After the birth of the baby, you may notice that your client's caregiver applies some tension on the umbilical cord. It may even appear to you that he/she is pulling on the cord. It may look like there is more pressure being used than in reality. Attempting to deliver the placenta before it is separated from the uterine wall is both useless and dangerous. How does the caregiver know when it has separated and tension can be applied? When the placenta has separated due to hormones and the reduced size of the uterine muscles (because of evacuation of the baby), the uterus moves upward in the client's abdomen in a reaction to the placenta moving down and out through the birth canal. During the process, the uterus often changes from the somewhat oval shape to a more round shape. The umbilical cord begins to move out of the vaginal opening by 2 or more inches. There may also be a trickle of blood. What happens when the placenta does not release from the uterine wall or portions of the placenta are retained?
Placenta accreta is the term for an abnormally firm adherence of the placenta to the wall of the uterus. Although rare (approximately 1 in 2500 births), the client and caregivers may not be aware of the condition until after the baby is born and the placenta does not detach and does not follow the normal course of action as stated above. Occasionally too, small portions of the placenta may not detach. Depending on the severity of the condition, the caregiver may be able to give pain medication to offset the severe pain affiliated with manual removal of the placenta or placental pieces. Repetitive and rigorous manual attempts at removal are often successful. If this immediate and rigorous removal did not take place, postpartum hemorrhage would be significant and tremendously severe. When manual attempts are not successful, maternal hemorrhage may be so severe that an emergency hysterectomy may become necessary. It is important to note that not all retained placentas are due to pulling or tugging on the umbilical cord.
The doula should stay with her client who experiences placenta accreta. The doula may find she also must doula family members as well. Manual removal is often traumatizing ~ increasing the need for the doula to remain calm and confident on the outside, regardless of the feelings on the inside.
- Bobak, I., Jensen, M. Maternity & Gynecologic Care: The Nurse and the Family. (1989) St. Louis: Mosby Publishers.
- Nichols, F., Humenick, S. Childbirth Education: Practice, Research & Theory (2000) Saunders & Co.
- Whitely, N. A Manual of Clinical Obstetrics (1985) Philadelphia: J.B. Lippincott Company.
- Reeder, S., Martin, L., and Koniak-Griffin, D. Maternity Nursing: Family, Newborn, and Women's Health Care. (1997) Philadelphia: J.B. Lippincott Company.