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Check the mother’s physical signs

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HealthWiki > A Book for Midwives > Chapter 13: The birth of the placenta: stage 3 of labor > Check the mother’s physical signs


In this chapter:

After the birth, you must watch the mother for signs of infection, pre-eclampsia, and heavy bleeding, all of which can be very dangerous. Check the mother's blood pressure and pulse every 30 minutes. Check her temperature every 4 hours. Check more often if you see warning signs.

Contents

Bleeding after birth

The main risk to the mother during stage 3 is heavy bleeding.

Normally, the mother pushes the placenta out soon after the birth. Then the womb contracts (tightens and shrinks) to stop the bleeding from the place where the placenta was attached. If the mother is not bleeding or having other health problems, the midwife can watch and wait while the family gets to know their new baby.

But if the mother begins to bleed, the midwife must take action. Heavy bleeding can cause the mother to be sick or very tired after the birth or can kill her. Around the world, very heavy bleeding after birth is one of the most common causes of death for women.

Most bleeding after birth comes from the place the placenta was attached. During pregnancy, the mother's blood vessels send blood through the wall of her womb to the placenta. As long as the placenta is attached to the wall of the womb, the mother will not bleed. When the placenta is born, the blood vessels can bleed too much if the womb does not quickly contract and squeeze them closed.

If the placenta has separated, even partially, but is still in the womb, it can hold the womb open. Even a small piece of placenta or a blood clot left inside the womb can keep it open in this way. When the womb is open, the mother's blood vessels continue to pump blood out and the woman will quickly lose blood. So to stop bleeding after birth, you must be sure the womb is empty and help it to squeeze into a small, hard ball.

The way you help depends on whether the woman has given birth to the placenta. After the placenta is born, rubbing the womb is a good way to contract the womb and stop the bleeding. Many women need their wombs rubbed to help them contract.

Rub the womb
The womb will usually contract and stop bleeding when it is stimulated by firm rubbing. Put your hand on top of the womb and squeeze while you move the same hand in a circle. The womb should get firm, and should be in the center of the belly, not off to the left or right. Check the womb every 1 or 2 minutes for a while. If it gets soft again, rub it until it contracts again.

Medicines to help the womb contract
Medicines can also help the womb contract and push out anything left inside. Some medicines can be given before or after the birth of the placenta, such as oxytocin and misoprostol. But another medicine, ergometrine, causes 1 strong contraction. You cannot give ergometrine until after the placenta is born and the womb is empty, or else it can cause the cervix to close with the placenta trapped inside. See more on medicines to stop bleeding.

Watch for heavy bleeding before the placenta comes

When the placenta separates from the womb, there is usually a small gush of blood. This is normal. Even bleeding a cup or more can be OK, as long as it stops quickly. But constant bleeding while the placenta is still inside is not normal. Bleeding too much after birth is the main cause of death in childbirth.

There are 3 ways a woman can lose too much blood (hemorrhage) after childbirth:

  • Fast, heavy bleeding. The mother may lose a lot of blood at once, or blood may flow heavily for several minutes. Often, she will quickly feel faint and weak. This is a severe emergency.
  • A slow trickle. This kind of bleeding is harder to notice. But any steady bleeding, even just a trickle, means the mother is in danger.
  • Hidden bleeding. This bleeding cannot be seen because blood collects in the womb or vagina. This bleeding is also extremely dangerous and is easy to miss. When there is hidden bleeding, you may not see the blood, but the woman may feel faint and weak. Her pulse will speed up or slow down, and if she bleeds for long, her blood pressure will drop. Her womb may also rise in the belly as it fills with blood.


Most bleeding after birth comes from the place where the placenta was attached to the womb. This blood is bright or dark, and usually thick. Usually, if the woman is bleeding before the birth of the placenta, part of the placenta has separated from the womb, and part of it is still attached. The placenta holds the womb open, so it cannot contract and stop the bleeding.

Sometimes, bleeding comes from a torn vagina, a torn cervix, or a torn womb. Usually this bleeding comes in a constant, slow trickle. The blood is usually bright red and thin.

Heavy bleeding, or feeling faint or dizzy after a birth, are not normal. You must act to stop the bleeding. Usually, bleeding will stop when the placenta comes out. If you cannot find the cause of bleeding, get medical help.

Watch for signs the placenta has separated

The placenta has probably separated when there is a small gush of blood and the cord looks longer.

The placenta usually separates from the womb in the first few minutes after birth, but it may not come out for some time. Signs that the placenta has separated from the womb are:

  • A small gush of blood comes from the vagina. A gush is a handful of blood that comes out all at one time. It is not a trickle or a flow.
  • The cord looks longer. When the placenta comes off the wall of the womb, it drops down closer to the vaginal opening. This makes the cord seem a little longer, because more of it is outside the mother's body.
  • The womb rises. Before the placenta separates, the top of the womb is a little below the mother's navel. After the placenta separates, the top of the womb usually rises to the navel or a little above.


If 30 minutes have passed since the birth and there are no signs that the placenta has separated, be sure the baby has started to breastfeed. Breastfeeding causes contractions, and will help the womb push the placenta out. If the placenta does not come out after breastfeeding, ask the mother to urinate. A full bladder can slow the birth of the placenta. If the placenta still does not come out, see below for how to help the mother push it out.

Help the mother push out the placenta

If the placenta does not come by itself after an hour, or if the mother is bleeding heavily, help her deliver it.

  1. Be sure the mother is already breastfeeding. If she is not bleeding too heavily, she should try to urinate.
  2. Put on clean gloves.
  3. Have the mother sit up or squat over a bowl. Ask her to push when she gets a contraction. She can also try to push between contractions. Usually the placenta slips out easily.
  4. The membranes (or bag) that held the waters and the baby should come out with the placenta. If some of the membranes are still inside the mother after the placenta comes out, hold the placenta in both hands. Turn it slowly and gently until the membranes are twisted. When they are twisted, they are less likely to tear inside. Then slowly and gently pull the membranes out.
  5. Feel the mother's womb. It should be about the size of a grapefruit or a coconut, or smaller, and it should feel hard. See what to do if it is not small and hard.

Give oxytocin

If the the mother cannot push out the placenta by itself or any time the mother is bleeding very heavily, give oxytocin to help her womb contract so the placenta can come out. Before you give oxytocin, gently feel the mother's belly to be sure there is not a second baby in the womb.

To help the placenta come out
  • inject 10 Units oxytocin
in the side of the thigh muscle
You can give 10 more Units of oxytocin after 10 minutes.
(See how to safely give an injection.)
or
  • give 600 mcg (micrograms) misoprostol
by mouth, 1 time only

Guide the placenta out by the cord

If the mother is bleeding a lot and cannot push the placenta out herself, the midwife can gently guide the placenta out by the cord.

If the mother is not bleeding, and there is no danger, do not pull on the cord. Only remove the placenta by the cord if there is an emergency.

WARNING!
Pulling on the cord is dangerous! If the placenta is stillattached to the womb, the cord may break or you may pull the woman's womb out of her body. If the womb is pulled out, the mother may die.Only guide the placenta out by the cord if you know that the placenta has separated.
  1. Check if the placenta has separated by gently pushing the womb upward from just above the pubic bone.
  2. Find the bottom of the womb. Push the womb up and watch the cord.
    If the cord moves back up into the vagina, the placenta may be attached to the womb.
    If the cord stays in the same place, the placenta is probably not attached. It is OK to guide the placenta out.
  3. Guard the womb. Put one hand on the mother's belly, just above the pubic bone. Use just a little pressure to keep the womb in place.
  4. Wait for a contraction. When a contraction comes, gently pull the cord downward and outward. Pull steadily and smoothly. A sudden or hard pull can tear the cord. Ask the mother to push while you are guiding the placenta out.
  5. If the womb seems to move down as you pull the cord, STOP. If you feel the cord tearing, STOP. If the mother says that the pulling hurts, or if the placenta does not come out, STOP. The placenta may still be attached. Wait until the next contraction and try again.
  6. Gently pull the cord until the placenta comes out.
  7. Rub the womb.


If the placenta still does not come out, and the mother is still bleeding, or if she feels faint or weak or shows other signs of shock, she is in great danger. Get medical help right away.

3 women and a man speaking; the man holds a woman, and 1 woman holds a baby.
I cannot stop the bleeding. Let's go to the hospital.
I'll watch
the baby.
I'll wake my brother so he can drive us.
Hurry!

On the way to a medical center, treat the mother for shock.

Take out the placenta by hand

If you think the woman will bleed to death before you can get to a medical center, you may need to put your hand inside the womb to loosen the placenta and take it out.

WARNING!   Taking out the placenta by hand is very dangerous. It can cause serious infection, or tear the cervix, the placenta, or the womb, and cause worse bleeding. Taking the placenta out by hand is very painful for the mother, and can easily cause her to go into shock. Do not take the placenta out by hand unless it is the only way to save a mother's life.

  1. Quickly scrub your hands and arms up to the elbows with soap and boiled water. Splash your hands and arms with alcohol or betadine if you have it. Put on sterile gloves, long ones if you have them. Then do not touch anything except the cord and the inside of the mother.

  2. Put one hand on the cord to hold it steady. With your other hand, follow the cord up into the mother's vagina — you will have to fit your whole hand inside. The placenta may be detached but just sitting in the vagina or in the bottom of the womb. If so, take the placenta out, rub the womb until it is hard, and give an injection of 10 Units of oxytocin.

  3. If the placenta is still partly stuck to the wall of the womb, you may need to reach inside and peel it off the womb wall with your fingers.

    Move your outside hand up to the mother's belly to support her womb. With your inside hand, keep your fingers and thumb close together, making a cone shape. Gently follow the cord up into the womb.


    Find the wall of the womb and carefully feel for the edge of the placenta with your fingers. This may be very painful to the mother. Have someone support her, and ask her to take deep breaths.


    Pry the edge of the placenta away from the womb wall using the side of your little finger. Then carefully peel the rest of the placenta off by sliding your fingers between the placenta and the womb. (It feels a little like peeling the skin off an orange or other thick-skinned fruit.) Bring the placenta out in the palm of your hand. Be careful not to leave any pieces or clots inside.

  4. Give medicine to stop the bleeding.


To stop bleeding from the womb after the placenta is out
  • inject 10 Units oxytocin
in the side of the thigh muscle
You can give this dose again in 20 minutes if bleeding does not stop.
or
  • give 800 mcg (micrograms) misoprostol
under the tongue, one time only
The woman should dissolve tablets against her cheek or under her tongue, and then swallow any remaining parts. If she is feeling nauseous, insert the pills into her rectum. Wear a glove.
or
  • inject 0.2 mg ergometrine
in the side of the thigh muscle
or
  • give 0.2 mg ergometrine pills
by mouth
You can give ergometrine every 2 to 4 hours for severe bleeding, or every 6 to 12 hours for less severe bleeding, but continue to give the medicine until bleeding has stopped and the womb is hard, usually about 48 hours. Pills do not work as quickly as the injections.


Do not give ergometrine to a woman with high blood pressure.
5. Firmly rub the womb or use 2-handed pressure to stop the bleeding.
6. Go to a hospital as soon as possible. If the mother has signs of shock, keep her head down, and
her hips and legs up. If the mother has lost a lot of blood, start an IV if you can. If you cannot give an IV, give rehydration drink or rectal fluids. She is also in great danger
of getting an infection.

To prevent infection if it will take more than 1 hour to get medical help
  • give 1 g amoxicillin
by mouth, 1 time only
and
  • give 1 g metronidazole
by mouth, 1 time only
You will need to give more antibiotics if the woman starts to show signs of infection.
a woman with part of her womb outside the vagina.
When you see this, the womb has turned inside-out.

When the womb comes out with the placenta

Rarely, the womb turns inside out and follows the placenta out of the mother's body. This can happen if someone pulls on the cord before the placenta has separated from the womb wall, or if someone pushes on the womb to get the placenta out. It can also happen by itself — even if no one does anything wrong. An inside-out womb can bleed heavily, so work quickly but calmly.

What to do
  1. Scrub your hands and arms up to the elbows and put on sterile gloves.
  2. Quickly pour antiseptic solution (like povidone iodine) over the womb if you have any.

  3. Gently but firmly put the womb back through the vagina and cervix into its normal position.If you cannot push it back up, you may have to roll it up with your fingers.

    Push the part of the womb closest to the cervix in first, and work your way along to the top of the womb, pushing that part in last. Do not use too much force.

    If you cannot push the womb back into the right place, put it into the vagina and take the woman to a medical center. Treat her for shock.

  4. After the womb is back inside, rub it to make it hard. You may need to use 2-handed pressure to stop the bleeding. Give oxytocin, ergometrine, or misoprostol to stop the bleeding.

  5. The mother should lie on her back with a pillow, blankets, or other padding under her hips. Give her antibiotics to prevent infection.
a woman speaking to a woman who lies with a pillow under her hips.
You could get an infection because your womb came out of your body. These antibiotics will protect you.

After putting the womb back into the woman's body, get medical help.

Check the placenta and cord

Whether the placenta comes out by itself or you guide it out, you should check to see that it is all there.

Usually the placenta comes out whole, but sometimes a piece of it is left inside the womb. This can cause bleeding or infection later. To see if everything has come out, check the top and bottom of the placenta, and the membranes from the bag of waters. Also check the cord to see if it is normal.

Wear gloves when you check the placenta and membranes. This will protect you from germs in the mother's blood.

Top of the placenta
The top of the placenta (the side that was facing the baby) is smooth and shiny. The cord attaches on this side, and then spreads out into many deep-blue blood vessels that look like tree roots.

placenta with a small piece attached to it by blood vessels.
extra piece
placenta with the ends of blood vessels showing.
blood vessels go nowhere
There may be an extra piece inside the mother.

Sometimes, but very rarely, there is an extra piece attached to the placenta. Check for blood vessels trailing off the edge of the placenta and going nowhere. This may mean that an extra piece is still inside the mother.

Membranes
You can see the membranes best on the top of the placenta. They will be broken open, but check to see if they are all there.

gloved hands holding a placenta with a hole in it.
piece
missing

Bottom of the placenta
The bottom of the placenta (the side that was attached to the womb wall) has many lumps. Sometimes the bottom of the placenta will have hard white spots or dark patches. This is not dangerous. To check this side, cup your hands and hold the placenta so that all the lumps fit together. Look for a hole or a rough edge where a piece might be missing. This piece may still be inside the mother.

Carefully look at every placenta after every birth just as you would carefully look at every baby. In this way, you will learn what is normal, and be able to quickly recognize when something is not normal.

the end of a cord, showing the large vein hole and small artery holes.
vein
arteries

Cord
If you look carefully at the end of the cord, you should see 3 holes — 1 large hole and 2 small holes. These are the arteries and the vein (or vessels) that carried the baby's blood to and from the placenta.

Some cords have only 2 vessels, and some babies with 2-vessel cords have problems later on. A doctor should check these babies.

A piece of placenta is left inside the womb

If a piece of the placenta or membranes is missing, it may still be in the womb.

Help the mother push the piece out by having the baby breastfeed or by massaging her nipples as if you were removing milk by hand. If the woman is bleeding, give oxytocin or misoprostol.

If the piece does not come out, get medical help.

If the woman is bleeding so heavily that she will probably die before getting help, try to take the pieces out of the womb yourself.

  1. Scrub and put on sterile gloves.
  2. Fold a piece of sterile gauze over your fingers. The womb is very slippery, and the gauze will
    help you scrape up small pieces of placenta. (Or tie a string to a strong piece of woven material like gauze, sterilize it, and keep it in your birth kit. The string will stay outside the mother so that you can easily pull the gauze out.) Be sure to use strong material that will not break apart and leave bits inside the mother's womb.
  3. Reach your gauze-covered fingers into the mother's womb and try to wipe out any pieces of placenta or membranes that are inside. This will be very painful for the mother. Make sure to explain what you are doing and why you are doing it — that any pieces of tissue left in the womb will make it impossible for her womb to contract and stop bleeding.
  4. After the pieces are removed, give antibiotics to prevent infection.


Even if you succeed in removing the piece of placenta from the womb, the mother still needs medical help. She may need a blood transfusion, and she is in danger of getting a serious infection. Take her to a medical center as soon as you can.

Watch for bleeding after the placenta is born

Womb stays soft

The most common reason a mother bleeds heavily after the birth is because the womb will not contract. Instead, the womb grows larger and feels soft after the placenta comes out.

The womb may stay soft because:

  • the mother's bladder is full.
  • there is a piece of placenta or membrane still inside the womb.
  • the womb needs more oxytocin to make it contract.
  • the womb needs more stimulation to make it contract.
  • the womb is infected.
What to do

If the womb is soft, there are simple ways to make it firm:

Check the placenta again to see if there is a missing piece
A piece of placenta still in the womb can keep it from contracting completely.

Breastfeeding makes the womb contract and stop bleeding

Help the mother breastfeed
When the baby sucks, the mother's body makes its own oxytocin. Oxytocin makes the womb contract just as it did during labor. This helps slow the bleeding.

Help the mother urinate
When the mother urinates, her womb may be able to contract more easily. If she cannot urinate after 4 hours, she may need to have a catheter (tube) put into her bladder to help her urinate. See how to help a
woman urinate and instructions for using a catheter.

a midwife touching a woman's belly while speaking with her.
Do you feel your womb?
Yes. It's round and hard.
Check it every few hours. If you start to bleed, or your womb feels soft, rub here until it gets hard.

Rub the womb
See how to rub the womb. Teach the mother and her family how to check the womb and how to rub it to make it contract.

Give medicines
If rubbing the womb does not stop the bleeding, give the mother oxytocin, ergometrine, or misoprostol.


Use 2-hand pressure on the belly
If bleeding is very heavy, and rubbing the womb does not stop the bleeding, try 2-hand pressure on the mother's belly.

Scoop up the womb, fold it
forward, and squeeze it hard.

Rub the womb until it gets hard.

Cup one hand over the top of the womb. Put your other hand above the pubic bone and push the womb towards your cupped hand. You should be squeezing the womb between your two hands.

As soon as the bleeding slows down and the womb feels firm, slowly stop the 2-hand pressure.

If you know of herbs or plants that stop bleeding and are safe, you can give those now. Do not put any herbs or plants in the vagina.

2 women speaking while 1 of them holds a plant.
Is this the plant you use to stop bleeding?
Yes. Boil it to make a tea, and then have the mother drink it.


Give pressure inside the vagina
If nothing else will stop the bleeding, try pressure inside the vagina.

  1. Scrub your hands and put on sterile gloves.
  2. Explain to the mother what you are doing.
  3. Make your hand as small as possible and put it into the vagina. Move your hand to the back of the vagina, above the cervix, and make a fist. Do not put your hand in the womb. Move gently — your hand will hurt the mother.
  4. With your other hand, hold the womb from the outside. Move the womb down towards your fist, and squeeze the womb as you move it. The womb should begin to harden.
  5. When the womb feels hard, slowly let go of the top of the womb and take your other hand out of the vagina. Pull out any clots of blood in the vagina with your hand.
  6. If you know how, start an IV.


Watch the woman carefully until the bleeding stops
Keep the womb squeezed down until it is firm and the bleeding stops. If the mother has any signs of shock, treat her for shock and take her to a medical center right away.

Torn vagina

If the mother is bleeding heavily and the womb is hard, she may be bleeding from a tear in her vagina. You may need to feel inside with a gloved hand to check for a tear. Learn about tears and how to sew them.

If you are not able to sew a tear that is bleeding heavily, try to slow the bleeding and get medical help immediately. Roll up 10 to 15 pieces of sterile gauze or another small, sterile cloth into a thick pad and push it firmly against the bleeding part of the tear. Hold it there until you get to a medical center.

Shock

When someone bleeds heavily she may go into shock. If a mother is bleeding, before or after the placenta comes out, watch for these signs:

  • dropping blood pressure
  • feeling faint, dizzy, weak, or confused
  • fast breathing
  • pale skin and cold sweats
  • sometimes loss of consciousness
  • fast pulse, over 100 beats a minute, that feels thin and faint


A woman in shock needs help fast. You must treat her for shock to save her life.
To help a woman in shock, get medical help. On the way:

  • have the woman lie with her feet higher than her head, and her head turned to one side.
  • keep her warm and calm.
  • give her fluids. If she is conscious, she can drink water or rehydration drink. If she is not conscious, give her rectal fluids or an IV.
  • if she is unconscious, do not give her anything by mouth — no medicines, drink, or food.

You may be able to get an anti-shock garment that uses pressure on the legs and lower body to help prevent shock in emergencies.

Note: Women who are in poor health before giving birth are more likely to have serious problems from bleeding after the birth. Helping women eat well and avoid sickness during pregnancy is one of the best ways to prevent problems during birth.



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