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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)

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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.

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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

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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

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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.

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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.

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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

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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.

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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

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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.

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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.

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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

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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

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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

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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

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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

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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

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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.

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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

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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

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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

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“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?

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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

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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}

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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.

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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.

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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.

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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