Cord Prolapse

This is another area I want to delve a little deeper into so people are more aware of this issue and know how to manage and what to expect if this occurs. I am thankful this does not happen frequently, but when it does it is a life or death situation for the baby.

What is umbilical cord prolapse?

An umbilical cord prolapse is when the umbilical cord comes out of the vaginal opening ahead of the baby. When this occurs, pressure is put on the cord cutting off oxygen to the baby, necessitating a quick delivery. 

What happens when this is found?

If the cord is in the vaginal cavity, you will immediately be laid as far back as possible and the bed put in the trendelenburg position (you will feel like you are standing on your head in the bed). A nurse or midwife will put her hand into your vagina and push the baby up into your uterus to take pressure off of the cord and you will be immediately rushed to an OR for a c-section.

What if I am not in the hospital when this happens?

If your water breaks and you can tell there is a cord coming out of your vagina find some way to get your hips in the air immediately! Then call 911 or have someone else to it if they are with you. Keep your hips in the air until you are positioned by the paramedics and they can help get the baby off the cord.

What are some risk factors?

Your water rupturing prematurely, having too much amniotic fluid, having a very long umbilical cord, the baby in an unfavorable position for delivery and having multiples

Do you have any experience with this type of emergency? 

Placenta Problems

I want to go a little more in depth into some of the placental problems that can occur with pregnancy and can cause complication with childbirth. The placenta is formed early in pregnancy and supplies oxygen and nutrients to the baby and removes waste from the baby. Normally the umbilical cord is attached to it carrying the oxygen, nutrients and waste. It is usually attached to the front or side of the uterus. It is an amazing organ that God has designed, but like everything else in this world there are opportunities for things to go wrong.

Placenta Previa

This is the most common of the abnormalities that arise with the placenta. A complete previa covers all of the cervix. A partial previa covers part of the cervix. There is also a marginal previa where the placenta is touching part of the cervix. If any of these do not resolve a c-section will occur. Approximately 90% of the time a previa seen in the 20 week ultra sound will resolve before you are ready to give birth. There is nothing you can physically do to make it move. If you are desiring a vaginal birth, pray hard for God to move it.

Placental Abruption

A placental abruption occurs when the placenta pulls away from the uterine wall before the baby is born. There can be a partial or complete abruption. Both can cause serious problems for both mom and baby, however complete is more likely to cause death in one or both. Know the signs of abruption so you can seek medical help immediately.

Common signs are: vaginal bleeding, abdominal pain (usually sharp and very painful, but can be less severe), Uterine tenderness, back pain and contractions that are very close or a long contraction that will not let up.

If you have any of these signs contact your provider immediately. If you're in excruciating pain get to a hospital asap.

Placenta Accreta, Increta or Percreta

These occur when the placenta attaches too firmly and deeply into the uterine wall at different levels. An accreta is too deep into the placental wall and may not detach properly. An Increta is implanted even deeper into the wall keeping the placenta from being able to detach after birth. A percreta goes through the uterine wall and can attach to other organs, typically the bladder.

The most common symptom is vaginal bleeding and can cause premature labor and delivery of the baby. If they are suspected ultrasound or MRI might be done to check the severity. If known before delivery a c-section might be done to try to preserve the uterus or a hysterectomy may be necessary. Thankfully these are quite rare.

Retained Placenta

Sometimes after birth the placenta does not want to come out, which is called a retained placenta. If this happens a D&C will be required to remove the placenta before there is too much blood loss. A retained placental can cause severe blood loss for the mother and can be life threatening.

Have you had complications with your placenta? Share your experience.

Other Reasons for C-sections

There are other considerations for having a c-section than the reasons mentioned yesterday that may not be known until labor or you have more of an option as to whether or not you will have a c-section.

1. Previous c-section- This one is tricky as the research goes "back and forth" as to the phrase "once a c-section, always a c-section" is really best. Having a previous c-section is something that must be considered, but does not mean you must have another c-section. Ask your provider where they stand.
2. Multiple Pregnancy- When pregnant with more than one baby it may be recommended that you have a c-section, especially if one or more babies is not positioned ideally. Providers will consider allowing you to labor with twins, but typically if there are more than twins, they are unlikely to allow you to labor. 
3. CPD- This is an abbreviation that means the baby's head does not fit in your pelvis. This is something that will likely not be known until you are actually in labor and may not discover until you have been laboring a while. Occasionally you may know if you have an oddly shaped pelvis ahead of time, giving you a heads up that this could be an issue, but many times this is not known until later. 
4. Labor being too long- This, of course, you cannot know ahead of time. Having a long labor is not indicative of needing a c-section, but often times, especially if you are in a hospital laboring, this will give providers "concern" and you can end up with a c-section.
5. Prolonged Rupture of Membranes- This, too, would not be known ahead of time. Once your water has broken you are "on the clock" in the hospital setting. They like the baby to be delivered by 24 hours after this happening. At the 24 hour mark it is likely they will begin talking about a c-section, especially if progress is slow. 
6. Placenta accreta- This occurs when the placenta is implanted to deeply and firmly into the uterine wall. If it is caught ahead of time a c-section may be scheduled in the hopes of saving the uterus. 

There might be other reasons, but these are the common ones that happen fairly often. Have you had experience with these? Are there other reasons you can think of?

C-Section, No Question

Yesterday we talked about c-sections covering what they are. I concluded that they are great when they are needed. Today I want to share situations when a c-section would be absolutely necessary, no questions asked. Some of the information may be a little scary, but I believe it is important for us to be informed about these situations so if it arises during our pregnancies or births, we know that it is necessary for the baby's health and ours and not simply doctors attempting to control a situation.

1. Placenta Previa- A previa is when the placenta is covering all or part of the cervix. A complete previa covers the cervix completely, a partial means it is over part of the cervix. Clearly if the previa is complete, there is no way for the baby to come out vaginally and a c-section is required. With a partial there is still a high bleeding risk involved and will still require a c-section. Often times previas will move. The placenta need to be at least 2 cm away from the cervix for a vaginal delivery. 
2. Placental Abruption- This occurs when part of the placenta begins to tear away from the uterine wall before the delivery of a baby. Typically it comes on very suddenly and there is a lot of bleeding and pain. Due to the blood loss the baby needs to be delivered quickly for the health of both mom and baby.
3. Prolapsed cord- This occurs when the umbilical cord comes down before the baby's head. This is an emergency and the baby needs to be delivered ASAP! 
4. Non-reassuring heart tones- This includes prolonged decelerations or persistent late decelerations that do not stop with intervention. A prolonged deceleration in the baby's heart rate is an emergency and you will be running back for a c-section. Late decelerations (slight decrease in heart rate that occurs after the contraction) is not an immediate emergency, but are a sign that there is a problem with the oxygen supply to the baby. Other interventions would be attempted before a c-section, but if there is no improvement a c-section will be needed.
5. Breech or Transverse Presentation- I mention these here because there are not many providers who will deliver a breech presentation vaginally and transverse presentation cannot be delivered vaginally. 
6. Medical Conditions- There are certain medical conditions that will not allow for a vaginal delivery such as certain heart conditions, previous uterine surgery and active herpes legion. These will be discussed with your provider ahead of time.

These are the primary reasons I can think of for immediate c-sections. Have you had any experience with these? 

What Is A C-Section?

A c-section is a surgical procedure that is done to take the baby out of the uterus when a vaginal delivery may not be possible. The procedure is done by cutting a horizontal incision in the pelvic region of the skin and typically a horizontal incision in the uterus. The abdominal muscles are also cut during this procedure. On occasion, if there is an emergency a vertical incision may be done on the skin and/or uterus. The type of incision on the uterus will determine if you will be able to attempt a VBAC in the future. After the baby and placenta have been delivered the uterus, muscles and skin are then sewn back together with sutures that absorb. Sometime staples are used on the skin.

Typically they will use epidural anesthesia for a c-section unless it is a true emergency or you are unable to have an epidural for medical reasons. If you are unable to have an epidural, they will put you under general anesthesia. Typically those who have epidural anesthesia have a quicker recovery due to the nature of epidural vs general anesthesia, so if you know you are having a c-section then if at all possible you would want an epidural.

We are blessed that we have the ability to do these easily when they are needed, but c-sections are major surgery and should be considered very carefully in healthy women. Know your providers c-section rate. Know if they are quick to do c-sections for non-emergent reasons. Know what they are and when they are necessary. Ask a lot of questions, especially if you are hoping to avoid a c-section.

Episiotomy

What is an episiotomy?

An episiotomy is when a cut is made in the perineum. There are 2 types: median and midline.
Midline is a cut made straight down the middle of the perineum.
Median is made at an angle to the right or left.

Are episiotomies necessary?

Generally speaking they are not necessary. Some providers use them as an alternative to tearing.
In the case of a emergent situation they can be necessary. For example, the baby is almost out at the vaginal opening, but the heart rate is dropping drastically. An episiotomy may be performed to help the baby get out quickly instead of doing a c-section.

Is an episiotomy better than tearing?

This question is clearly up for debate and you can find research supporting both views. From my personal understanding and experience I believe it is better to tear for healing purposes. The reason for this is it's a natural process and the tear fits back together upon repair like a puzzle. When there is a clean cut this does not happen. Also, with a cut it becomes easier to rip like when you cut a piece of paper.

Have you had an episiotomy? What are your thoughts on them?

Pain Medication

What pain medications are available during labor?

There are a few that are used in labor and it depends on the provider what they generally use. It also depends on the stage of labor you are in what they might use.

If early in labor or being induced overnight, they are more likely to give you something longer lasting, while in active labor they are more likely to give you a short acting drug.

Some of the drugs that might be used include stadol, fentanyl, morphine, dilaudid, and demerol.

Are there risks involved with these drugs?

Like with all medication, there are risks. They give temporary relief, but they have the possibility of suppressing the baby's breathing upon birth. This can lead to needed interventions when they are born. Generally speaking this is not severe, but can be.

When can these be given?

Each provider and hospital have there different policies, but once you are dilated to about 7 cm or so, they will not give these for the risk above. Up until then they can be given every 2 to 6 hours depending on the drug.

Have you had any of these drugs during labor? What was your experience?