Meconium

Meconium comes from the Greek word "meconi" which means poppi juice or opium. Meconuim is composed of all the substances that have built up in the baby’s gut during pregnancy. Meconuim is a sterile compound and is mostly water (70-80% and a number of other interesting ingredients: small bile pigment, bile acids, residue of intestinal secretions, mucus glycoprotein’s, lips and proteases etc. About 15% of babies are born with meconuim stained liquor (MAS).

Meconuim stained liquor occurs when the baby inhales meconuim during labour, birth or immediately following birth. You can see a simple explanation of MAS in utero here. Many theories have been proposed to explain the passage of meconium in utero; however, the precise mechanisms remain unclear. The fetal bowel has little peristaltic action and the anal sphincter is contracted. It is thought that hypoxia and academia cause the anal sphincter to relax, whilst at the same time increasing the production of motilin, which promotes peristalsis.

Risk factors that may cause stress on the baby before birth include:

• Aging" of the placenta if the pregnancy goes far past the due date
• Decreased oxygen to the infant while in the uterus
• Diabetes in the pregnant mother
• Difficult delivery or long labour
• High blood pressure in the pregnant mother
• Smoking
• Direct pushing
• Lack of antenatal care
• Cord involvement
• Natural therapies
• Rupture of membranes early

Induction of labour is a strong risk factor. We know that we see more meconium in induced babies. A logical guess may be that we see more meconium in postdates babies simply because postdates babies are far more likely to be induced than are 40 week.

A careful review of the recent literature indicates clearly that a policy of non-suctioning is as safe as routine suctioning at the perineum for infants born with meconium-stained amniotic fluid. Risks of intrapartum suctioning include causing the fetus to “gasp,” and causing vagal stimulation and postnatal fetal depression and / or bradycardia. Instead, the baby should be transferred quickly to the neonatal team, who will initiate  management of the neonatal airways as indicated. Evidence of the effectiveness of intrapartum suctioning comes from the results of a single retrospective cohort study indicating a non-significant trend towards improved outcomes. The results of that study have been subsequently contradicted by two other studies showing equivalent outcomes with no intrapartum suctioning.

If meconium is present during labour and birth, the pregnant should be watched more closely for signs of fetal distress. Alone, meconium staining of the amniotic fluid does not mean that a baby is suffering from fetal distress. However, since it is one sign, the labour and birth team will look for others signs and continue with the pregnancy as normal as possible without causing any discomfort.

Unsworth, J., Vause, S. (2010). Meconuim in Labour. Obstetrics, Gynaecology & Reproductive Medicine, Volume 20, Issue 10, October 2010, Pages 289-294

Amniotic Fluid

Amniotic fluid is the fluid that surrounds the fetus. Amniotic fluid is 98% water and 2% salts and cells from the baby. A pregnant woman carries about 500-1000 ml of amniotic fluid. Until the fetal kidneys started working during month four, amniotic fluid is made by the mother’s body. But after month 4, the foetus started to make his/her contribution to the amniotic fluid by urinating into it. Successful pregnancy requires the accumulation of significant amounts of water, both to support fetal growth and to allow for maternal physiologic changes.

So let’s say amniotic fluid is to be found in the amniotic cavity. It completely surrounds the embryo after the 4th week of pregnancy. In this way it insures:

• Freedom of movement for the embryo.
• Space for development of the respiratory, digestive and musculoskeletal systems.
• Absorbs blows against the mother's abdomen.
• It has antibacterial properties that provide some protection from infection.
• Serves as a back up of nutrients and fluids for the baby.
• Protect the foetus from heat loss by helping to regulate the correct foetal body temperature.
• Keeps the embryo from sticking to the placenta. Towards the outside, the amniotic cavity is delimited by the amniotic epithelium, the chorionic leave and the deciduas’ capsularis.

The amniotic fluid is a clear, watery fluid that is filtered out of the maternal blood via the amniotic epithelium into the amniotic cavity. A large portion stems also from the fetus itself (from the skin, the umbilical cord, the lungs and the kidneys). The makeup of the amniotic fluid is thus quite complex, with many maternal and fetal constituents. The main constituents are water and electrolytes (99%) together with glucose, lipids from the fetal lungs, proteins with bactericide properties and flaked-off fetal epithelium cells (they make a prenatal diagnosis of the infantile karyotype possible). Its quantity changes over the course of the pregnancy (20 ml in the 7th week, 600 ml in the 25th week, 1000 ml in the 30th to 34th week and 800 ml at birth). From the 5th month the fetus also begins to drink amniotic fluid (400 ml/day). Close to the end of the pregnancy the amniotic fluid is replaced all 3 hours, stressing the importance of this exchange between the amniotic fluid and the maternal compartment.

Amniotic fluid is also important for the health of the mother. This fluid fills the whole womb, so as the foetus grows and gains weight, no pressure is exerted on the womb itself. If this fluid were not present, the growing foetus would weigh the uterus down and the counter-pressure exerted by the uterine walls would make the normal development of the foetus impossible.

If there is a single problem with the production of this fluid, with its continuous purification or the adjustment of its volume, the natural development of the foetus is impaired. For example, if the amount of amniotic fluid is less than required, or if it is not present at all, a series of abnormalities begins to appear. Limbs wither and become deformed, joints fuse, skin loosens and, because of pressure, the face is deformed. The most serious problem is that the development of the lungs is impeded and the baby dies immediately after birth.

 

Related Video
In this pregnancy video section a whole range of videos are provided to watch which cover a whole range of subjects, from general pregnancy, complications, newborn care and even beauty.

Lowermilk, D., Perry, S. (2007). Maternity & Women's Health Care. 9th Edition. Mosby/Elsevier: St Louis, Missouri.
Underwood, M. A., Gilbert, Sherman M. P. (2005). Amniotic Fluid: Not Just Fetal Urine Anymore. Journal of Perinatology. 25, 341–348. http://www.nature.com/jp/journal/v25/n5/full/7211290a.html

Artificial Rupture of Amniotic Fluid

Amniotic fluid is a clear, slightly yellowish liquid that surrounds the foetus during pregnancy. It  is contained in the amniotic sac. The purpose of the amniotic sac is to protect the foetus from infection to cushion the foetus in the womb, a medium for foetus to grow in and thrive by maintaining a constant temperature, allowing movement to aid muscle development, protecting against infection – the membranes provide a barrier- the fluid contains antimicrobial peptides, assisting lung development, baby breathes fluid in and out of the lungs, and also plays an important part in developing many of the baby's vital internal organs, such as the lungs, kidneys and gut.

At full term, there is between 500-1000 ml of amniotic fluid. This is mostly made up of amniotic fluid secreted by the amniotic sac (the membranes). The baby also contributes urine and respiratory tract secretions into the fluid. The amniotic fluid is constantly being produced and renewed – Baby swallows the fluid; it is passed through the gut into the baby’s circulation; then sent out through the placenta. This process continues even if the amniotic membranes have broken. The amniotic fluid contains substances such as albumin, urea, uric acid, creatinine, lecithin, sphingomyelin, bilirubin, fat, fructose, leukocytes, proteins, epithelial cells, enzymes, vernix and lanugo.

Unfortunately artificial rupture of membranes (AROM)has become "routine practice". It is useful if there is delay in progress. But it really has no place in normally progressing labour. Very often the membranes will rupture just before birth. In the animal kingdom the offspring are very often born in their amniotic sacs. The research indicated that it does not shorten labour by any significant amount. It is a method of inducing labour but that is another story.  In my experience, AROM usually benefits the midwife or obstetrician. It speeds things up for them, and also gives them peace of mind as they can see whether or not there is meconium in the liquor so they can get a paediatrician ready to be present at delivery. There is no indication for it in normal labour.

I was at a workshop many years ago where a midwife was giving a talk about home birth and leaving the membranes intact. After the lecture, one of the attendees was horrified that a midwife would not perform AROM as it was so dangerous not to know if there was meconium! She definitely needed a chat! Then there was the OB/GYN who commented on labour ward protocols: " there is no reason to keep membranes intact even in a labour that is going "normally," all membranes should be ruptured because they serve no pupose at all." Of course the fact that most women report more pain is neither here nor there, because there's probably no randomised control trial that proves it! That means mother nature has got it horribly wrong for the last 100,000 years and you've managed to figured it out completely in the last 100 years!

But it is not only the providers that can be the problem, birthing mothers can be just as uninformed. I  have frequently had multiparous women request AROM for relief of pressure and I often find they tend to progress very quickly post AROM - tends to bring the head down onto the cervix and enhance uterine contractions. However, a cochrane review of the available research states that “the evidence showed no shortening of the length of first stage of labour and a possible increase in caesarean section. Routine amniotomy is not recommended for normally progressing labours or in labours which have become prolonged.”

Gabbe, S. G., Simpson, J. L,  Niebyl, J. R. Galan, H., Goetzl, L. Jauniaux, E. R. M. Landon, M.  (2007). Obstetrics: Normal and Problem Pregnancies. 5th ed. Philadelphia, PA: Elsevier Churchill Livingstone. 

Smyth, R., Alldred, S. K., Markham, C. (2007). Amniotomy for shortening spontaneous labour. Cochrane Database of Systematic Reviews. Issue 4. Art. No.: CD006167.

Private or Independent Midwives in South Africa

A Registered Midwife in South Africa is someone with a diploma or degree in  nursing. Nurse midwives work in public hospitals or clinics while others work in private hosptials as obstetrics nurses not as midiwves because all births are in the hands of obstetricians. It is so sad that when deciding whether to go public or private,  a pregnant woman need to weigh up what she want out of the birthing experience, as well as what you can afford and if their medical aid cover will absorb the costs of going private.

In South Africa, there seems to be a demand for a less technological medicalised birth. There is an increase in women who are express a preference for a birth with a private midwife. In South Africa the trend back towards delivering with a private midwife is relatively recent and the field of private practicing (independent) midwives a growing one. Midwives offer the same care as any obstetrician or general practitioner who delivers babies.

It was not so long ago when the previous government forced out all private midwives out of practice. Before 1976 all black women gave birth at home in the comfort of a midwife. Unfortunately some people still frown when I tell them to plan to have their baby born naturally and at home. It would be nice if natural home birth becomes the normality, like it used to be before medicalization of birth and the takeover of birth by men. Natural birth makes you think and I don’t think many people want to think. We have to unlearn to what was normal before and to do this will take time, determination and lots of education.

As mentioned most mothers prefer to be with a private midwife, than giving birth with an obstetrician/gynecologist. The problem is there are not enough of them. We are facing a dilemma of hospital births with an expert such as an obstetrician/gynecologist or overworked, and underpaid, nurse midwives in South Africa in poor resourced facilities. We wish for more nurses to go into private practice and support the thousands of South African women, black or white who demand good care and in the comfort of their homes.

There are no statistics available of the number of babies delivered by private midwives and no register exists of the names and numbers of private midwives available. These private midwives need to be registered with the South African Nursing Council every year as a professional Midwife.  She also needs to be registered as a Private Nurse Practitioner with a practice number.

A nurse practitioner in South Africa is a nurse who has been trained in general nursing and midwifery and who has additional skills gained from additional course work. These nurses are usually experienced in a certain field in which they practice. They must be registered with the Board of Healthcare Funders of SA as a Practitioner or Agency and pay a fee  after which they will be given a practice number, which must appear, on all your stationary. This is recommended but not obligatory.

Their address:

P O Box 2324, Parklands 2121

Telephone: 011 880 8900

Indemnity insurance, although not compulsory, is a basic essential for any practitioner. The most cost effective and efficient insurance available in South Africa at present is that afforded to members of DENOSA and HOSPERSA. In addition one can take out additional insurance cover through DENOSA should you be practicing in a high-risk area such as home deliveries? Indemnity insurance is also available to members of the Occupational Health Nurses through the organisation.  

 HOSPERSA:

P O Box 12266 Queens wood 0121

Telephone 012 333 6252

DENOSA:

P O Box 1280, Pretoria 0001

Telephone: 012 343 2315 

 Licensing to prescribe and store medications are available on a limited basis through the Department of Health but there is a delay at present, while midwives planning to do home deliveries are required to register with the Local Authority for a permit. Current legislation, s38A, does not apply to nurses working in the private sector. Should South Africa consider state funding for home births as an alternative to hospital-based delivery? Midwifery services should be fully funded by the government of South Africa. This might be the answer to our overcrowded understaffed maternity units and high maternal mortality rates.

A midwife typically meets an expectant mother early in her pregnancy and sees her regularly throughout. Once labour begins, the midwife often goes to the home of the mother-to-be to check whether active labour is in progress or can also meet her patient at the hospital. The midwife attends the woman continuously during labour and delivery at the hospital. Barring any complications, the new mother can then choose to stay in the hospital or go home with her baby within hours of the birth. The midwife visits the mother and baby at home on days one, three and five and sees them at a clinic two, four and six weeks after birth. This is what birth should be like, not be controlled by surgeons, they should only take care of complications during chilbirth.