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Friday
Oct032008

Misc. Learning Pictures

I have a few photos of interesting babies and medical/midwifery goodies (and not so good-ies) that I'd like to share, especially with students. Some things you might not see very often; others you see all the time, but it's good to have a picture in your head of what it looks like anyway. I have found even the most obvious malady can be overlooked when the midwife/apprentice is looking too hard.

Comments are welcome, of course.

THRUSH

THE COMMON MEDICAL REMEDY FOR THRUSH

Nystatin typically is made with sugar as an ingredient, but the client can ask the doctor or CNM to prescribe Nystatin without sugar.

FRENULUM THAT HINDERED BREASTFEEDING AND NEEDED TO BE SNIPPED

AQUA DOULA

PUMP THAT DRAINS THE AQUA DOULA

CLOSE-UP OF AMNIOHOOK'S HOOKIE PART

BABY BORN IN THE CAUL (with THE AMNIOTIC SAC INTACT)

I learned to pull the sac off the face from mouth to nose because a baby can breathe in the sac once the nose is able to breathe. Apparently, that happened to a midwife in our area... it made sense to me, so that is how I do it.

CORD BLOOD COLLECTION KIT

CUTTING THE CORD (CORD HAS STOPPED PULSATING AND IS WHITE, BUT NOT TERRIBLY FLACCID YET)

MONITOR SENSORS - CLOSE ONE IS FOR BABY'S HEART BEAT; BACK ONE IS FOR CONTRACTIONS 

Note the center button... it is pressed down onto the belly during a contraction, giving the monitor the reading of the depth and length of the contraction. Variations/Incorrect readings from this monitor come from incorrect/sliding placement on the belly. When there is a question about the strength or length of contractions, the internal monitor is much more accurate. The description that made the most sense to me is: The external monitors are the tv's with antennas and the internal monitors, while much more invasive for mom AND baby, are like having Hi-Definition channels.

ELECTRONIC FETAL MONITOR

Keyboard is for notes to be made on the strip. In the old days, and occasionally now, nurses write directly on the strip if something like "mom off monitor" or "mom on hands and knees" demonstrates a variation in the fetal heart tones or contraction length or strength. It's important to know that the contraction monitor is zero'd out (or is supposed to be) when mom gets on the monitor or changes positions. Some women will see their contractions "off the charts" - above the top of the paper, but that usually means the monitor wasn't zero'd out at some point of change.

DELIVERY SET-UP IN HOSPITAL

From the front: Tenaculum forceps (used to stop a "bleeder" - an artery that opened during the delivery. A bleeder can kill a woman if it isn't taken care of by suturing. If suturing doesn't stop it, cauterizing does.) Dressing Forceps (These are used when something is hard to hold, usually because of blood.) Straight and curved scissors (Used for an episiotomy. They look like sharp/sharp ones, but it is hard to tell for sure. I use blunt./sharps and put the blunt side inside, close to the baby and the sharp side on the outside of the perineum.) Forceps (A wide variety of lengths of the forceps, usually used to clamp off the umbilical cord or to pull out some "trailing membranes" [when the placenta has been delivered, but there are still some membranes hanging out of the vagina). It is really important to get trailing membranes out intact, so the manuever is usually very slow and each person has their own method. I tend to go side to side, very gently. Sometimes up and down. I have seen others twirl the membranes around the forcep.) Ring forceps (up at the top, turned lengthwise on the tray, are the ring forceps. Some people use the ring forceps to get trailing membranes. We can also use the ring forceps to close off the open artery. Placenta Tray The blue tray at the top right is used to catch the placenta as it is delivered. The open, flatness allows for the placenta to be seen as a whole - to see if anything is missing. I rarely see anyone in the hospital look at a placenta. Light blue and dark blue Sterile Drapes These are used to cover a variety of areas from the thigh to using them as a protection between the sterile gloves of the doctor/midwife and the unsterile stomach of the mom when rubbing up the uterus is done (routine). Bulb Syringes Two sizes to account for the different sizes of infants. Blood Tubes Used to get cord blood to Type the baby's blood and sometimes used for drug testing and/or infections in the baby (including sexually transmitted ones). Gauze Lots of gauze used for a variety of things, usually mopping up blood to aid visualization of the area. I can't tell what the dark blue long things on the gauze are... Dr. Jen? Some docs/midwives prefer to use the Silver Placenta Bowl, but that can be used to catch hemorrhaging blood so it can be measured.

Okay, that's it for now! I hope these things were helpful.

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Reader Comments (30)

The "dark blue long things" are just a strip sewn onto the lap pads (these are bigger pieces of guaze-like fabric used to soak up blood) . Sometimes, if someone is bleeding a lot and I can't locate the source, I will use a lap pad to pack into the vagina and then the long blue strip can be clipped with a hemostat to the drape or bed so you remember you put a packing into the vagina and don't lose it or forget it. Those type of lap pads are commonly used in the operating room - and my delivery pack includes just 1 in case I need it for the above mentioned use.
There is also a needle driver in that pack, for suturing with (hopefully not.)
And I look and EVERY placenta - for completeness, to count the cord vessels, and just because placentas are cool :)

October 3, 2008 | Unregistered Commenterdoctorjen

I love your pictures. The baby in the caul is amazing! Especially with all that amniotic fluid collected at the bottom. The picture of the thrush, that looks like an intense case. I have seen just scanty or patchy growth, which can be hard to dx, but causes so much problems for Mom! The tongue tie, I would love to see a picture that shows more of the mouth, where you can really see the heart shaped tongue. Lastly the last photo, oh how I love medical equipment. It reminds me of my strong desire for school supplies!!!!!

October 3, 2008 | Unregistered CommenterCristina

My boobs burn just looking at that thrushy baby. Yeowch! We always used gentian violet though. Nasty stuff too.

October 3, 2008 | Unregistered CommenterSoirenoir

Hi there,
I'm just beginning the long journey to becoming a Midwife and I was curious about some of the tools. When and why is it necessary to perform episiotomies? I've only heard negative things, so I'm interested when a midwife uses them. This isn't a criticism, I just want all the info I can get.

Thanks,
Natana

October 3, 2008 | Unregistered CommenterNatana Gill

Natana... great question and one I hoped would be asked.

I have done 2 episiotomies since 1993 and they were both because the baby needed to get out NOW. When the midwife is looking at a head still 4+ (estimate) contractions from being born and the baby's head is ghost white or dark purple and/or fetal heart tones are horrid, an episiotomy is appropriate.

I know you said you are beginning in midwifery, but I do hope that midwives and schools are teaching WHEN an epis is appropriate. As with any midwifery/medical tool, judicious use is great, whereas indiscriminate use is abhorrent.

October 3, 2008 | Registered CommenterNavelgazing Midwife

Wow, thanks! Your answer has really been enlightening.
I'm excited about the journey, but fearful of being too indoctrinated into one way of thinking. I hope to be openminded enough to put the woman and baby's health first.
Natana

October 4, 2008 | Unregistered CommenterNatana Gill

Are their any tubs available that are not either made of plastic or lined in plastic? The blow up "fishy pools" look extremely uncomfortable to me, but this one lined in plastic doesn't look much better. Stepping on and leaning up against plastic is probably the furthest thing away from comfort that I can think of. And if plastic is absolutely necessary for some reason, what type of plastic is it? Is the baby born into a pool of chemicals leached out of the plastic?

October 4, 2008 | Unregistered CommenterJennifer (mama blogess)

Re: plastic in pools

They are what we kindly call "condoms" because each woman gets her own plastic lining; it's disposable.

I don't know what kind of plastic it is... never thought of it. Even the greenest of clients never asked. I suppose the woman would have to weigh the choices (perhaps not being submerged in water) versus the comfort of the Aqua Doula.

You could always buy your own and not use the liner, but the bottom is still plastic, so not much better.

Women who can't afford either of the two options will either use their own tubs or just use the shower... water seems to help no matter where it comes from.

I've never had anyone complain about the comfort of either the fishy pool or the Aqua Doula. I suppose in the middle of labor, when most women get in, that issue becomes a non-issue to the huge relief getting in the water is.

October 4, 2008 | Registered CommenterNavelgazing Midwife

Natana,

Don't worry about such things yet. Just your understanding of balance brings balance!

I *highly* encourage midwifery students to doula for women in the hospitals. Learn the lingo, memorize the equipment, learn to walk as the medical staff do, gracefully, dancing with the accoutrements of the L&D. You will learn SO much about birth in our culture this way, as well as garnering that balance you will be looking for. Be ready to be swayed by each "side" at times, but know that those pendulum swings are part of finding *your* center as a midwife.

Learn as much as you can about birth, not just natural birth! Don't listen to people who tell you you don't have to know about this or that because that isn't a midwife's territory anyway. It is ALL our territory. How will we recognize normal if we don't know what is abnormal? And vice versa.

But, at this jumping off point, just remain open to all you will hear and learn. Even if what you are learning is, "Egads, I sure don't want to be like her!"

And keep reading midwifery, nurse and physician blogs. You will learn loads from those in the "trenches" (so to speak).

October 4, 2008 | Registered CommenterNavelgazing Midwife

Waterbirth Int.l sells a "birth pool in a box eco" that is plastic without any phthalates. A step in the right direction....

As an apprentice in my final year, I have deep appreciation for my hospital birth doula experiences. Helps me explain to homebirth transfer clients what might happen, what to expect, side effects of potential medications or procedures, etc. And makes for a more seamless transition from midwife to grateful, respectful labor support.

October 4, 2008 | Unregistered Commenterabundant b'earth

I found the "birth tub in a box eco" here: http://www.waterbirthstore.org/index.asp?PageAction=VIEWPROD&ProdID=48 It's only $185.00, but, it's only 23 inches of water depth. That seems not deep enough to me. What is the aqua doula's depth? Of course, I would want the comfort of the water either way, eco friendly plastic or not, but it's nice to have it as an option.

October 4, 2008 | Unregistered CommenterJennifer (mama blogess)

Thank you so very much for this informative post! As a birth junkie and someone feeling pulled toward midwifery, your blog has been a wonderful inspiration to me! Your comment about encouraging all future midwives to doula in a hospital resonated with me . I have been hemming and hawing over this because I did not want to witness all of the "horrors" and unnecessary interventions that so commonly take place there. How would I be able to keep my mouth shut and not get kicked out? Would I be able to emotionally handle it?But you are so right, how can you know what is normal if you do not know what is abnormal? How can I know where my comfort level is if I don't see a variety of situations? There certainly is a lot to learn on BOTH sides and I am now beginning to see that it doesn't have to be one side pitted against the other. Balance is definitely the key word.

October 4, 2008 | Unregistered CommenterAlicia

The blue strips sewn into the gauze rags are also radio-opaque. That way if something is left INSIDE it can be visualized via x-ray.

October 5, 2008 | Unregistered CommenterBrenna

My baby was born in the caul and the nurse tried to say not to push after the head came out. I think she came out partway before she got the membranes off. My husband says the head was out and he recalls maybe the body before she pulled it off...is that possible? I didn't look in the mirror as I was on my side and didn't much care. Wish we had photos or something though, I'd love to know how far the baby can get out in the caul. The doctors (OB and family doc) seemed amazed in their reaction that baby was born in "the intact bag." I would think it wouldn't be THAT rare especially for a senior OB in a large practice.

October 5, 2008 | Unregistered CommenterDawn

Just wanted to comment on external vs internal contraction monitoring. The external monitor (the one with the button in the picture) is a simple pressure monitor. The sensor senses pressure and the pressure change is recorded on the paper. An external monitor can accurately tell when a contraction starts and stops, but it can't accurately measure strength of a contraction. Thin women, or women in who the uterus is near the abdominal wall tend to trace very big contractions and fluffier women tend to trace smaller contractions as the uterus isn't as near the surface. Position changes, where the monitor is placed on the abdomen, whether the monitor is resting likely on the abdomen or pressed in harder by belts or belly band - all these things can make a contraction look stronger or weaker. Sometimes, late in labor when contractions tend to be centered low, contractions will look much smaller on the monitor than they do earlier in labor. Even some labor nurses make the mistake of telling clients that their contractions must not be strong since they look small on the monitor, or vice versa.
For most puposes, knowing when a contraction starts and stops is enough. Occasionally, it is helpful to know the actual strength of contractions - and and internal monitor does tell strength accurately. If someone is laboring for a long time without progress, an internal monitor can tell if the contractions are "adequate" and strong enough that they should be expected to cause cervical change. I also use an internal monitor in VBAC mamas - especially if they are having pitocin and double especially if they are having an epidural and pitocin. This can prevent us from causing overly strong contractions with pitocin in a woman who can't feel them accurately with an epidural.
An internal monitor can also be used if there are fetal heart rate decelerations and the external contraction monitor is not tracing well due to maternal body shape, or if the mother is moving a lot, or whatever. An internal monitor can then tell accurately when a contraction is happening in relation to the deceleration and it can be determined if they are benign early decelerations vs. possibly ominous late decelerations.

October 5, 2008 | Unregistered Commenterdoctorjen

In my experience, it is REALLY rare to see a baby born in the caul in the hospital.

I heard a great story from a CNM friend back in the 80's... she said that a doctor worked in a hospital that believed no babies were born in the caul... it just could never happen. The doctor, prone to the natural side of things, put a $50 bounty on babies born with the membranes intact. Suddenly - and amazingly - babies were born in the caul all day long!

Even in the birth center I studied and worked in, it was rare to see babies born in the caul... because students had to learn how to rupture membranes! And if you are learning to rupture membranes, you aren't seeing babies born in them. Well, a group of experienced students, including myself as overseeing midwife, got a wild hair up our butts and put a moratorium on breaking water. The picture in this post is the first result of that string of babies born in the caul.

October 5, 2008 | Registered CommenterNavelgazing Midwife

Dr. Jen... Thank you for explaining SO clearly the mechanism of the external monitor. It is really helpful for folks to hear the nuances and you explained them perfectly. I can't thank you enough!

October 5, 2008 | Registered CommenterNavelgazing Midwife


I rarely rupture membranes in my hospital-based practice, but in my experience MOST membranes do rupture spontaneously in late labor or pushing. I have had a number of a babies born in the caul, but considering how infrequently I AROM, not as many as I would have guessed. Maybe my clients aren't doing something right nutrionally or something. I especially like upright positions for moms who are pushing with an intact bag. That way, if an amniotic fluid explosion happens, it all just hits the bed or floor. If mom is pushing semi-sitting or lithotomy, you can get a face full if you aren't paying attention :)
I especially hate to hear someone say "They had to break my water" - meaning that they believe (and were likely led to believe) that the water would never break if someone didn't get in there with an amnihook, and that something dire would happen if the membranes were left intact in late labor. I like to say that there are several situations where we may choose with good reason to rupture membranes, but they never HAVE to be ruptured unless the whole baby is out and needs to breathe. (Since so far, I haven't seen a human baby peck its way out the way a baby chick does!)

October 5, 2008 | Unregistered Commenterdoctorjen

have you had good experiences with the fishy pool. I just got one 75% off at Target and am stashing it away for our next birth, that i am hoping will be here at home. :) Such a more affordable option than an actual birth pool so i would love to hear success stories!

October 6, 2008 | Unregistered CommenterRachael

Before I had an Aqua Doula to rent, my clients and the clients of midwives I assisted all used the fishy pool if there was a waterbirth. It works great! The biggest downside is it gets cold if mom is in for any length of time and someone (or many someone's) have to schlep cold water from the pool and then pour hot water into the pool to keep the temp a stable one for mom and, eventually, babe. It isn't such an issue for the mom as it is for the ones around her.

It isn't as deep as the Aqua Doula, of course, but it works well. Just blow it up TIGHT.

October 6, 2008 | Registered CommenterNavelgazing Midwife

That picture of tongue-tie is very helpful! Even considering that I work with breastfeeding women, I've never actually seen it before. I've *heard* about it a million times, but never seen it. I think this is going to help me visualize it if/when I do encounter the problem.

October 7, 2008 | Unregistered CommenterTrish

I just have to brag - I am so geeked! I just tested my dh on these pictures and he knew every single one except Nystatin! As he says, he "knows more about birth than any man ever should". :o)

And he said 'fetal heart monitor... it's the machine that goes 'PING!'' :o)

October 9, 2008 | Unregistered CommenterNicole D

So the whole baby can be out and have an intact bag. I know the nurse was saying, "don't push" and I did anyway when the head was out...and was told by my husband it seemed that more than the head came out before the nurse pulled the bag off breaking it. I am still so very interested in knowing how far the baby got out before the nurse did that...anyone seen a whole body caul?

Also, I had a blood clot after baby was out and placenta was managed by the OB (pulled on the cord and all). Any insight as to what would cause a clot? He pulled out the placenta, and then watched for bleeding. He said, "huh, she's still bleeding, wonder what's causing that?" He then dug around somehow and said, "oh, it was a clot." Then the bleeding slowed down. I was fine, though they wouldn't let me eat or drink and kept me on observation for longer than I'm used to. Would managing the placenta do it, or pushing before at 10 cm...for over an hour and 1/2? I recall much blood when I was at home before I went to the hospital compared to my other births, and every time the nurse checked me (ever 20 minutes in 5 hours) there was clumpy blood on her gloves. No one commented on my bleeding at all outloud though. Never had a clot before...but I've also never had an OB pull the placenta out. Usually I do the birthing myself.

October 10, 2008 | Unregistered CommenterDawn

All 3 of my babies had tight frenulums and all 3 were clipped. Apparently it is a strong genetic factor that runs in the family (my side, I am pretty sure). I am really hoping that my next doesn't have the same problem because I am very curious to see if my milk supply is different. That is a good picture of it though!

October 11, 2008 | Unregistered Commenteramelia

I think *hypothetically* a baby can be born completely in the caul, but any midwife/doctor I know would pull that membrane off as soon as the head is born because the baby is going to take a breath and we don't want the kid to suffocate. I also think the membrane would stretch so much that it would break on its own, but down near the feet (if born vertex) once the baby was nearly born; it isn't meant to stretch indefinitely.

Clots are the body's way of stopping bleeding and it isn't unsual for a woman to pass (small) clots for a couple of weeks after the birth. They usually mean the mom is doing too much, causing the placental site inside the uterus to bleed. The body clots it off and it has to go somewhere, so it goes out the vagina.

Immediately after the birth, clots can come from a variety of places. Yes, I think a highly managed placental delivery causes more clots (in my experience, anyway) and I think that's because the placenta is "torn" off the uterus, opening edges of the "fingers" of the placental cotyledons in places it might not have if the placenta was left to detach on its own. (I don't know if this makes sense without knowing placentas intimately... I'm trying, though!)

So, when the sites are "raw," they bleed, then clot (because the body is trying to stop all the bleeding). BUT, some clots are so large they keep the uterus from clamping down as tightly as it needs to and until the clot is removed, there will be bleeding from the rest of the unclamped uterus. So, the clot is removed (manually or, as I do, pressing damn hard to express it) and then the uterus is able to close itself down good and hard to staunch the bleeding.

Does that explain it okay?

October 11, 2008 | Registered CommenterNavelgazing Midwife

My third son, first homebirth (physician-attended), was born in the caul. My recollection is that the doctor slit the membrane after he was completely out, but that for a moment we had an intact sac full of baby.

I'm curious -- if baby is practicing breathing amniotic fluid for weeks in utero, and then takes a final breath of amniotic fluid in the caul but outside the uterus, where does the suffocation risk come in?

October 12, 2008 | Unregistered CommenterCJ

Because once the body/cord hit the air, the entire mechanism of breathing changes. Heart chambers that were open inside the uterus, close forever and new chambers open for the first time. The same for the lungs. They practice breathing *movements*... not breathing per se. They don't breathe in liquid because the lungs aren't inflated until they are outside the uterus, but the release of uterine/vaginal pressure on their body/chest releases a reflex to inhale. This is why babies that are born underwater MUST be brought up to the surface immediately; the risk of drowning is very real in waterbirths.

This is, of course, an oversimplification of the first breath a baby makes, but is the gist of it.

October 12, 2008 | Registered CommenterNavelgazing Midwife

My daughter was born 3 weeks ago with the membranes intact and the midwives had to break the bag open. They didnt have time once her head was delivered because her body followed immediately after. She was OK for the first 15 minutes until I looked over at my husband holding her and she was very dark purple. I alerted the midwives and doctors who were concentrating on stopping my heavy bleeding by setting me up on a drip. She had to be resusitated and have her airways suctioned out. Strangly her Agpar scores were 9 at one minute 6 at five minutes and 8 at ten minutes. It took about half an hour for her to pink up and we were allowed home about 8 hours later. I didnt get to see her still in the bag of waters but my husband did and said it was an amazing sight! A friend of a frind delivered her Son with his caul intact about 9 months ago. She was in a birth pool and stood up to get out and he literally slid out with no warning and they had to fish him out of the pool and break the bag open!!

July 11, 2009 | Unregistered CommenterKerri

I'm impressed and worried because I'm pregnant and the look bad
my husband used generic viagra and now look at I'm pregnant

October 19, 2009 | Unregistered CommenterGeneric VIagra

Why, when I see such beautiful spontaneous births, and birth without medical intervention - do you still use a bulb extractor at birth. In the UK we stopped that years ago. It risks damage to the palate and delays breast feeding. x

June 26, 2011 | Unregistered CommenterJess

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