Wednesday, February 25, 2009

Leopald's manoevers

According to the midwives and gynaecologists and obstetricians there are some 'manoevers' that allow you to determine in which position the baby is lying. Hard to do if you are the pregnant mum trying to feel things, but easier for the other person (plus, theres one that needs the more skilled hands).

Leopald's manoevers:
  • The initial maneuver involves the examiner placing both of his or her hands on each upper quadrant of the patient's abdomen and gently palpating the fundus with the tips of the fingers to define which fetal pole is present in the fundus. If it is the fetus' head, it should feel hard and round. In a breech presentation, a large, nodular body is felt.
  • The second maneuver involves palpation in the paraumbilical regions with both hands by applying gentle but deep pressure. The purpose is to differentiate the fetal spine (a hard, resistant structure) from its limbs (irregular, mobile small parts) to determinate the fetus' position.
  • The third maneuver is suprapubic palpation by using the thumb and fingers of the dominant hand. As with the first maneuver, the examiner ascertains the fetus' presentation and estimates its station. If the presenting part is not engaged, a movable body (usually the fetal occiput) can be felt. This maneuver also allows for an assessment of the fetal weight and of the volume of amniotic fluid.
  • The fourth maneuver involves palpation of bilateral lower quadrants with the aim of determining if the presenting part of the fetus is engaged in the mother's pelvis. The examiner stands facing the mother's feet. With the tips of the first 3 fingers of both hands, the examiner exerts deep pressure in the direction of the axis of the pelvic inlet. In a cephalic presentation, the fetus' head is considered engaged if the examiner's hands diverge as they trace the fetus' head into the pelvis.

When the baby is anterior, the back feels hard and smooth and rounded on one side of your tummy, and you will normally feel kicks under your ribs. Your belly button (umbilicus) will normally poke out, and the area around it will feel firm. When the baby is posterior, your tummy may look flatter and feel more squashy, and you may feel arms and legs towards the front, and kicks on the front towards the middle of your tummy. The area around your belly button may dip in to a concave, saucer-like shape.

If you feel the baby move, try work out what body part was moving. Remember that heads feel hard and round, while bottoms feel soft and round! It may take a lot of concentration and trying to work things out at first, but you soon get the hang of it. You may find it easier to feel your baby's position if you lie on your back with your legs stretched flat out.

If your baby is posterior, you may find that you suffer backache during late pregnancy (of course, many women suffer backache then anyway). You may also experience long and painful 'practice contractions' as your baby tries to turn around in order to engage in the pelvis.

Optimum foetal positioning

So I had a baby in today who had one painful delivery into the world. The mother, trying to hide her distress, was trying to convey her whole ordeal with 'back labour' for 24 hours and how the child proceeded to get stuck in the pelvis, due to its 'anterior positioning' with the cord around the neck. This child, needless to say, needed a little help.

So what was this 'back labour'? what was the 'anterior' positioning of the child? and what is the optimum positioning for the baby pre-labour?

Optimum positioning of the baby prior to labour should be a position called 'left occiput anterior' (LOA). This is where the child's occiput (base of the skull) is halfway facing away from the mother's back. Hard one to explain: see photo:
LifeART (and/or) MediClip image copyright 2008Wolters Kluwer Health, Inc.- Lippincott Williams & Wilkins. All rights reserved.

When the child is in this position, mothers usually complain of the child kicking the right ribs. Plus, you'll see the majority of the weight being on the left side of the pelvis/tummy.

The postion that the mother was talking about was the child being in the left occiput posterior position. It appears like the child is looking out forward and the child's back is more against the mother's spine.
In this position the mother will usually take longer to go into labour and the pelvis will be pushed to its limits with trying to expand to allow baby to engage. Its not that the baby is too big for the pelvis - it's just in the wrong position.

Due to this LOP positioning, the child's head will have the widest diameter, and cannot flex its head to get through the birth canal. Either way, its not good for mum and not good for child.
LifeART (and/or) MediClip image copyright 2008Wolters Kluwer Health, Inc.- Lippincott Williams & Wilkins. All rights reserved.

This is one of the positions that leads to 'back labour'. Meaning all the pain and contractions are felt in the back. But don't worry. Aparently it has been found in studies that up to 87% of occiput posterior babies turn to occiput anterior positioning during labour. Great!

I'll talk about trying to avoid posterior positionings in another blog. There's too much!

I also had one mum talking about 'star gazers'. This is the also another word for the posterior positioning. Basically meaning the child is looking out towards the belly.

Good website found for explaining the whole postioning thing is:http://www.homebirth.org.uk/ofp.htm


Thursday, February 19, 2009

PDA baby

I've had a few parents come into my clinic and just casually mention their child has/had a PDA.

So what on earth are they meaning? They were born with an inherant ability to tell you the time, calculate your diary, remind you of your impending appointments and meetings!?!

PDA means Patent Ductus Arteriosus. Ever heard of 'hole in the heart'? Basically its that.

"All babies are born with this connection between the aorta and the pulmonary artery. While your baby was developing in the uterus, it was not necessary for blood to circulate through the lungs because oxygen was provided through the placenta. During pregnancy, a connection was necessary to allow oxygen-rich (red) blood to bypass your baby's lungs and proceed into the body. This normal connection that all babies have is called a ductus arteriosus.

At birth, the placenta is removed when the umbilical cord is cut. Your baby's lungs must now provide oxygen to his/her body. As your baby takes the first breath, the blood vessels in the lungs open up, and blood begins to flow through to pick up oxygen. At this point, the ductus arteriosus is not needed to bypass the lungs. Under normal circumstances, within the first few days or weeks after birth, the ductus arteriosus closes and blood no longer passes through it. Most babies have a closed ductus arteriosus by 72 hours after birth". http://www.schneiderchildrenshospital.org/peds_html_fixed/peds/cardiac/pda.htm

In some babies, however, the ductus arteriosus remains open (patent) and becomes a problem, PDA. The opening between the aorta and the pulmonary artery allows oxygen-rich (red) blood to pass back through the blood vessels in the lungs, which should solely be carrying only oxygen-less (blue) blood.




















PDA is common in the preterm infant and especially when respiratory distress syndrome (RDS) is present. Also genetic kiddlies like downs syndrome and kids are more at risk if mother had german measles (rubella) during the pregnancy. PDA is the sixth most common congenital heart defect, occurring in 6 to 11 percent of all children with congenital heart disease. Patent ductus arteriosus occurs twice as often in girls as in boys.

In pre-term infants the PDA normally closes on its own within the first few weeks of life. If the PDA is in a full-term infant, it is unlikely to close on its own. The PDA can be closed by giving a prostaglandin synthetase inhibitor (e.g. indomethacin), but sometimes surgical closure is required.

So when do the doctors check for this PDA? Usually they will hear it on the initial examination once your child is born. They listen for a murmur. Sometimes you won't hear it, then they go on the signs and symptoms later on.
Symptoms of a fairly larger PDA are:
  • Bounding pulse
  • Fast breathing
  • Poor feeding habits
  • Shortness of breath
  • Sweating while feeding
  • Tiring very easily
  • Poor growth
Then its on to the tests of an echocardiogram, chest x-ray, ECG, or cardiac catheterization.

Wednesday, February 18, 2009

Lactose intolerance

I wanted to include this little tit-bit of information that I came across whilst trying to write the info about foremilk and hindmilk.

I have had a couple of mums telling me that they have been told that their breast fed children may be reacting to the amount of lactose that they are eating in their diet and may be affecting their children.

According to the La Leche League International: "Lactose intolerance is not a problem for babies. They are born with the ability to produce lots of lactase because they depend on their mother's milk for nutrition in the first year of life and the lactose in mother's milk is needed for brain development. Lactase production decreases as children get older, because in the world of mammals, milk is a food for babies, not adults. This is why some adults (especially the elderly), become gassy and uncomfortable when they eat dairy foods high in lactose, which their bodies can no longer digest. True lactose intolerance in infants is called galactosemia, an extremely rare genetic condition (approximately 1 in 30,000 US births) that is present from birth and fatal if not treated; a baby with the disorder would not gain weight well and would have clear symptoms of malabsorption and dehydration." Leeson, R. Lactose intolerance: What does it mean? ALCA News 1995; 6(1) 24-25, 27.

Yes, it is true, a high amount of lactose can affect the child/ overload the digestive system and cause the gassy symptoms with green, watery/foamy stools. However, this usually comes about by the poor breast feeding technique of too much foremilk...see my other post re: foremilk and foremilk.

No change in maternal diet (regarding lactose) is ever going to change the breast milk, the amount of lactose in breast milk is a set thing for that mum. If the child does seem to respond to decreasing the amount of dairy in the maternal diet it is more likely due to the child being sensitive to a protein from the cow's milk that CAN come through to the breastmilk.

Foremilk and Hindmilk

The statement put to me by one of my mums was concerning her production of foremilk and hindmilk when breastfeeding. She had helped her child stay satisfied longer and put on more weight by letting the child feed longer on the breast to allow the 'hindmilk' to come in.
So my question was "how long does it take for the hindmilk to come in?"

Foremilk is the watery, high in lactose milk that is meant to come in first to satisfy the thirst of the child and provide the short term energy and help for brain development. Hindmilk is the more 'fatty' satisfying milk that allows the child to grow.

Apparently according to the La Leche League International webiste: http://www.llli.org/FAQ/foremilk.html there are no different types of breast milk production cells, they all produce the same type of milk, its the fat content of the milk that is provided that varies according to how long the milk has been collecting in the ducts and how much of the breast is drained at the time. They say that the watery foremilk comes first, leaving the fat cells sticking behind in the milk ducts. The longer the child sucks, the more amount of fat cells end up coming through along with the 'hindmilk'. They describe it as the appetizer (foremilk) and dessert (creamy hindmilk).

So the question remains: how long does it take for the hindmilk to come in? Apparently it depends from person to person, each mum provides the right amount of fat content in their milk to help their child grow and devlopment. It seems the two ways to tell are: seeing how quick your milk supply comes (if you are over producing) or whether the child is getting that 'drunkeness'/ coming off the breast volontarily.

If you are overproducing milk, the child with be coming off the breast quickly and choking and spluttering - this means that your milk is coming too quick for the child and will inevitably make the child take in a lot of foremilk - which mean lots of lactose and may create gassiness and crampings, green frothy stools and less satiation (the 'colicky' symptoms). There are numerous ways of counteracting this...see link: http://www.llli.org/FAQ/oversupply.html

But, to answer the question, the best way to tell is to stay on the same breast until the child unlatches volontarily and pulls the 'milk drunk' look. The child knows when they have had enough (cool hey?). If they wake back up quickly again after 5-10mins and still seem hungry - then go on the other breast. The routine of feeding 10 mins on each breast doesn't seem to work and is appearing to be counterproductive in terms of composition. One quick note: if the child never does come off the breast on it's own accord, something is going on with the latching or positioning.

HOWEVER, there appears to be also a 'let out' clause for this understanding. In the first week of breastfeeding it seems to be quite important to make sure that the child feeds from both breasts in one feed. The mother's body needs to be 'stimulated' in a way to help get the milk production off to a good start. Hey, in a way it makes sense that you are only producing colostrum in the beginning (no worrying about foremilk and hindmilk yet). Only when you get into the routine and the milk production goes full flow...do you need to start looking at getting the right amount of time of the breast.

A good summary: the baby should be finished with the first breast before being switched to the other side - thats how long it takes....it's 'child led'. These babas are smart!