Questions & Answers for Student Midwives

Question: My patient is in early labour. She was 3 cm dilated with a posterior cervix, ruptured membranes and well applied head. At her next assessment, five hours later, there was no change. Cervix is still very posterior and can only be walked up to midway. Generally, I would just let things plug along, but after 24 hours, the hospital protocol where I work is to administer IV antibiotics. I really want to avoid that. Baby is in an anterior position.

 

Answer: It’s difficult to avoid antibiotics at this point, when you’ve done at least two pelvic exams. You’ve now pushed her up to a 25% risk of acquiring an ascending infection.

https://i0.wp.com/www.moondragon.org/images/pelvicexamdiameters.jpg?w=584(illustration from “Heart and Hands” by Elizabeth Davis)

The only way to sit on your hands and let her birth naturally is to not do any pelvic exams. In Europe, the rule is “the baby should be born within 24 hours of the first pelvic exam” with PROM. That gives you weeks, if you don’t examine. Listening to fetal heart tones daily and taking the maternal temperature every four hours while the woman is awake is the appropriate course of action when the membranes release. Many midwives will leave a fetoscope at the house for the parents to listen to the baby’s heart rate for reassurance.  Iatrogenic infections are a serious problem in obstetrics.  There was a time when no vaginal exams were done in hospitals at all because of the danger.  If a cervix had to be examined, it was done with a rectal exam to keep fingers out of the vagina.  Just because we now have a wide variety of antibiotics is no reason to expose women and babies to this danger.  Gloria

Question:  I have some questions about how to collect the umbilical cord blood when the birthing woman is Rh negative.  Should one wait until the cord has stopped pulsating – and find there is probably little blood to collect or clamp the cord whilst pulsating and take the sample then unclamp the cord? Or none of the above?!

I look forward to hearing your views,  Charlotte

Answer:  Thanks for asking, Charlotte.  Here’s something I wrote for Midwifery Today which will give you detailed instruction on Collecting Cord Blood

When the mother of a newborn baby is Rh negative and the father is Rh positive, there is a good chance that the baby will be a positive blood type. Blood in the umbilical cord and the placenta will be the baby’s blood. Here are instructions on how to obtain a sample:

1.            At the time of birth do not rush the clamping and cutting of the cord. I like to see the placenta birthed (this will take approximately 30 minutes) before clamping and cutting of the cord.

2.            Take the bowl with the placenta to the kitchen and get everything together before taking your blood sample. You will need

2 pairs of nonsterile gloves to protect yourself from body fluids

1 container with a lid in which to put the placenta

1 blue waterproof 17- by 21-inch underpad

1 3-cc syringe and needle

1 purple test tube with stopper (Check with your local hospital to determine what color stopper they prefer. The purple stopper tube has an anticlotting chemical in it to prevent the blood from clumping.)

3.            Before putting on your gloves, write the necessary information on the label of the test tube in very tiny printing. Remember: it is very important that blood samples not get mixed up at the hospital. You will get along well with the blood bank if you mark your samples carefully. In my area, we print the mother’s full name and date of birth, the title “Cord Blood,” baby’s date of birth, and mother’s personal health number. When you get to the blood bank, they will also want you to fill out a requisition. On that form, I put my name, pager number, the physician’s name, and the mother’s date of birth and personal health number. I also write for the order “Type infant cord blood for screening of Rh negative mother.”

4.            Now that you have all your supplies together and the tube is labeled, take the cord blood before inspecting the placenta. Pull the placenta out of the bowl and put it on the blue pad so that it is sitting on the counter with the cord draped over the edge of the counter; the clamp is on the end of the cord. You want to keep the label of the tube clean and legible, so you may want to change your gloves or wipe blood off them on the blue pad’s edge. Take the lid off the tube and hold it at the clamped end of the cord. Take off the clamp and allow the blood to run into the test tube. When a half-inch of blood has accumulated in the bottom of the tube, close the tube and rock the blood back and forth. If you can’t get enough blood you may have to squeeze the blood down from higher up in the cord. Occasionally you may have to run the 3-cc needle into one of the vessels on the fetal side of the placenta, draw back on the plunger to extract the blood, and then squirt it into the test tube.

5.            Now you can do a complete inspection of the placenta and then put it away with a lid on it in the refrigerator.

6.            When you take the test tube to the lab, ask the technician to page you with the results as soon as possible. If the baby’s blood is Rh negative, ask the lab to fax a copy of the record for your records. If the baby’s blood is Rh positive, the lab will require a blood draw from the mother’s arm. The maternal sample is taken to the lab and checked for baby’s blood cells. If there are none in the mother’s blood, a low dose (120 micrograms) of WinRho (Rhogam in the United States) is given. If baby cells are present in mother’s blood, I have had as many as 900 micrograms prescribed. The package includes instructions on how to give the injection intramuscularly. It is given into the large muscle on the upper outer quadrant of the thigh. If you have to give more than 300 micrograms, you must give it in multiple sites. Injecting anything under the skin can cause harm, so be very careful you are sure of what you are doing and that you’ve had good instruction.

Rh positive sperm and Rh negative egg

— “Collecting Cord Blood: Guide for Student Midwives,” by Gloria Lemay, first published in The Birthkit Issue 35

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HEBREW LANGUAGE BIRTH ARTICLES

Some of my articles are being translated into Hebrew and published online here.

http://www.leida.co.il/page.asp?id=99197

It all looks like Greek to me, of course, but if you know anyone who would like to read about birth in Hebrew, feel free to pass it on.  Gloria

11 thoughts on “Questions & Answers for Student Midwives

  1. Thank you for your questions and answers about midwifery. It is an art that has been much maligned by the medical establishment undeservedly. It is a complicated process of learning where very many things can go wrong in urgent situations which are a matter of life and death. It is so important that these sudents are taken as seriously as their chosen profession. It is no easy job to teach how to bring life into this world safely. Thank you agin for your insights on the teaching of this crucial service.

  2. Hi Gloria,
    For those UC-ing moms, the testing can all be done with using an Eldon card, right? Or are they not accurate?
    Also, I am thinking that in an unmanaged third stage, the chances of crossing is low if not rare, and if mom wanted the shot with a positive baby, just one dose would most likely be fine? I don’t remember my midwives sending in my blood to have the amount of fetal cells checked. I just had the shot after the birth of those kids that are positive.
    I guess a UC mom could also chose to have her blood drawn within say 48 hours too so that there is time to have it tested at a lab, I suppose. Mmmm.

  3. If the Eldon card clearly a negative baby blood type, some UC parents feel comfortable ending the process there. The instructions on the card say not to make any medical decisions based on the accuracy of the card.

    I recommend that homebirth Rh neg women get going at about 24 hours to get their blood drawn and tested because there can be delays and you want to be injected with the Rhogam by 72 hours.

  4. hope you don’t mind.. I just found a discussion about rhogam and posted a link to this. Very good. I like the answer to the first question a lot too =)

  5. Gloria, can you answer something for my own personal curiosity please?

    My husband and I are both Rh neg but they still worried because of course I couldn’t *know* he was the father. I remember them giving me Rhogam in late pregnancy but not after birth. Do you know why it was done that way? I always forget the protocols because of my experience.

    • When you and your husband are both negative, the baby will ALWAYS be negative. They tested the baby’s cord blood found him to be negative and then, everything stops, because the mother will not be sensitized by a negative (neutral) baby. In future, refuse to accept the pregnancy shot if you are sure of the father.

    • I’m always astounded that people assume the mother doesn’t know (or care?) who her baby’s father is and insist that she accept prophylactic Anti-D. When I still worked in a hospital I would just ask the parents to get me a record of Dad’s blood group to put in her chart (to cover my own butt, basically) and I wouldn’t insult them by the above sort of statement.

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