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physiological third stage and retained placenta in previous birth.

(16 Posts)
PavlovtheForgetfulCat Tue 13-Oct-09 22:05:37

Last birth, I had a retained placenta. There were never any reasons given. But, this is what I recall.

DD was low birth weight. I needed ventouse intervention.

I recall having injection in thigh, but cannot remember when this happened, DH thinks this was after the birth.

The cord was pulled by a midwife, and it snapped. I do not know exactly when this happened, but it was cut straight away after birth, and it is my understanding that this is normal with a managed third stage.

(I do not know why I had a managed third stage, did not ask for one).

DH and best friend who was present said that when the cord snapped, something was mentioned about it being weak, and we had alway thought this was why it snapped, rather that it should not have been pulled? hmm.

Anyway, placenta was not deliver. They attempted to inject oxytocin I beleive into my veins, but were unable to do this successfully, this was not immediate.

I had a spinal tap and manual removal of placenta several hours after birth, resulting in the placenta breaking up and having to be fished out bit by bit [ouch].

So that is the background.

I would like to ask for a physiological third stage this time, but have read that this should not be considered if retained placenta occured in previously pg, due to risk of heavy blood loss and it occuring again.

But, I do not beleive that the retained placenta was a natural occurance, but rather somthing related to something dont immediately after birth.

Should I consider this? What do I need to think about? I do not want to put myself in danger, but also, I do not want to put myself at risk of another retained placenta if it was the fault of the medical team, not my body?

Can anyone shed some light on this? Can I demand one? Should I demand one if it what I want? Should I just accept a managed third stage?

Rosebud05 Tue 13-Oct-09 22:09:21

If I was in this situation, I think my first step would be to request a copy of my labour notes to see if they give you any more details. Then I'd ask to talk it through with a senior midwife/consultant. As far as I understand, 'they' can't make you have any procedure, but it's probably best to find out as much as possible about what actually happened.

PavlovtheForgetfulCat Tue 13-Oct-09 22:11:19

How long will it take to get notes? I am 35 weeks so leaving it too late, but forgot about this! I was reading my birth plan and realised it is not mentioned, and that I wanted it in?

How do I request a copy? call the hospital? I have a consultant appt at 36 weeks in fact, so could discuss it then?

PavlovtheForgetfulCat Tue 13-Oct-09 22:41:57

Just mentioned it to DH and he agrees we will try to get notes from last birth.

I think after talking over with him again, that perhaps the midwife pulled the cord straight away thinking i had the injection, but I had not, and then they carried on with me as if it was physiological labour, but in fact had messed it up by pulling? I do recall being asked if I wanted oxytocin to help the placenta come about a while after birth, but thought that the canula/drip was that?

Oh i don't know, its all a blur!

PavlovtheForgetfulCat Wed 14-Oct-09 07:45:26

any more suggestions of what I should ask, what to expect re request for physiological third stage?

PavlovtheForgetfulCat Wed 14-Oct-09 09:21:57

I just spoke to ante natal clinic to discuss notes. Apparantly as I gave birth at same hosp last time the consultant would already have all the hand written etc notes with my current notes.

Funny that they don't ever bother to refer to them then isn't it hmm. Last time, the consultant looked at the front page of my current notes and said 'why are you here then?'.

I do not have any notes from last time, and they use the ones I provide or so it seems so I am confused as to where I get tho ones from my last birth now. Probably left it too late.

alana39 Wed 14-Oct-09 10:15:44

Pavlov I wouldn't have thought it's too late, especially as you've got another consultant appointment. Even if you don't have your notes you can still ask about the possiblity of having a physiological 3rd stage. They will continue to monitor you during that time and at our hospital if the midwife is concerned about either the level of bleeding, or the time it is taking to deliver the placenta, they will then suggest a managed 3rd stage, but at least it gives you the opportunity to see if you can deliver it naturally.

PavlovtheForgetfulCat Wed 14-Oct-09 10:19:26

I recall being told last time that the longer is was left the more likely it was that the uterus would close around it, esp a I breastfed. I guess I am worried that if i have a natural 3rd stage and it was my body not doing as it should last time, rather than them not doing it right, then I am more likely to need another manual removal. They waited for around 3 hours last time before prepping me for manual removal, which subsequently took almost an hour, i do not want that again, and I just worry that whatever route i choose will increase the risk of it happening again!

Tangle Wed 14-Oct-09 10:53:17

If you want a copy of your previous notes then the hospital have a legal obligation to provide them (I think its under the freedom of information act, but could be wrong) - they are allowed to charge you a "reasonable" amount for finding them and copying them (usually <£50), but they are not allowed to deny them to you. If the consultant already has them then it should be nice an easy for them to find them, shouldn't it!

Do you remember if your labour had been augmented at all? If you'd already had some form of synthetic oxytocin (I think its usually called syntocinon in the UK) then my understanding is that you no longer had a real choice in having a true physiological 3rd stage as your body was no longer in control of the hormones floating around it.

Standard practice in most maternity units in the UK is to give synotmetrine as the baby is born and proceed with a managed 3rd stage - to the degree that there are many NHS MWs that don't understand how a physiological 3rd stage works and so unknowingly sabotage it. In a physiological 3rd stage it is important to have skin-to-skin contact with your new baby, and for the baby to suckle as soon as it wants to (both of which are huge triggers for natural oxytocin, the hormone that triggers the womb to contract and release the placenta). It is also important to NOT have cord traction applied before the placenta has been released by the womb contracting - and as there are no external signs of when this happens its safest to have no cord traction. It is not unusual for a physiological 3rd stage to take an hour or so.

Compare this with a 3rd stage managed with synotmetrine - the syntocinon forces the womb to contract and the ergometrine starts to close the cervix. The two together tend to mean that there is a fairly tight time frame for the placenta to come out before the cervix is shut and a surgical removal is required - as MWs know there is plenty of syntocinon to contract the womb and expel the placenta it is usual to pull the cord to try and make sure it all comes out before that time has gone.

At the end of the day it is your right to refuse any or all medical intervention, but its far easier to do so if they'll make it easy for you to understand what happened before as far as possible. If I were in your position I would try hard to get hold of a copy of your notes from last time round and go through them (it sounds like they know were they are, so it shouldn't be a problem). If they recommend a managed 3rd stage, ask for the research supporting that decision (there often isn't any) and how it applies to you as an individual. "Hospital policy" isn't sufficient reason - you're not their employee and so you don't have to follow their policy. One thing to consider is that you can switch to a managed 3rd stage whenever you want - before the birth, immediately after the birth, if you show signs of a serious PPH, or if you've feel you've waited long enough and a physiological 3rd stage doesn't seem to be happening.

If you do decide to go for a physiological 3rd stage, just make sure you and your DH (or other birth partners) are fully versed on the ins and outs to make sure that it is handled appropriately.

Fingers crossed you can find everything you need to make a properly informed decision this time round, and that things go more smoothly than with your DD. (Oh, and sorry it turned out to be so long blush)

Tangle Wed 14-Oct-09 11:28:20

Having read the last couple of posts, I think you really need to understand how your last birth (labour through to the manual removal of the placenta) was managed - if you had any form of induction or augmentation then it was innapropriate to try a physiological 3rd stage and so saying that "your body" wasn't doing what it was supposed to is meaningless.

You also need to know what your hospital understands a physiological 3rd stage to be, as there are a scary number of differernt meanings.

It would also be worth finding out what the hospitals's definition of "retained placenta" and "primary PPH" are - sometimes a "retained placenta" is diagnosed if it is still in place 1/2 hour after the baby is born, even if there are no indications of any other problems and ergometrine hasn't been administered (ie there's every chance of the placenta still coming out under its own steam), and a primary PPH can be anything over 500ml (which many women won't even notice). MWs with a lot of experience in both managed and physiological 3rd stage also often state that, annecdotaly, they believe the total blood loss is the same - just with a physiological 3rd stage the initial blood loss tends to be higher where as with a managed 3rd stage the lochia tends to be heavier and last longer.

I find it concerning that you were told "that the longer is was left the more likely it was that the uterus would close around it, esp a I breastfed." - to me this suggests that the MW either didn't understand or couldn't explain how a physiological 3rd stage works, as everything I've read says that the uterus closing is a good thing and causes the placenta to be expelled - its only if the cervix closes before the placenta is out that there's a problem, and that's very unlikely to happen in a physiological 3rd stage.

You might want to try and get hold of Beverly Beech at AIMS - she's very helpful and knowledgable, and will probably be more up to speed on current research than many of the MWs (and possibly, and scarily, some of the consultants).

Fingers crossed for you.

suiledonne Wed 14-Oct-09 11:46:47

Pavlov Not sure this will be helpful but my experience on dd1 sounds similar. She was born a couple of days before due date after a short, intense labour.

She was also quite small (6lb3) despite being almost full term. I had not thought about 3rd stage at all and am still unaware if I got the injection at all. I do remember waiting and waiting and midwife asking if I felt any contractions or urge to push which I didn't. I was bf dd at this stage and just wanted to get cleaned up and back to the ward.

The midwife tugged on the cord and the cord came away from the placenta. At this point the midwife said there was nothing to be done but to have a manual removal. She called in a doctor who explained it would be easier to have it done under general anaesthetic and before I knew it I was knocked out and taken to theatre.

I had dd2 2.5 years later. Had a very fast labour again and arrived at the hospital ready to deliver. In the panic of the moment I forgot to mention the retained placenta and only thought of it when the midwife said the placenta had delivered quickly with no problem. She was shocked when I told her about the retained placenta as there is a good chance it will happen again, I think. Don't know if I had the injection that time or not either

I think in the minutes post birth it is hard to be fully aware of everything going on.

After we had dd2 DH said that the two cords were completely different to cut and that he had always felt there was something wrong with dd1's cord although we have never investigated this.

Anyway the point of all this rambling is that it doesn't necessarily meant you will retain placenta again and also I think you would be wise to investigate now so you will have your wishes followed as much as possible as I left too much to chance.

PavlovtheForgetfulCat Wed 14-Oct-09 12:08:34

Thank you tangle and sulle, both great information. sulle DD was 5lb full term, and they said that while the placenta was working fine, it was small and the cord was weak and this is why it snapped. I asked for general to have it removed and the consultant said it would be better to be awake for it. He also said it would only take 10 mins but in fact took much longer as the placenta was breaking and he had to fish it out. Luckily, my friend who is a nurse was my birthing partner along with dh and she asked to accompany me into theatre, so they let her scrub up don the green outfit and hold my hand.

tangle I do recall an injection in my thigh. I also know they attempted a canula in my hand, would not go in, so they did one in my elbow crease, but the consultant kept coming along saying it was not taking or something like that? I also had ventouse delivery, so I guess that makes it likely that it was a managed 3rd stage then?

I shall talk to the consultant next week abut my notes. I am seeing him or her to check growth of this baby due to DD not growing well last time (no known reason), but have not seen the same consultant twice! They are very hurried and dismissive, and not interested in talking, but i guess they feel there is nothing to talk about this time as baby is growing fine. Should I pre-empt it by informing them I want to talk about it, or just start the conversation when I see them?

PavlovtheForgetfulCat Wed 14-Oct-09 12:16:21

tangle I am sure this delivery will be fine. I just want to make sure I cover bases not covered last time as like suile i had not considered the 3rd stage at all, and an otherwise great birth ended with the op I had. TBH even when I look back it did not really traumatise me, in the grand scheme of things it was over relatively quickly, but I would prefer not to experience the after op again if I can help it, by being as informed as I can and doing whatever I can to reduce the risk of it happening.

I intend to bf immediately anyway, I did last time and it was the best feeling ever to feed the baby I had waited so long to meet. Just wonderful.

alana39 Wed 14-Oct-09 12:19:50

If you haven't seen the same person twice there's probably no point even trying to get a message to them in advance. Start the conversation there, go in prepared with some notes and facts to back up what you're saying based on other people's advice above, and don't let them fob you off.

Is DH going with you? Not that you need a bloke there wink but just having another person can make you stand up for yourself more, and fill in the gaps if you miss anything out.

Good luck.

PavlovtheForgetfulCat Wed 14-Oct-09 12:23:24

alana we can apparantly request when we get there that we speak to a specific consultant, but it can mean a wait. I am guessing that i would request the name on my sheet as being the name consultant to see hmm.

DH is coming with me, but mainly to see baby on the scan beforehand. He gets quite upset at MW and consultant appts as he feels they completely ignore him, right down to saying 'hello Mrs Pavlov', not "hello Mr and Mrs Pavlov' and do not respond to questions he asks directly, but talk to me! It won't stop him asking the questions though grin!!!

madmissy Wed 14-Oct-09 19:48:59

i have a thread knocking about somewhere which may help you

i recently got my midwife to go through my actual hosp notes which was very helpful as so much happened that i had no idea or recollection

its looking like i will need a c sec at the moment but if i do have vag birth i will have the injection

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