Priscilla’s Biology class

During the month of January, we received an amazing guest: Priscilla Kramer.

Priscilla is a young North-American Midwife who studied and who is currently working in the State of Florida (USA).

She is levelheaded, intelligent, capable and well prepared. She has been involved in a lot of Natural Water births, home births and births at birthing centers in the USA.

With her at our side, we were able to perform a few deliveries at the Caja de Seguro Social (Panama’s Public Health System’s Hospital) and they were wonderful and caused huge impact in the Labor and Delivery Unit’s personnel, doctors, nurses and aides. The happier ones were the mothers that had the privilege of being assisted by Priscilla and experienced a gentler birth.

In future blog’s entries we’ll continue sharing the enriching experience we lived together.

Today, for example, I’m going to share with you one of these experiences.

Mason was born a few days ago, Sheila’s third son. Graciela and I have assisted her in all her children’s births: José, Ria and now Mason.

This last child was also born in water and at home, as did Ria.

It was a beautiful and gentle birth like the previous ones.

The children stayed with their father Joe during labor and arrived a few minutes after Mason’s birth.

As if it were the most natural thing in this world, they walked to their mother’s and brother’s side. There was only peace and happiness in the room.

After the placenta was expelled, Priscilla was able to answer all of Jose’s (the older brother) questions regarding how the placenta, this human and mammal organ, works.

Priscilla showed them every detail. Vessels, umbilical cord, cotyledon and placental membranes…

It was an unforgettable biology class for Sheila’s and Joe’s children.

When I live these kinds of experiences I realize that Panama’s has a long road ahead to learn about things so simple and life changing as the birth of a child into this world.

We would like to say: Thank you Priscilla for your sensitivity and lessons that we will never forget.

Dr. Rodrigo Aybar
Dra. Graciela A de Aybar

The placenta and the umbilical Cord.

When we talk to a future mom, we try to answer all her concerns, which is a continual process throughout her entire pregnancy. We do not limit the questions she can ask. The purpose is for the expectant mom to know we are there for her and we will always answer any concerns she may have.

One of the aspects that are generally hard for the future mother to understand is the placenta and umbilical cord. What they are made of, how they work and their role during the pregnancy and during labor and delivery.

We recognize how difficult it can be for a future mother to understand the role of the placenta and the umbilical cord. Once the placenta is expelled (afterbirth) along with the umbilical cord, we show it to the mother. At that point she is surprised, and with her eyes wide open and great satisfaction, she then understands what this very important organ is made of.

During ultrasounds, we often take advantage of the visuals to talk with expectant moms about the importance of the placenta, umbilical cord and membranes. During the entire pregnancy a woman shouldn’t have more than 3 ultrasounds (1 each trimester).
It is a perfect opportunity to clear any doubts.

Future moms are particularly concerned about the umbilical cord. Often scared that “something could happen” with it during the pregnancy or during childbirth. With great fear and quite insistently they ask about the possibility of a nuchal cord, known as the umbilical cord wrapped around the child’s neck.

We will try to explain some important factors:

The placenta is an extraordinary vascular organ. It is everything for the baby meaning that it supports hormonal, metabolic, respiratory, protective and immunological functions, and many more.
We want to point out two important elements that reach the baby via the mother through the placenta and the umbilical cord. Those are the Glucose (energy and food) and Oxygen (breathing) molecules.
Without these two elements human life is basically impossible.
The blood that comes from the placenta to the baby comes from two umbilical arteries along the cord. The blood that returns from the baby to the mother travels through a single umbilical vein.
The umbilical cord is soft and elastic and very resistant. It floats in the amniotic fluid and surrounds the baby.
When the baby moves and as he grows, often he will press against it often.

What does it feel like, what happens to the fetus/baby when the umbilical cord is pressed or squeezed?
The answer is quite simple: He is left without air/ oxygen to breathe, without food (glucose). The same happens with an adult if you cover their mouths and nose and isn’t allowed to breathe.

How does the fetus/baby react when this happens?

The answer is also simple, he tries to get out, to move and “escape” from that dangerous and uncomfortable situation.
This is a vital exercise: compressing the umbilical cord, moving, getting out of danger. The baby does this thousands of times prior to birth. Really, permanently! In other terms, the baby isn’t dumb; he knows he has to do this. This vital exercise while in the womb will help him/her for life.

The baby’s Fetal Heart Rate (FHR), meaning the amount of heartbeats from the baby’s heart is quite stable. It fluctuates between 120 to 160 beats per minute. It is easy to find and listen to with a Doppler placed directly on the mother’s womb.

If the umbilical cord is pressed, what happens to the FHR? That answer is also obvious: The Fetal Heart rate drops drastically and a bradycardia occurs (slow heart rate), meaning the amount of beats per minute of the heart diminishes. It can drop to 60 – 80 bpm (beats per minute).

If the baby is uncomfortable it moves, changes position, moves a limb and rotates a little. They are perfectly prepared and programmed to face constant adversity during the pregnancy and during labor so they permanently prepare for it.

During the third and last trimester, slowly, another event interferes periodically with the process of a body delivering blood to the placenta and the umbilical cord. During the last trimester the mother will start feeling Braxton Hicks until eventually she feels real contractions.

A true breathing exercise that prepares the child for birth.
What happens?

The answer isn’t complicated: the uterus is a powerful muscle. When it contracts, it tightens and blood vessels close (the lumen the blood vessel collapses) and blood doesn’t reach the baby.

As the pregnancy progresses, the length and frequency of the contractions changes and during labor they happen every 3 minutes and can last up to 40 to 50 seconds and they are more intense.

Something similar to what happens to an adult when their heads are submerged under water for 40 to 50 seconds and only give them two seconds to breathe before plunging them again happens to the baby.
How does the baby react to this experience?

Logically this situations causes the baby stress which releases huge amounts of adrenaline and noradrenaline which alerts it and activates mechanisms that allow him to adapt which then allows him to face adversity.
In other words, uterine contractions are nature’s mechanism that prepares the baby for life outside of the uterus.

It is an extraordinary breathing exercise prior to birth.
Then, what should the birthing partner do during the pregnancy and birth?
What we do when a natural birth happens, we motivate the mother to move.

We allow her to change positions as many times as she desires. She can move freely and should avoid laying down all the time.
Offer her soft foods and liquids during labor and delivery.

Avoid binding the mother or any type things that could restrict her movements such as IV’s and fetal monitors.
The child tells the mother when they are uncomfortable with a position and asks the mom to move. Meaning, when the child feels asphyxiated briefly, it does things such as kick, move the head, rotates for the mother to change and be allowed to move out of that uncomfortable feeling that comes from lack of breathe.

Avoid the use of synthetic Oxytocin that produces intense and frequent contractions of the uterus and do not allow the mother or child to rest during delivery.
Allow the mother’s oxytocin to do the job. It enters the mother’s bloodstream naturally and not continuously how it happens when administered via an IV.

Avoid rupturing amniotic sac as much as possible or completely avoid it. That way the amniotic fluid cushions the pressure that the uterus could have on the umbilical cord.

When the baby is born: do not cut the umbilical cord immediately and do it when it stops beating or pulsating spontaneously a few minutes after birth.

If any degree of pressure had been placed on the umbilical cord in the last few minutes of birth, delaying clipping the umbilical cord until it has stopped pulsating allows for the compensatory tachycardia (fetal heart rate speeds up – FHR) compensate for “lost time” and send the child the Oxygen and Glucose molecules the child direly requires at birth (FHR increases to 180 BPM).
The placenta revives the baby after birth.
Finally, allow the placenta, the umbilical cord and related membranes to be expelled softly, by itself without any unnecessary maneuvers which ensure that it remains intact and we avoid further discomforts for the mother who just completed such an incredible task and we avoid interrupting both mother and child that spiritual moment of their lives.

To show it (the placenta) so that the mom can better understand and see this very important organ that managed to nourish her child during the course of the pregnancy.

Dr. Rodrigo Aybar
Dra. Graciela de Aybar

Is Episiotomy necessary?

When a future mother goes to the beginning of her prenatal control, she always asks about the episiotomy.  In Panama it is known as “stinging” or “cutting”.  It is a real torment.  To feel that it’s obligatory in order to have a natural birth, the doctor has to cut the vulva and the perineum!

The answer is NO!

Medicine based on evidence, which means that after multiple studies with large groups of populations, recommends clearly not performing a routine episiotomy in any birth.

Every woman knows what they have to do for her not to get hurt.  The only thing we do is discuss during pregnancy how does she have to let the head and the body of the baby out, slowly so that she doesn’t have any lacerations.  Surprisingly they all make it. And it’s not even hard.

 The last time I did an episiotomy was 12 years ago and personally I attend births every day.

If a tearing or laceration is produced, it is always going to be less than a cut with a scissor that is very anti natural and painful.  Little lacerations in the vaginal membrane may be produced, that most of the times doesn’t require any stitching, because the vaginal tissue it’s extremely noble and heals wonderfully.  The pain after birth it is enormously greater if an episiotomy was performed in comparison with the lacerations that may occur.  Also the risk of an infection it is significantly smaller and the sexual life doesn’t suffer any changes of any kind to the women who hadn’t had and episiotomy performed.

So the answer is NO. It isn’t necessary to perform a routine episiotomy and it’s scarcely the situations when it’s necessary to do it, independently of the existence of previous births or not.

Dr. Rodrigo Aybar