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Archive for November, 2007

Placentae

twins-placenta.jpg

The twins placenta, although, apart from the 2 cords it looks just like any other. This is how it would look to you if you were inside the uterus, it’s the baby’s side. The greyish/white covering is actually the membranes, the sac, there are 2 of them, the chorion which is the outer one, and the amnion which is the inner one.

inside-a-placenta.jpg

This is the inner surface and it is attached to the wall of the womb. It is implanted into the tissue of the uterus and it basically peels off when the size of the uterus reduces. A placenta is usually about the size of a small dinner plate so you can see why bleeding following birth can be massive, imagine that where the afterbirth comes from is a huge wound and it’s easy to understand why, if the uterus doesn’t contract down tightly, there can be rapid blood loss, a postpartum haemorrhage, PPH.

Anyone feeling squeamish? When I was a new student midwife I hated placentae. They had a strange odour, were mucky, cold and I was expected to handle them. This wasn’t some strange initiation, it is part and parcel of the tasks following a birth. The placenta has to be checked, are the membranes intact or are they ragged? If they are ragged then there is a chance of bleeding or infection. How about the placenta itself, is it all there? In the second picture a small lobe of placenta can be seen a couple of inches away from the main body, but attached by blood vessels. This lobe could have been left behind, undetected it would have prevented the uterus from contracting down and this would have precipitated a PPH. However, when examining the placenta all the edges are checked, attention being paid to if there are any blood vessels which come to a sudden end.

The cord, umbilical cord is also checked. Does it look normal, are there any knots in it? How many blood vessels are there, there should be 3, 2 arteries and a vein.

cord.jpg Cross section of a umbilical cord true-knot.jpgA true knot

It may also be necessary to take blood from the cord, perhaps there are concerns that baby may have been compromised during labour or birth, cord blood gases can indicate if baby has been affected and may require intensive care. Mum may be rhesus negative, we need to know what baby’s blood group is, the blood in the cord will tell us this.

My attitude toward the placenta has softened, it does help that when I touch them  they are warm, but I now appreciate quite how amazing they are. With all the technology we have there is nothing that can do the same job as a placenta, without it a baby wouldn’t start growing and a successful pregnancy is dependent on a healthy placenta, it is an amazing life-support system. Researchers are now finding out that it is even more wonderful, even more sci-fi, it hides itself and the baby from the Mother’s immune system and so protects from rejection. It has long been believed that eating the placenta can reduce the risk of postnatal depression, I can’t say that it appeals to me, but if anyone out there fancies cooking up a feast then here’s a link to some recipes. Mmmmm, placenta lasagne, tasty! I wonder if that is how Tom Cruise enjoyed Suri’s afterbirth?

So, having been tongue-in-cheek about munching on a placenta, or placentophagia what did I do with my Grandchildren’s placentae? Being a silly, sentimental old fool I bought them home, buried them in the garden and planted the area with flowers that would bloom, be at their best, at the time the afterbirths had finished their work of growing my Grandchildren. I am not alone in celebrating their part in creating a healthy baby. In the Philippines the placenta is buried on the seashore in the belief it bestows good health on the baby. In Vietnam the placenta is buried under the Mother’s bed, obviously acknowledging it’s significance to the baby. Hawaiian culture best sums up my feelings about the placenta, they bury it and plant a tree over it, as they perceive it as part of the child. There are ten’s of traditions involving the placenta, one acquiring popularity at the present time is lotus birthing, I can see possible problems, but the reason I wouldn’t want it for me, or mine, is that I know what an umbilical cord smells like just before it separates, rank.

I’ve enjoyed writing this, there is so much information about customs and beliefs concerning placentae, it has really re-inforced my wonder about this basic looking companion to a baby.

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Wasting money in the NHS

Waste money + NHS? What’s that about? Well, if you have any ideas about how to save money, and what wastes money in that august body, but no one seems to listen, well here’s your chance to air your ideas (managers need not respond, I’ve had enough of your money saving schemes, on the whole they do not benefit patients or staff). ITV’s Tonight are looking into how large public bodies waste money –

Waste Watchers
If you work in, or are a user of, the NHS and  if you  think you’ve come across an example of money being wasted ,  then please email us at tonight@itv.com.   We promise to keep your identity confidential.

I love the way they phrase it, ‘think‘, there is no ‘think’ about it, money is wasted. Away days/weekends for managers; catered lunches, for managers, doctors, and the Trust board; all those alcohol gel dispensers for ‘cleaning’ hands when soap and water works better at eliminating C.Difficile. How’s that for starters? Anyone else got any ideas?

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Yippee

Louis is home. The boys are reunited and Amy has her Mummy back!

Work today was relatively relaxed, sub-text means that I finished on time! I have been musing about 3 of the ladies that I saw at clinic,all had SPD or, as we now label it, pelvic girdle pain. Certainly this is a more accurate description as this condition involves the whole pelvis rather than just the symphysis. I am just amazed at how much more common this sometimes disabling condition has become. I do believe that modern lifestyle plays a part in the increase in the number of women experiencing it as I can’t think of any other reason why so many more pregnant women are presenting with it. During my updates last week we had a talk from a physio specialising in women’s health. Yes, there were reminders about pelvic floor exercises but she then went on to discuss pelvic girdle pain and one of her theories for it’s increased prevalance is women working later in their pregnancies. Of the 3 women I saw today with SPD 1 was a ‘stay at home Mum’ with a toddler, he requires carrying everywhere, on one hip, and the other 2 were 36 & 34 weeks, still working, taking the train and tube (lots of standing) and carrying briefcases and laptops (unbalanced loads). These examples would appear to support the physio’s supposition so how should I advise women? Stop working, start your maternity leave early, make your child walk, use a wheeled bag to carry your laptop etc., at least that is better than ‘we can’t do anything for you’ but it amounts to about the same thing.

To end on a really positive note. I booked a woman, L, today. She had been really patient as our first contact had been cancelled due to my shingles, then she was on holiday, and when I phoned her the other day, on my day off, to finalise our meeting Amy was in the background playing ‘copycat’ and echoing everything I said. Anyway, at the end of todays meeting L expressed her joy at being pregnant by saying ‘It’s like Christmas everyday’, it made her joy quite infectious.

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The boys are really fulfilling their description of ‘identical’ twins. Today Jamie was discharged from hospital……….and Louis was admitted. Poor old daughter had about half an hour when she thought she would be coming home, then the Docs saw Louis and she was destined to stay in hospital. There was some good news, Louis has been passed perfect, his ‘occult spina bifida’ is nothing to worry about, other than a slight risk of infection, and his heart murmur has disappeared! When the ‘team’ were doing their rounds they were accompanied by 2 medical students, apparently the boys were a big hit as they could compare the breathing, lung sounds between identical babies, excellent teaching material. Later the students returned and spent an hour examining them in detail an taking a comprehensive history of the whole family.

Other than feeling as if an angry horse has kicked me the stomach I am well but still steering clear of eating anything more than toast. I had Amy again today, we are becoming quite the odd couple, chattering away and playing Amy’s favourite game, invisible pets. She has an extremely active imagination, which can sometimes cause problems. I’m not always sure what we are playing with, as it’s invisible, and Amy’s speech can be difficult to understand. I really hadn’t anticipated that a lion might be coming into the kitchen to eat a baby duckling whose Mummy had gone shopping!

Back in the world of midwifery and the maternity services I found thispaper about working conditions and the quality of care, it was published in 1999 and what struck me was that nothing has changed, in fact the situation has worsened. There were sections which really jolted me as it was reading what I have blogged on lots of occassions, the piecemeal approach to implementing change, the reliance on staff goodwill, the essential downgrading of midwives etc. It is long, 72 pages, but well written and researched, every maternity unit in the UK was asked to contribute, 50% did. Any student who is commenting on ‘Changing Childbirth’, and the constraints affecting the success of achieving the targets, will certainly find a great deal to discuss in this paper.

 

 

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Time of the year

First the good news, Jamie is no longer on oxygen and is maintaining his oxygen saturations. He is also managing to keep down some of his feeds and daughter says that he is much better in himself. Unfortunately Louis’ breathing and cough are worsening and he is not keeping his feeds down now.

Yesterday I had Louis and Amy because their Daddy had the sickness bug which has been making it’s way round their family, and last night and today I have it. I think that I’m luckier than they were as it doesn’t seem to have been as violent, certainly I’ve had worse. I just really hate being sick. If someone gave me the choice of have flu, or have a stomach bug, I would go flu everytime. Yes, you feel absolutely terrible, everything aches and there is a complete lack of energy but you can just give in to it and stay in bed, there is not the time spent rushing to and then paying homage at the porcelain god. It’s that time of the year though, lots of nasty little bugs.

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Back to the hospital

Ove the weekend Jamie has become quite poorly with a nasty cough. We saw him on Sunday and I told his Mummy that if he became any worse then she needed to take him to the Doctors. When I saw him he was quite wheezy, his breathing was slightly fast and he was flaring his nostrils ( a trick babies have to enable them to breathe in more air ). This morning daughter phoned and asked me to look after Amy, she has diahorrea and vomitting, whilst she took the boys to see the G.P. When I got round there I saw how much Jamie was struggling and warned her that the Doc may refer them to the hospital, I believe that forwarned is forarmed. Long story short, referral to paediatrician via A & E. Son-in-law decided to stay at home with Amy whilst I accompanied daughter and the twins to A & E, in our family the men-folk have problems coping with children who are really unwell. I think it’s a fear of showing emotion.

Staff on A & E were great. Triaged immediately. Sent straight to ‘resus’ as Jamie’s oxygen sats were rubbish, 80%, and his pulse rate was 180 bpm. He is now in a cubicle on children’s ward, in headbox oxygen, on a monitor and with a naso-gastric tube, he has bronchiolitis. This evening the paed came to review and whilst she was there decided to check Louis over. His chest is clear but………..she found a heart murmur. When she said this there was silence, poor old Louis again. Having just found out that his hearing is OK we thought that the only question mark left was his occult spina bifida but as the Doc said, at least he is seeing the neonatologist on Wednesday so there isn’t long to wait for a referral. Every cloud has a silver lining, I think.

It has been a long day, and it hasn’t finished for daughter who is staying in the hospital. Let’s just hope that the Docs are right and that today is crisis day and then a rapid improvement will follow.

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Mandatory Refresher

The last two days have been spent in the classroom. Yes, I have been attending 2, out of the 3, required mandatory study days we are required to attend to enable us to remain updated. Yesterday was the ‘important’, well in my eyes at least, obstetric emergencies day; eclampsia, cord prolapse, major postpartum haemorrhage, shoulder distocia, vaginal breech delivery, neonatal resuscitation, it’s down to basics, known risk factors, presentation, management and the accompanying emergency drills. Always a day that brings it all home, especially when the majority of midwives there are hospital based. When the part of the drill is reached ‘call for assistance’, their list is senior midwife, obstetrician, anaesthetist, paediatrician, scribe ours is paramedic, makes you feel a bit alone really.

Today was, blood transfusion (of course we have loads of those in the community), infection control, physiotherapy, antenatal/newborn screening updates and fire.

I’ve still got cardiotocograph interpretation, adult resus, record keeping, data protection, moving and handling, child protection, mentor and assessor update and breastfeeding to attend. I’m saving that day until December, too much excitement is not good for a midwife.

I’ve just read the entry about ‘News’, and realised that I didn’t actually say what the news was, just rambled on about how happy I was! Not too hard to guess really that it was excellent news as Louis has been passed fully functioning in the hearing catagory.

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