MicRhogam is an option as well.
Medical Help after Birth: Antibiotics – may be given, particularly in a second or first trimester operative birth
Sleep Medication – may be given to the mother who is grieving and having a difficult time sleeping
8
Kick Counts
Learning to count the baby’s kicks can help reassure the mother, as well as help her to spend some intentional time focusing on and bonding with her baby. This is a kick count chart. The mother would identify the time during the day the baby moved the most, and use that time to chart his movements. Twisting and bumping count as kicks.
Nulliparous mothers (remember, they may sometimes be called primiparous) may not feel their baby’s movements until approximately the 25th week of pregnancy. Multiparous mothers may feel their baby’s movements by the 15th week. It may take a couple of weeks to identify a pattern with the baby.
Time Week
Sun
M
T
W
Th
F
Sat
Minutes
10
20
30
40
50
Hours
1
1.5
2
2.5
Some helpful tips when counting kicks:
choose the time of day the baby is most active
use the same time every day
If the baby seems less active, there are a few things the mother can do to help stimulate him:
drink fruit juice
drink water
have a small amount of caffeine
some believe hot sauce or other spicy foods may help, but these may cause heartburn
after these, the mother should rest in a comfortable place
using a small flashlight on her abdomen can be a fun way to help play with the baby (and can help guide a baby to the head down position later in pregnancy.
9
Warning Signs
These are warning signs for the mother to watch out for in an otherwise uneventful full term live birth. Preterm Labor (3 or more weeks before due date) -Contractions: more than 3 occurring in an hour -Menstrual-like cramps: may come and go or be constant -Abdominal cramps: may occur with or without diarrhea -Low backache: comes and goes or is constant -Pelvic pressure: feels like baby is pushing down -Change in vaginal discharge: a sudden increase in the amount or may become more mucous-like, watery and slightly blood-tinged (mucous plug)
Water Breaking Note: -T: Time you suspect it broke -A: Amount of fluid -C: Color of fluid (clear, or greenish) -O: Odor (body/sperm smell, or pungent and strong)
Vaginal Bleeding (bright red vaginal blood is not normal) Note: -Amount of bleeding -Presence of clots
Abdominal Pain: -Seek health care provider immediately
Decreased Fetal Movement -The mother may choose to use a fetal activity chart the last few weeks of pregnancy to track movement -Absence of movement or significant lessening of movement may be of concern; notify provider
Fever -The mother should notify her health care provider if she has a fever
Headache -Unusually severe -Seeing spots or flashing lights -Other neurological symptoms: numbness, loss of vision, weakness, loss of balance or speech difficulty
Urinary Discomfort -Frequency with small amounts -Painful urination -Blood-tinged urine or pus in urine
10
Medical Options in Labor We will begin with full term live birth medical augmentation options. Then we will discuss the medical options for births in loss, by trimester.
Induction & Augmentation
Augment means to change, and these medical intervention options can either prompt labor (induce) or
change labor once it’s begun.
This is a general (not complete) list of hospital birthing options. Some of the more prevalent items have already been added to the birth plans at the website. These items have been adapted, as best as possible, for stillbirth delivery. Not all of them are used for every delivery.
Each item has positives (why it might be needed for labor), negatives or side-effects (things to watch out for; it is important to know even very rare risks of interventions, even if they are absolutely medically necessary interventions, so that you can be prepared to work with any of those side-effects and so that neither you nor the mother/parents are startled or terrified by them), suggestions that may offer similar results to possibly avoid those negatives, and finally, once an item is indicated for a birth, a list of options the mother and couple still have to choose from to allow her a constant sense of control and understanding of what is happening during her labor
In this way, she will come to know that the events of her labor, while surely overwhelming, are for her safety, protection, and comfort.
Following the Induction and Augmentation segment, we will discuss Pain Management Options.
Artificial Induction starts labor. Augmentation changes the pace of labor.
11
Induction and Augmentation medical options are listed both in as chronological as possible, and from
least interventive to most interventive:
Pelvic Exams
Determine status of cervix and position of fetal head Can further progress cervix dilation (any touching can change)
You might try:
Positions to apply baby to cervix: Squatting, lunging, hip rotations, abdominal lifting, showering, slow dancing Requesting 1 per hour for minimal manual assistance
Requesting additional exams to progress labor Once it is indicated:
o Work with attendants in getting into reasonable position for exam o Relaxation o Mental acceptance of process o Eliminate fear-tension-pain o Recognize that dilation is only PART of progression (7 ways to progress)
IV
Administration of medication
Administration of liquids
Administration of calories
Allows for intake if mother is nauseated or exhausted
Allows for intake if attendant wants empty stomach
Maintains open vein
Used for general anesthesia
GBS positive requires IV antibiotics
- Cumbersome/ gives an impression of illness
- Glucose may affect mom insulin levels You might try:
Requesting Heparin Lock Hydration Light nutritional snacking: yogurt, honey, tea, crackers
Once it is indicated:
o Relaxation o Mental acceptance of process o Eliminate fear-tension-pain MOM CAN WALK IN LABOR WITH A “HEP LOCK” & SHE CAN
STILL ENJOY MOBILITY (EVEN IF LIMITED) WITH A FULL IV UNIT.
12
External Fetal Monitor
Records strength of contractions
Records baby’s heart rate
Allows for overall picture of labor pattern
Telemetry units are possible for mobility
- Difficult to assess if mom is obese
- Can read mom’s heart rate when baby’s isn’t present You might try:
Asking for a hand-held Doppler unit Asking for intermittent monitoring (every 15-30 minutes) – live birth
Asking for no monitoring if baby’s heart may stop during birth Once it is indicated:
o Relaxation o Mental acceptance of process o Eliminate fear-tension-pain
Artificial Rupture of Mucous Membranes (AROM/AROMM) / Amniotomy May help speed labor
Allows caregiver to see color of amniotic fluid to assess fetal distress
- Most caregivers want mother to deliver within 24 hours
- Breaks germ barrier (often contraindicated in a stillbirth delivery)
- Labor contractions may be more intense without cushion of amniotic fluid You might try:
Positions to apply baby to cervix: Squatting, lunging, hip rotations, abdominal lifting, showering, slow dancing Upright positions Hydration
Once it is indicated:
o Relaxation o Mental acceptance of process o Eliminate fear-tension-pain
13
Intrauterine Pressure Catheter (In Trans)
Records strength of contractions
Records baby’s heart rate
Allows for overall picture of labor pattern
Taped to side of leg, no laceration to baby
- Internal, more invasive than external monitoring You might try:
Asking for external monitoring
Asking to switch positions for better reading Once it is indicated:
o Relaxation
o Mental acceptance of process o Eliminate fear-tension-pain
Fetal Scalp Electrode (Internal Fetal Monitor)
Records strength of contractions and baby’s heart rate
Allows for overall picture of labor pattern
- Can be placed improperly and cause serious injury (in face or brow presentation)
- Can cause a very small injury to baby’s head
- Requires rupture of membranes You might try:
Asking for In Trans instead
Once it is indicated:
o Relaxation o Mental acceptance of process o Eliminate fear-tension-pain
14
Cervical Ripening Agents: Cervidil (E2)
Softens cervix, preparing it for dilation
generally the BEST option when monitored closely
May start contractions
Prepares cervix if Pitocin is needed
Ability to remove medication on demand/application similar to tampon
- Mom chance of bradycardia or tachycardia
- Mom chance of vasoconstriction
- Diarrhea
- Headache You might try:
Upright positions Positions to apply baby to cervix: Squatting, lunging, hip rotations, abdominal lifting, showering, slow dancing Hydration
Once it is indicated:
o Relaxation o Mental acceptance of process o Eliminate fear-tension-pain
Cervical Ripening Agents: Cytotec/Misoprostil (E1)
Softens cervix, preparing it for dilation
Prepares cervix is Pitocin is needed
Able to induce or augment labor
Can stop postpartum hemorrhage
Allows mom to go home, use bath after administered (mobility)
- Medication may not be evenly distributed throughout pill, broken into fourths
- Mom chance of retained placenta
- Any augmentation to labor is through its side effects and not its intended purpose
- FDA approval status in Student Resources You might try:
Upright positions Positions to apply baby to cervix:
Squatting, lunging, hip rotations, abdominal lifting, showering, slow dancing
Hydration Once it is indicated:
o Relaxation o Mental acceptance of process o Eliminate fear-tension-pain
15
Pitocin IV
Can start labor (Pitocin is artificial Oxytocin)
Can speed up a slowed labor
Can increase intensity of contractions
Can stop a postpartum hemorrhage
Can be regulated and monitored closely
Can be turned off if necessary
- Difficult to produce natural progression of contractions
- Pain from Pitocin is often more difficult to deal with
- Requires IV and constant monitoring
- Mom chance of hyptertensive episodes
- Mom chance of tetanic contractions
- Mom chance of uterine spasm
- Mom very small chance of coma You might try:
Upright positions Positions to apply baby to cervix: Squatting, lunging, hip rotations, abdominal lifting Positions to increase relaxation: Showering, slow dancing Creating comfortable birth environment Breathing, Prayer, Affirmations Creating natural OXYTOCIN with massage, love, and support team Ask attendant about natural stimulation Oxytocin, Endorphins, Serotonin working together
Once it is indicated:
o Anticipate the need for pain relief o Relaxation o Mental acceptance of process o Eliminate fear-tension-pain
OXYTOCIN means: “Quick Birth”
Did you know? There is evidence to suggest that an unsupported laboring mother may hormonally seek out what a doula can provide. This is good news to affirm doulas who meet and support on-the-spot at the birth.
The Two Faces of Oxytocin
16
Assisted Delivery: Forceps
Assistance when baby cannot deliver past pubic bone or lower birth canal
Used when speedy vaginal is safer than cesarean
May offer best navigation ability for attendant
Used for aid in delivery when any occur:
Maternal exhaustion
- Inability to push (from epidural)
- Posterior position of baby’s head
- Your doctor is NOT able to choose between vacuum or forceps (or episiotomy)
- Small chance of fetal lacerations on face or skull
- Forceps failure when fetal head does not advance with each pull
- Cesarean required if forceps fail You might try:
Avoiding epidural for optimal ability to push Staying nourished and well rested to avoid exhaustion Positions to encourage descent, like squatting
Once it is indicated:
o Relaxation o Mental acceptance of process o Eliminate fear-tension-pain
Assisted Delivery: Vacuum Extraction
Assistance when baby cannot deliver past pubic bone or lower birth canal
Used when speedy vaginal is safer than cesarean
May offer best navigation ability for attendant
Used for aid in delivery when any occur:
Maternal exhaustion
Inability to push (from epidural)
Posterior position of baby’s head
- Your doctor is NOT able to choose between vacuum or forceps (or episiotomy)
- Chance of damage to baby’s skin increased in stillbirth You might try:
Avoiding epidural for optimal ability to push Staying nourished and well rested to avoid exhaustion
Positions to encourage descent, like squatting Once it is indicated:
o Relaxation o Mental acceptance of process o Eliminate fear-tension-pain
17
Assisted Delivery: Episiotomy
Small, repairable incision
Used when speedy vaginal is safer than cesarean
Easier for attendant to repair than a tear
- Unable to predetermine need of episiotomy
- Small chance of mom infection
- Small chance of mom discomfort during intercourse later
- Longer healing period than a tear You might try:
Perineum massage during pregnancy Perineum massage during birth Positions to encourage descent, like squatting Asking if you may tear
Once it is indicated:
o Relaxation o Mental acceptance of process o Eliminate fear-tension-pain
Vacuum, Forceps and Episiotomy are all manual ways to help with birth.
18
BIRTH METHODS IN CONJUNCTION WITH THE DECISION OF DURATION OF LIFE IN UTERO (DOLIU) SOMETIMES HAVE DIFFERENT NAMES. IN “HYSTEROTOMY ABORTION”, THE BABY IS BORN VIA CESAREAN BIRTH BUT THE CORD IS CUT BEFORE BIRTH.
Cesarean Birth
Now perform a low-transverse incision (bikini)
Also Vertical, or Classical incision
Can be life-saving
Date of delivery can be scheduled
Used for aid in delivery if any of the following occur:
Mal-presentation of fetus
Abruptio placenta
Placenta previa (placenta over the cervical opening)
Cord prolapse (out of uterus before baby is born)
Pregnancy Induced Hypertension/toxemia
Can be helpful (but not necessarily automatically required) in a multiples birth
Some severe diagnoses of baby may increase likelihood of Cesarean birth
Mom poorly controlled diabetes
Mom high blood pressure
Very premature infant
Chance of less stressful birth in a fatal diagnosis
Previous Classical incision (pulling against SMOOTH MUSCLE
- Mom chance of infection
- Interrupted bonding time with mom and baby, which can have exponential results
- Major abdominal surgery & not considered a cure for any of the complications it may address
- Mom very small chance of death
You might try:
Avoiding pain alleviation which may stall labor progress Positions that will aid in labor progress, such as squatting, walking Avoiding epidural for optimal ability to push Staying nourished and well rested to avoid exhaustion Positions to aid in relaxation: shower, slow dancing Creating relaxed birth environment with breathing, prayers, affirmations Positions that will aid in repositioning baby, such as abdominal lifts, external shift, slow dancing
Once it is indicated:
Relaxation Mental acceptance of process Eliminate fear-tension-pain Continue to be involved: ask about partner involvement: Trimming cord, photography Use your special items you brought (eye mask, etc) Ask to raise baby or lower screen for birth
Our exam this week will give you a richly beneficial opportunity to expand on any of the
medical birth options mentioned in this chapter in your own perspective, so that you and your
fellow classmates can learn even more from one another’s experiences and perspectives.
19
Additional Information
Pitocin is a synthetic form of our naturally occurring (enogenous) oxytocin, which we learned about in
chapter 2. The difference between the two is that Pitocin inhibits the release of adrenocorticotropic
hormone (ACTH). ACTH is a hypothalamic hormone that regulates the release of cortisol in response to
stress, and like 6-endorphin, it is regulated by corticotrophin releasing factor (CRF). Pitocin causes a
decrease in both 6-endorphin and ACTH by interfering with the release of CRF. Because 6-endorphin
helps reduce contractions, the lack of a rise of 6-endorphin levels after Pitocin is administered is a likely
reason for its production of unnaturally strong and frequent contractions (Genazzani et al, 1985).
Bishop Score
Parameter/Score 0 1 2 3 Description
Position Posterior Intermediate Anterior - The position of the cervix varies between women. The anterior position is better aligned with the uterus.
Consistency Firm Intermediate Soft - In primagravid mothers the cervix is more resistant to stretching and younger women it is more resilient.
Effacement 0-30% 31-50% 51-80% >80%
Dilation 0cm 1-2cm 3-4cm >5cm Baby’s Station -5 to -3 -2 -1,0 +1,+2
A score of 5 or less suggests that a medical induction at that time may be less likely to succeed; the lower
the score may also indicate additional interventions or a failed induction (a need for a Cesarean birth). A
score of 9 or more suggests that a medical induction may be more successful at that time, which may also
suggest that labor may more likely to begin spontaneously at that time. Knowing what the mother’s Bishop
score is when there is talk of induction can help the mother determine what is best in her situation.
20
Medical Information in Labor: Fatal Diagnosis
In birth when the baby has already died or is expected to die, external fetal monitoring should be discussed. Does the mother want to have continual fetal monitoring (CFM) to know when the heart stops beating? This will change some mobility in her labor, as well as impact her emotionally when she learns the baby’s heart has stopped.
Does she want to have increased interventions in the event of the heart rate dropping or ceasing?
Does she want additional medical staff involved during the labor or birth, or does she want medical
presence remained to a minimum? Does she want the care given to her baby during labor, delivery and birth to be focused on life preserving or delaying care, or does she want the care given focused on comfort (palliative)?
Umbilical cord can possibly still remain intact during medical assistance.
Medical protocols for neonatal asphyxia.
21
Second Trimester
Induction and Augmentation Whether miscarrying naturally at home, experiencing very early labor with the possibility of infant survival,
or early labor with the established or imminent death of the baby, mothers do labor and deliver in the
second trimester. Her options are much like the options of third trimester births; what are noted are the
decreased risks of certain medical augmentation.
Cytotec, while not FDA approved for labor and delivery in the third trimester, is actually considered a safe
drug to use in the second trimester. This may have to do with the size of the uterus and placenta.
Prometrium is an oral option that may help augment prodromal labor.
Induction generally takes significantly longer than in third trimester. The need for additional medical
augmentation is increased (the mother may be given several doses of cervical ripening agents).
The mother may be given the choice of oral or vaginal misoprostol. Oral misoprostol is absorbed faster
than vaginal application. Vaginal application has a lower peak level of misoprostol acid. When repeated
doses are anticipated (as in the case of most second trimester births), vaginal misoprostol can lead to
additional vaginal bleeding and degredation of absorption. Oral misoprostol has a higher level and onset of
production, although it is linked to additional side effects such as fever and chills. Vaginal misoprostol is
usually considered the most effective form of dilation, with the least side effects to the mother.
Induction is more effective in IUFD (intrauterine fetal demise – the baby has already died before labor) than
in cases where the baby is still alive during the labor.
The risk of Cesarean birth decreases in the second trimester, even for VBAC mothers. It is considered
safest to have a vaginal delivery in the second trimester.
The Bishop score is not a very reliable tool in second or first trimester births.
Baby Innocent, 13 weeks – beginning of second trimester.
22
D&E From stillbirthday:
If your doctor has recommended a D&E to help deliver your baby, the very first thing to consider is
changing the perspective you may have about this approach.
Many mothers have very strong objections to having a D&E performed because of the comparison to an
elective abortion.
A D&E is a way to medically assist in the delivery of a baby. The medical operation is the same if the baby
is alive or not. But, the operation itself is not abortion. It is a medical way to assist in the delivery of your
baby. If this method is needed, perhaps it might be more healing for you to consider it more of a “vaginal
Cesarean“, in that the doctor is going to manually assist in the delivery of your tiny baby.
Another thing you may consider, is that some women recall feeling doubt or uncertainty that their child had
in fact died prior to the D&E. This doubt is part of the grieving process, and is normal. But it can be terribly
difficult to move past any feelings of doubt or uncertainty after the D&E has been performed. For this
reason, I strongly suggest utilizing any ultrasound or doppler device that you can prior to the D&E. Perhaps
contact a local crisis pregnancy center to see if they offer free ultrasounds. This extra step can provide you
with the certainty you need in knowing that you are not “electively aborting” your baby. Remember, a D&E
does not mean elective abortion.
The third thing to consider, is asking your provider if artificial induction may be a simpler, safer way to
deliver your baby. Sometimes, a doctor will plan for a D&E (or a D&C, which is a different birth method that
may also be an option to ask about) simply because it can be easier on you than trying to really navigate
different approaches. Even if your doctor has recommended a D&E, it might be a good idea to just mention
the option of artificial induction, and allow your provider to discuss your options with you so that you can
have the safest delivery of your baby possible.
Now, with all of that said, a D &E (sometimes mistakenly called a DNE) is a method of delivery, used most
often in inevitable or missed miscarriages, or for miscarriages that occur later in the second trimester, after
your baby’s bones have begun to harden (approximately at 16 weeks or older). It may also be used if a
miscarriage had not completed naturally (any placenta fragments remain in the uterus). It is a combination
of the D&C birth method, with additional delivery tools used, such as forceps, to help deliver your baby.
You may be given an antibiotic and/or pain medication, and physical recovery may include spotting for
several days. Your birth plan for this method will include additional information. Generally, it is best to not
plan on conceiving again until after you have had the first subsequent menstrual cycle, to ensure that your
uterus is completely clear; waiting at least a week to introduce anything into your vagina (tampons,
intercourse) is also recommended. Your provider will discuss these things with you.
23
D&C From stillbirthday:
If your doctor has recommended a D&C to help deliver your baby, the very first thing to consider is
changing the perspective you may have about this approach.
Many mothers have very strong objections to having a D&C performed because of the comparison to an
elective abortion.
A D&C is a way to medically assist in the delivery of a baby. The medical operation is the same if the baby
is alive or not. But, the operation itself is not abortion. It is a medical way to assist in the delivery of your
baby. If this method is needed, perhaps it might be more healing for you to consider it more of a “vaginal
Cesarean“, in that the doctor is going to manually assist in the delivery of your tiny baby.
Another thing you may consider, is that some women recall feeling doubt or uncertainty that their child had
in fact died prior to the D&C. This doubt is part of the grieving process, and is normal. But it can be terribly
difficult to move past any feelings of doubt or uncertainty after the D&C has been performed. For this
reason, I strongly suggest utilizing any ultrasound or doppler device that you can prior to the D&C. Perhaps
contact a local crisis pregnancy center to see if they offer free ultrasounds. This extra step can provide you
with the certainty you need in knowing that you are not “electively aborting” your baby. Remember, a D&C
does not mean elective abortion.
The third thing to consider, is asking your provider if artificial induction may be a simpler, safer way to
deliver your baby, or if natural miscarriage would also be a safe alternative for your unique situation.
Sometimes, a doctor will plan for a D&C simply because it can be easier on you than trying to really
navigate different approaches. Even if your doctor has recommended a D&C, it might be a good idea to just
mention the option of artificial induction, and allow your provider to discuss your options with you so that
you can have the safest delivery of your baby possible. D&C can have possible long term side effects
(including on your future fertility), so please ask your provider to be very clear about explaining these to
you.
Now, with all of that said, a D&C (sometimes mistakenly called a DNC) is a method of delivery, which
includes medically assisted dilation of your cervix, and the use of a medical instrument called a curettage,
which is applied onto the endometrium within your uterus; it is this tool by which the medically assisted
birth of your baby will take place. The D&C is a birth method used most often in miscarriage between
weeks 10 and 12 weeks (after which point a D&E may be suggested). It may also be used if a miscarriage
has not completed naturally (any placenta fragments remain in the uterus).
You may be given an antibiotic and/or pain medication, and physical recovery may include spotting for
several days. Your birth plan for this method will include additional information. Generally, it is best to not
plan on conceiving again until after you have had the first subsequent menstrual cycle, to ensure that your
uterus is completely clear; waiting at least a week to introduce anything into your vagina (tampons,
intercourse) is also recommended. Your provider will discuss these things with you.
24
Additional Information
The D&C birth method is used for early pregnancy loss including molar pregnancies, including partial and
complete. It involves first dilating the cervix, and then using an instrument called a curettage to help deliver
the baby. Dilation is done through induction, which will be discussed for first trimester loss. After dilation is
complete (complete dilation is not 10 cm as in full term birth, but is approximately 3-7 cm depending on
gestational age), an instrument will be used to hold the cervix open, much like in a vaginal “pap smear”
exam. The curettage is inserted into the vagina, and gently scrapes the uterine wall until the baby and
placenta detach. The provider can then guide the baby through the remainder of the birth.
This birth method may be performed in the doctor’s office with a local anesthetic or in the hospital with a
general anesthetic, depending on various factors including the mother’s preference. If the birth is under
general anesthesia, the mother will remain in the hospital for a few hours after the birth. If the birth is with
general anesthetic, the entire process will take less than an hour.
A D&C procedure can also be performed postpartum, that is, after the baby has been born naturally, to help
remove any remaining placental tissue, which helps lower the risk of infection and cancer and can help
preserve fertility.
The D&C procedure, used either as a birth method or postpartum, does come with health risks, including
complications to the mother from the anesthesia used, perforation of the uterus, damage to the cervix, scar
tissue on the uterine wall, and infection. It can lead to secondary infertility through Asherman’s syndrome.
Yes, a D&C can help with fertility, and it can endanger it. The D&E birth method is for babies who are approximately 16 gestational weeks and older, and is just like
the D&C, only that as the provider is guiding the baby through the remainder of the birth, he or she will
manually assist in the birth with the use of forceps or vacuum extraction. This is because of ossification, or
the hardening of the baby’s bones, along with the baby’s size, making it more difficult to pass through the
birth canal without assistance.
The tools used in a D&C birth.
25
First Trimester
Artificial Induction
From stillbirthday:
Medication can help stimulate labor, and allow you to birth your baby, including the birth of blighted ovum. These are a few common medications that are used to help deliver miscarried babies, and they may be
given separately or in conjuction with each other:
Mifepristone
Misoprostol
methylergometrine (methergine) Mifepristone blocks a hormone (progesterone) from completing its pregnancy function of supporting the
uterine lining that the baby has been growing in. This will stop your body’s efforts of sustaining the
pregnancy. In some cases, this will be enough to trigger “permission” to your body to begin expelling the
placenta and delivering your baby.
Misoprostol (a prostaglandin) causes your uterus to contract, so that your baby can be delivered. “Cytotec”
is one prescription name used, and misoprostol is said to have about an 80-90% effectiveness rate in
delivering miscarried babies and completely expelling all of the placenta pieces. Cytotec does not have the
same negatives in this use as it does in full term live birth.
Methergine helps to control excessive bleeding and can cause your uterus to contract, so that your baby
can be delivered.
You may be asked to stay at the hospital to deliver your baby, or you may be permitted to deliver your baby
at home. This will depend on the age of your baby, and other factors including your hospital’s policies.
Using labor stimulating medication to help with the delivery of your baby in early pregnancy is generally
considered a medically safe approach, one that doesn’t have the possible adverse side effects as more
medically involved births. In rare instances, medication does not deliver the entire placenta, and more
medically assisted support (D&C) may be needed to help completely deliver the placenta.
When using a labor stimulant to help in the delivery of a very young baby, you should expect to see a
heavier blood discharge than your menstrual period, and possibly small tissue-like pieces of uterine lining.
Your baby’s placenta, as it detaches from your uterine wall, is very soft and will most likely break into
smaller pieces. By the eighth week of pregnancy, the placenta is about the size of a peach, and by the
twelfth week it’s about the size of a pear, and so the pieces as it is delivered may roughly be the size of
grapes.
26
Your doctor will discuss with you the side effects and warning signs to look out for when taking induction
medication, including fever, too much bleeding (hemorrhage), and the amount of time it should take to
complete the entire process.
Generally, you will probably be cautioned that filling a regular-absorbancy maxi pad sooner than one hour,
at any time, is cause of concern; immediately postpartum (that is, right after the baby is born), generally
speaking you should not fill a regular-absorbancy maxi pad sooner than a half-hour in the first hour (so, you
can go through 2 pads in the first hour postpartum), as it is common to experience some increased
bleeding at the actual time of delivery.
Besides medication to help stimulate labor, other options to assist in the dilation of your cervix may include
seaweed laminaria or the use of a Foley catheter. The Foley catheter (sometimes called Foley ball or
bulb) will manually dilate your cervix; this is not a medication but is instead a tool/instrument. Your doctor
will insert the Foley into your vagina and the process can be uncomfortable but should resemble a vaginal
exam. The ball has a small tube at the end of it. After the ball is in place, the doctor will fill up the ball like a
balloon. The sensations from the Foley vary to feeling bloated, crampy, to a feeling of having tetanic
(constant) contractions. As you dilate large enough, the Foley will fall out. Each of these options can help
dilate your cervix to approximately 3 or 4 centimeters, which should be enough for early pregnancy loss.
Pregnancy losses that occur later in pregnancy may be supplemented by the use of Pitocin to continue to
dilate the cervix for birth.
Your doctor will discuss these options with you according to your unique situation. If at any time you fill a maxi pad sooner than a half hour, experience dizziness, tingling in your
hands or feet, or a racing heart (or any of these even with light bleeding), you should consult a
medical professional immediately.
If you are hoping to be able to find and identify your baby, the chances are increased if you have a general
understanding of what to expect to find. We have photos of babies per gestational week to help you.
27
Ectopic Pregnancy
From stillbirthday:
Laparoscopic Surgery
Surgery for ectopic pregnancy may either be laparoscopy (explained here) or minilaparotomy. Because ectopic pregnancy can be fatal to the mother unless the pregnancy ends as quickly as possible, I
will only include very early development links to fetal information (and there is a probability that the
development of an ectopic baby may be a little different; still, it can be nice to have a general idea of what
your baby’s last developments will be). This surgical birth method may be used if methotrexate was
ineffective.
The full medical term for laparoscopic surgery is “Laparascopic Salpingotomy”. Laparoscopic surgery is
performed under general anesthesia. Your doctor will use a tool called a laparoscope to enter your
abdomen through a small incision, deliver the baby, and to repair any affected part of the fallopian tube.
Once the doctor determines the condition of the fallopian tube, if it is not repairable, a “Laparoscopic
Salpingectomy” will be performed (a “laparotomy”, which is a larger abdominal incision, may be required),
which is the partial or the complete removal of the damaged fallopian tube.
Methotrexate Methotrexate is administered to mothers who have been diagnosed with an ectopic pregnancy very early in
their pregnancy (generally about 6 weeks and under). It can be given orally, however, it is usually
recommended that it be administered by injection, with either one or two injection sites. It is considered a
noninvasive procedure and reduces the amount of scarring to your reproductive organs. On rare occasions,
this medication may also be administered after laparoscopic surgery to prevent any cells from growing that
may have been left behind.
The medication will simply tell your baby to stop working. After the medication is administered, you will probably be allowed to return home, with a follow up
appointment a few days to a week later.
Within that time, your baby’s efforts to grow will be rested to the point that the baby dies.
You will bleed just as in a natural miscarriage, for at least the first few days.
28
How far along are you? Because ectopic pregnancy can be fatal to the mother unless the pregnancy ends
as quickly as possible, I will only include very early development links to fetal information (and there is a
probability that the development of an ectopic baby may be a little different; still, it can be nice to have a
general idea of what your baby’s last developments will be). Your doctor will advise you against using any
of the following, as they can interfere with the concentration of medication:
vitamins containing folic acid (including prenatal vitamins)
alcohol
penicillin
ibuprofen Your doctor will also cover side effects and warning signs with you, including discussing the potential risks
Methotrexate (possibly referred to as chemotherapy) can have on trying to conceive in the near future.
Some studies indicate that the medicine from Methotrexate may remain present in your own body’s cells for
up to 7 months after use; doctors generally recommend waiting at least one ovulation cycle before TTC
after Methotrexate to prevent complications in fetal growth in the subsequent pregnancy.
29
Stalling Labor
We discuss medicinal labor stalling options further in chapter 6 with NICU care, but what I want to talk
about here as we look at the differences of medicinal support in stalling or stopping labor between
trimesters is how labor stalling options are not available throughout pregnancy.
Medicinal labor stalling care only has a small window; it is generally provided between 24-36 weeks gestation.
Medicinal labor stalling options usually aren’t offered if the mother is considered full term or near full term.
Very few mothers deliver on their due dates, but rather deliver somewhere between 38-41 weeks. The
importance of stalling labor is to help the baby continue to develop in the womb if he hasn’t reached 37
weeks gestation.
The earliest pre-term labor is considered to be in the week the baby reaches viability, which is at 24 weeks
gestation. While some medical care can be given to babies younger than 24 weeks gestation (the
youngest surviving baby to date was born at 21 weeks gestation), for the most part doctors believe that
providing life sustaining care to babies born younger than the age of viability to be “futile medical care”.
Futile medical care means that there is no reasonable hope of a benefit from the care.
Because of this, babies who are born because of unstoppable labor younger than this and who actually
take a breath or even live for several minutes are held by their mothers, who helplessly watch as their baby
dies in their hands.
Many mothers erroneously believe that “making it past the first 12 weeks” brings them into something of a
safe zone in their pregnancy, when in reality the life saving medical support available for their baby doesn’t
begin until approximately 12 weeks later. In short, the window of stalling labor in pregnancy, and caring for
those babies born prematurely, is a small one.
These babies are known at stillbirthday as being born via live miscarriages. It is important to honor the reality of what
these mothers and families experience. A live miscarriage has no legal status – the mom cannot receive a certificate
of birth, but it is validating to allow the mom to express the unique situation in which her child was born. Being
unable to stop labor is only part of their heartbreak. Helplessly watching their child die compounds this.
30
Pain Relief Pain relief is divided in two sections: regional, and systemic. Many of the augmentations involved in labor
will add to the need for medical pain relief because of the way they function. Again, we will begin with full
term live birth, and then move into the different trimesters.
PAIN ALLEVIATION: SYSTEMIC
Analgesics=no pain relief Anesthetics=pain relief
Sedative: Seconal, Secobarital, Nembutal
Given orally in Early Labor (or in Active Labor)
Can be administered ASAP
Allows laboring mother to rest
Helps to coordinate an ineffective latent phase of labor
Stops Braxton-Hicks contractions
- Drowsiness for both mom and baby
- No pain relief
- Mom small chance of increased sensitivity to pain
- Mom small chance of edema (fluid retention)
- Mom small chance of panic/anxiety
- Mom small chance of urticaria (hives)-inflammatory reaction to skin You might try:
Relaxation Mental acceptance of process Eliminate fear-tension-pain Continue to be involved
Once it is indicated:
o Continue relaxation o Mental acceptance of process o Eliminate fear-tension-pain o Continue to be involved o Anticipate Active labor
31
Analgesics/Narcotics: Demerol, Stadol, Morphine, Fentanyl, Nubain
Given IV in Active labor (3-7cm)
Increases pain tolerance (doesn’t eliminate pain)
Takes “edge off”
Increases ability to relax
Best for over anxious, high stress, PTSD
Can be given ASAP
Useful for prolonged, hard labor/malpositioned baby
- Contraindicated 1 hour prior to birth/ limited availability:
- Barbiturate derivative: anticonvulsive and hypnotic properties (“I feel drunk or something.”)
- Highest incidence of reported side effects
- Wears off/ ACCLIMATION, need for increased dosage
- Can either increase or decrease labor (unpredictable)
- Need blood pressure cuff and pulse oximeter on finger
- Can cause mom vomiting
- Newborn may be drowsy (use if birth is >2 hours away)
- Can still feel highest peak of intensity, just not building up or let down You might try:
Continued relaxation Mental acceptance of process Eliminate fear-tension-pain with oxytocin Continue to be involved Avoiding Early labor sedative Positive affirmations, breathing, prayer
Once it is indicated:
o Continued relaxation o Mental acceptance of process o Eliminate fear-tension-pain o Continue to be involved o Ask for ½ dose (.5mg of Nubain) o Options: shot=more power for less time, IV=less power, more time o Anticipate pushing and delivery o Seek labor partner for direction of when to push
Taking the edge off, means that the build-up of the contraction is relieved, but the mother will feel the peak of the contraction.
32
Tranquilizers/ Anxiety: Promethazine HCI, Vistaril, Atarax, Phenergan (these are rarely given)
Given IM or IV in Early or Active labor
Lowers anxiety
Increases ability to relax
Alleviates nausea and vomiting caused by narcotic
Given in conjunction with narcotic, helps to increase the effectiveness of narcotic
Is an antihistamine
- Offers no pain relief if used alone
- Mom chance of uncontrollable twitching
- Mom chance of problems urinating
- Mom chance of high blood pressure
You might try:
Continued relaxation Mental acceptance of process Eliminate fear-tension-pain Continue to be involved Avoiding Early labor sedative Positive affirmations, breathing, prayer Stay HYDRATED
Once it is indicated:
o Continued relaxation o Mental acceptance of process o Eliminate fear-tension-pain o Continue to be involved o Avoiding Early labor sedative o Positive affirmations, breathing, prayer o Stay HYDRATED
33
PAIN ALLEVIATION: REGIONAL
Local Anesthetic: Novacaine, Lytocaine (Sensorcaine/Bupivacaine)
Numb perineum for episiotomy
Numb perineum for stitching after a tear if it is needed
Administration is easy
- Only blocks pain in the immediate skin area (not entire Ring of Fire, or abdomen)
You can still use a birth ball or a peanut ball with an epidural.
Epidural Block (=”-cain”+ narcotic, such as demoral)
Catheter into epidural space in spinal column (1st space)
No need to repeatedly puncture: catheter can re administer or continue dosage
Given during Active labor (3-7cm)
Does not alter mom’s consciousness
Can relax mom with extreme anxiety
Can help lower blood pressure of a PIH patient with high enough blood platelets
- Goal of 80% relief, not 100%
- Completely immobilizes patient
- Not administered promptly: same anesthesiologist for entire hospital
- Chance of longer second stage/ More difficult to push - Increased chance of needing Pitocin to speed up labor
- Message of pain from uterus to brain is blocked in spine, preventing brain to respond with helpful hormones to continue labor
- Mom chance of hypotension (drop in blood pressure) - Inability to get mal-aligned baby into place
- Mom chance of itching in face, neck and throat
- Mom chance of nausea, vomiting
- Spinal headache healed by patching hole with mom’s blood
- Postpartum headache/backache
- Uncontrollable shivering
- Uneven, incomplete or failed pain relief
- Loss of perineal sensation: inability to push: increase cesarean chance
- Mom need catheter
- Very small chance of:
- Mom convulsions
- Mom spinal cord damage
- Mom cardiac arrest
- Mom chance of fever
34
You might try:
Continued relaxation Mental acceptance of process Eliminate fear-tension-pain Continue to be involved Avoiding early labor sedative, active labor narcotic or
tranquilizer Positive affirmations, breathing, prayer Continue to create positive birthing environment
Once it is indicated:
o Continued relaxation o Mental acceptance of process o Eliminate fear-tension-pain o Positive affirmation, breathing, prayer o Asking for dosage to be turned down before pushing o Seek help and support of partner in pushing and delivery o Push in side lying or semi sitting position
Spinal Block
Click photo for video
Only used for cesarean
Complete relief from nipple line down
Mom awake and alert for birth of baby Once it is indicated:
o Relax: body will naturally breathe!! (Breathe on your own hand for assurance) o Mental acceptance of process o Eliminate fear-tension-pain o Positive affirmations, breathing, prayer o Ask to raise baby or lower screen for birth
35
“Cascade” of Interventions
The use of just one medical tool for labor often necessitates the use of another, particularly of medicinal pain relief, resulting in a complex spiral of interventions. This chart gives a couple of examples:
36
Pain Relief in Loss
Medicinal pain relief for the physical discomforts of labor are generally the same for full term stillbirth as in live birth, with the difference being if the mother plans on donating her colostrum. If she is planning on donating her colostrum or if she is currently nursing an older infant, she will be given pain medication that is safe for breastmilk. You can research the Drugs and Lactation Database or motherisk.org to confirm. Sleep medication may also be prescribed.
Second Trimester – pain relieving medicine is generally offered whenever medical assistance was involved in the birth, whether it was an operative birth or induction. Pain relieving medications include:
Morphine
Valium
Vicodin
Naproxen
Ibuprofen
First Trimester – pain relieving medicine is generally the same for first trimester birth as in second trimester birth.
37
Subsequent Pregnancies
It doesn’t matter if it’s the first or several subsequent after a loss, aspects of labor can impact the mother and so can medical augmentation.
Contractions
Mucous Plug – bloody show
Water breaking – artificial or not
Pushing
Crowning Giving birth/ meeting the baby
Cutting the cord
Caring for a newborn
Taking baby home
SBD Resources: Fertility Information Rainbow Pregnancy Rainbow Birth Plan Rearing while Grieving
38
Immediate Care of the Newborn In an effort to keep things chronological, I am adding this section again to show the medical care given to newborns. This time, however, I will discuss Pulse Oximetry Screening.
Establish Respiration
Establish Warmth
APGAR Reading
Umbilical Cord
Erythromycin
Vitamin K
As we learn about non-medical birth options in chapter 4,
you will learn that many newborn care medical practices can
either be declined or delayed.
Pulse Oximetry Screening – seven Critical Congenital Heart Defects (CCHDs) can be identified through this simple test (hypoplastic left heart syndrome, pulmonary atresia with intact septum, tetralogy of Fallot, total anomalous pulmonary venous return, transposition of the great arteries, tricuspid atresia and truncus arteriosis); these seven represent approximately 30% of all congenital heart disease. Without this screening, some babies could be missed – and treatment can be life saving. A pulse oximeter is used to measure the percentage of hemoglobin in the blood that is saturated with oxygen. What is the status of CCHD newborn screening in your state?
39
Medical Care of Newborn in Fatal Diagnosis
Establish Respiration
Increased interventions in labor in the event of decreased or undetected heart tones on monitor
Nose and bulb suction at perineum
Delayed cord clamping
Intensive efforts at perineum to create any spontaneous breaths (prolonged or forceful bulb
suctioning)
Possible resuscitation including positive pressure ventilation, oxygen, intubation, chest
compressions
Preparing to Meet
Possible wrapping any open areas at perineum area (out of mom’s site) before introducing baby to
mom
Establishing Warmth
Possible skin to skin
Possible having baby swaddled in receiving blankets and a “warm blanket”
Held by parents first
Additional Medical Involvement
Possible routine infant care (Erythromycin, Vitamin K, APGAR)
Possible pain medication (Fentanyl)
Possible anti-seizure medication
Possible transportation to NICU – carried in arms only or by hospital bassinet
Hospitals often offer in-house newborn photography for babies. This may be something the family
will want to utilize, in addition to bereavement specific photography
Nutrition
Possible direct breastfeeding, fingerfeeding, snuggling at breast, droplets of milk
Possible nasogastric tube
Possible nutritional supplementation (enhanced breastmilk)
Bonding
Medical release of baby and/or placenta to family to leave hospital with
Privacy from additional medical personnel for photography and bonding
Lactation professional or SBD to help with post loss lactation/donation
This will be discussed in chapter 4, including bathing and dressing the newborn
40
Medical Care of Newborn in Stillbirth
Establish Respiration
Increased interventions in labor in the event of decreased or undetected heart tones on monitor
Nose and bulb suction at perineum
Delayed cord clamping
Intensive efforts at perineum to create any spontaneous breaths (prolonged or forceful bulb
suctioning)
Possible resuscitation including positive pressure ventilation, oxygen, intubation, chest
compressions
Preparing to Meet
Possible wrapping any open areas at perineum area (out of mom’s site) before introducing baby to
mom
Establishing Warmth
Possible skin to skin
Possible having baby swaddled in receiving blankets and a “warm blanket”
Held by parents first
Additional Medical Involvement
Possible routine infant care (APGAR)
Possible transportation to on-level refrigerator or to the hospital morgue – carried in arms only or
by hospital bassinet
Care of possible leaking fluids with extra bandaging between baby and clothing or under clothing
Bonding
Medical release of baby and/or placenta to family to leave hospital with
Privacy from additional medical personnel for photography and bonding
Lactation professional or SBD to help with post loss lactation/donation
This will be discussed in chapter 4, including bathing and dressing the newborn
{photo: CarlyMarie has so many beautiful resources for support}
41
Special Permissions
While these options will be covered at greater length in chapter 6, they are listed briefly here for
chronological continuity as they pertain to special requests that require medical permission.
The family may want to take their baby home. If there is a fatal diagnosis but they’ve been given extra
time, perinatal hospice can help support the transition. If the baby has already died, there may be certain
hospital policies that may make this option more challenging.
The family may not have selected a mortuary. The hospital staff and you can help them determine the right
one for their needs. Is there a local cemetery where the family’s ancestors are buried? Is there a local
funeral home that offers special pricing or arrangements for infants?
The family may want a representative of their funeral home to take the baby from the hospital to their
mortuary. The family can request the representative carry her baby out of the hospital in his arms, rather
than in a closed container.
The family can request the baby never leave them during their stay, and that they hand their baby to the
funeral home representative.
The family can request the baby remain on the maternity unit rather than be taken to the hospital morgue.
Many hospitals have a special refrigerator on the unit for the stillborn babies.
If the hospital plays music at the birth of babies, the family can request music be played for their baby as
well. Conversely, they can ask that no music be played for other births during their stay or to be moved
away from the speakers (and away from the nursery, the nurse’s desk, and/or other laboring mothers).
The family can request the baby’s placenta be released to them. Consumption of the placenta has
unproven postpartum benefits including helping with the hormonal transition of birth to postpartum.
Depending on the unique situation, the placenta may not be considered safe to consume when the baby is
stillborn. A little more on this is in chapter 6.
The family may request the release of the baby’s placenta so that they may bury it in a special place or
have it cremated. They might use the ashes in a piece of jewelry or other keepsake.
Stillbirthday has placenta burial kits as well, that are safe for cremation and beautiful for burial.
Some mothers, after live births, consider “planting” their baby’s placenta (left photo). Mothers after loss may prefer to call it “burying” their placenta, and may want to wrap it in a blanket, cloth, or placenta burial kit first.
Nesiah’s decidual cast and placenta was lovingly
wrapped in a Miscarriage Blanket, placed in a special
box made by a friend, and lined with a piece of baby
blanket that all of her children used. Nesiah’s mom
purchased a ceramic heart that can be broken, with a
smaller heart found inside. She broke the heart, and
placed the smaller one in the box (a piece of her heart
went with him). Then she closed the box and had it
cremated. The ashes are in a special urn.
42
Second and First Trimester When the birth of a baby in the second trimester is either spontaneous or induced, the mother will have
many of the same options as in a third trimester birth.
The most significant difference in options is when the baby is born alive, as there may or may not be
options to help resuscitate the baby or to keep the baby alive. In a live miscarriage, for example, the baby
can take several breaths after birth and before dying.
Even in the event of a live miscarriage, depending on gestational age, the mother may not receive a
certificate of live birth.
The special permissions are significantly different in an operative birth (D&C, D&E), either in the first or
second trimester, than in a vaginal birth:
The mother will be alone in the birthing room with the medical professional. She will not be permitted to
see or hold her baby, and she will not be permitted to take her baby home.
If the mother wants to have her baby returned to her after an operative birth, she will need to request
permission prior to the birth, and understand her hospital policy. It is highly likely that even if the hospital
agrees, once the baby has been genetically tested, they will report that they do not have the baby or that
there was nothing left to return to the mother.
Communicating with the hospital staff as early in the experience as possible can help ensure that they act
in accordance with hospital policy as well as with the mother’s wishes. In these situations, the mother may
be told that within 2 weeks after the birth the baby’s physical form may be returned to her, and she will wait
for a call to return to the hospital to receive a small covered cup, with her baby’s physical form inside.
Having a funeral home representative present may make this transition smoother for the hospital staff in
remaining in compliance with their policies. Having a doula and/or a friend present is very helpful as well.
If in this process the mother is told that there simply are no more remains to be returned to her, she may
pursue receiving photocopies of any microscope slides.
All of these options will be discussed further in chapter 6.
43
Universal Precautions
Chapter one included information on your physical safety in regard to location and that others who love you know where you are going. In chapter eight we’ll look more at safety in the perspective of keeping your assets, family and business safe. But keeping yourself safe is a medical and health issue as well. You’ll find some great resources in this week’s module page, including research articles pertaining to medical involvement in birth, as well as real application resources including information on Universal Precautions. Please take the time to utilize these resources. Here are some safety tips from SBD alumni:
Don’t be afraid to use medical gloves. You can even buy a small box to keep in your bag as you serve families outside of hospitals as well.
When supporting a mother laboring in water, you can use gloves as your hands touch the water.
Wash your hands often.
Keep your meal items separate than your doula supplies.
Attend a L&D tour by your hospital, and ask if you can have a demonstration or even a set of items for Cesarean birth: full outfit and shoe covers. That way you’ll dress quickly and properly if/when you’re called to serve and use them.
You don’t need to be afraid to touch the baby, but bathtime can always be a good time for gloves.
You might bring a change of clothes and change in your car.
Use sanitizer wipes for immediate cleaning of your birth ball, and then your steering wheel when you get in your car. Later, you can use your more lasting cleanser.
Have a security guard walk you to your car at night. You’ll be groggy and your supplies will feel even heavier, and you may be more clumsy than otherwise.
Go home directly after the birth. Bring your things in through the garage. Wash your clothes; don’t leave them with the other laundry. Shower, and then go to pick up your kiddos from the sitter. Post doula showering, by the way, is marvelous.
44
Dear Student,
You may have found that this chapter of the training brought your own experiences, or the experiences of your grandmother, your mother, or other loved one to the surface.
If you’ve never considered a farewell celebration for your own experience, or, if the farewell you had seems as if it is somehow missing something, or if it just needs to be re-done, know that it is never too late to create a farewell celebration that is personal, meaningful, and healing.
In the next chapter, we’re going to be looking at non-medical options for birth, then in chapter five we’re going to be looking at immediate postpartum, including NICU support.
The weeks after that, weeks six and seven, will highlight more information about grief, about farewell celebrations, and about healing. If this chapter in particular brought back feelings about your own experience, take some time to look around stillbirthday in our farewell resources and ideas, and let yourself ponder the possibilities you might honor your own unique journey.
With Love, Heidi Faith