I am sure all know the 3 P's

Passage
Passenger
Power
placenta
well finally seen the 4th one in A text book!
Physche
it claims that the ability to have adequate 2nd stage can be effected by:
-fear
-mothers confidence in her ability
-support she recieves
-response from health care workers
-labor enviroment
it also states that for women who feel overwhelmed, the psycological stress added to the physical stress
interferes with labor progress
there were a few others but i can not recall them at the moment.
I always thought the physche had a great effect on labor and birth. finally someone agrees with me

Hearing the Fetal Heartbeat

by Marjorie Greenfield, M.D.

reviewed by Marjorie Greenfield, M.D.
If you're like most parents-to-be, hearing the fetal heartbeat for the first time is an exciting moment. Even
if you've already seen the embryo on an ultrasound, there's something about that steady little drumbeat
that makes you realize that you really, truly are going to have a baby soon. Here is some information
about when you would expect to hear the baby's heart beating and what those sounds mean.

The fetal heart

The embryonic heart starts beating 22 days after conception, or about five weeks after the last menstrual
period, which by convention we call the fifth week of pregnancy. The heart at this stage is too small to
hear, even with amplification, but it can sometimes be seen as a flickering in the chest if an ultrasound is
done as early as four weeks after conception.

The Doppler instrument

After the 9th or 10th week after your last menstrual period, you might be able to hear your baby's
heartbeat at your prenatal appointment. Your obstetrical practitioner probably uses a Doppler instrument
for this purpose, which bounces harmless sound waves off the fetal heart. The way the sound comes
back is affected by motion, so a beating heart creates a change in the sound that can be picked up by the
receiver in the Doppler. Whether you actually hear the heartbeat at 9 or 10 weeks depends partly on luck-
the instrument must be placed at just the right angle. It also depends on the position of your uterus, and if
you're slim or heavy. By the 12th week, the heartbeat can usually be heard consistently, using the
Doppler instrument for amplification.
Measuring the heart rate
To measure the baby's heart rate, your practitioner will count the heartbeats for a full minute, or count for
15 seconds and then multiply by four. Some of the instruments eliminate the need for this by providing a
readout of the rate. And some practitioners are so attuned to the normal range that they listen carefully
and only count if it seems high or low.

At times, the Doppler picks up sounds from the mother's side of the placenta and relays her heartbeat
instead of the fetus'. A normal heart rate for the mother is under 100, but the baby's should be over 120,
so they sound different. If there is a question, the practitioner will feel the mother's pulse and see if it's the
same as what he's listening to through the Doppler instrument.

Interpreting the fetal heart rate

A normal fetal heart rate usually is between 120 and 160 beats per minute. While rumors abound, the
truth is there is no difference between girls' and boys' rates, so knowing if the heart beat is fast or slow
can?t help you to choose baby clothes or room decor. The loudness or quietness of the heartbeat also
doesn't mean anything. The sound has to do only with the volume controls on the instrument, as well as
the distance and angle from the heart to the Doppler. So don't worry if it sounds quiet or far away
sometimes.

In a twin pregnancy, it can be hard to distinguish the two heart rates, especially if they are similar. Your
practitioner will listen at different places on the uterus, and try to identify two distinct rates. If there is a
real question whether both babies were heard, ultrasound can be used to see each twin's heart.

Listening for the heartbeat without amplification

Starting at about 20 weeks, the heartbeat can be heard without Doppler amplification. A special
stethoscope called a fetoscope can be used, or the bell (concave) side of a regular stethoscope can be
pressed firmly onto your abdomen. The heartbeat is best heard over the baby's back, which often seems
firm when you feel around on the uterus. If you are overweight or if the placenta is on the front wall of the
uterus, it may be difficult to hear the fetal heart by stethoscope. It gets easier later in the pregnancy.

Postpartum Hemorrhage
What is postpartum hemorrhage?

Postpartum hemorrhage is excessive bleeding following the birth of a baby. About 4 percent of
women have postpartum hemorrhage and it is more likely with a cesarean birth. Hemorrhage
may occur before or after the placenta is delivered. The average amount of blood loss after the
birth of a single baby in vaginal delivery is about 500 ml (or about a half of a quart). The average
amount of blood loss for a cesarean birth is approximately 1,000 ml (or one quart). Most
postpartum hemorrhage occurs right after delivery, but it can occur later as well.

What causes postpartum hemorrhage?

Once a baby is delivered, the uterus normally continues to contract (tightening of uterine
muscles) and expels the placenta. After the placenta is delivered, these contractions help
compress the bleeding vessels in the area where the placenta was attached. If the uterus does not
contract strongly enough, called uterine atony, these blood vessels bleed freely and hemorrhage
occurs. This is the most common cause of postpartum hemorrhage. If small pieces of the
placenta remain attached, bleeding is also likely. It is estimated that as much as 600 ml (more
than a quart) of blood flows through the placenta each minute in a full-term pregnancy.

Some women are at greater risk for postpartum hemorrhage than others. Conditions that may
increase the risk for postpartum hemorrhage include the following:

 placental abruption - the early detachment of the placenta from the uterus.

 placenta previa - the placenta covers or is near the cervical opening.

 overdistended uterus - excessive enlargement of the uterus due to too much amniotic
fluid or a large baby, especially with birthweight over 4,000 grams (8.8 pounds).

 multiple pregnancy - more than one placenta and overdistention of the uterus.

 pregnancy-induced hypertension (PIH) - high blood pressure of pregnancy.

 having many previous births

 prolonged labor

 infection

 obesity

 medications to induce labor

 medications to stop contractions (for preterm labor)

 use of forceps or vacuum-assisted delivery

 general anesthesia

Postpartum hemorrhage may also be due to other factors including the following:

 tear in the cervix or vaginal tissues

 tear in a uterine blood vessel

 bleeding into a concealed tissue area or space in the pelvis which develops into a
hematoma, usually in the vulva or vaginal area

 blood clotting disorders such as disseminated intravascular coagulation

  placenta accreta - the placenta is abnormally attached to the inside of the uterus (a
condition that occurs in one in 2,500 births and is more common if the placenta is
attached over a prior cesarean scar).

 placenta increta - the placental tissues invade the muscle of the uterus.

 placenta percreta - the placental tissues go all the way into the uterine muscle and may
break through (rupture).

Although an uncommon event (one in 2,000 deliveries), uterine rupture can be life threatening
for the mother. Conditions that may increase the risk of uterine rupture include surgery to
remove fibroid (benign) tumors and a prior cesarean scar in the upper part (fundus) of the uterus.
It can also occur before delivery and place the fetus at risk as well.

Why is postpartum hemorrhage a concern?

Excessive and rapid blood loss can cause a severe drop in the mother's blood pressure and may
lead to shock and death if not treated.

What are the symptoms of postpartum hemorrhage?

The following are the most common symptoms of postpartum hemorrhage. However, each
woman may experience symptoms differently. Symptoms may include:

 uncontrolled bleeding
 decreased blood pressure
 increased heart rate
 decrease in the red blood cell count (hematocrit)
 swelling and pain in tissues in the vaginal and perineal area

The symptoms of postpartum hemorrhage may resemble other conditions or medical problems.
Always consult your physician for a diagnosis.

How is postpartum hemorrhage diagnosed?

In addition to a complete medical history and physical examination, diagnosis is usually based
on symptoms, with laboratory tests often helping with the diagnosis. Tests used to diagnose
postpartum hemorrhage may include:

 estimation of blood loss (this may be done by counting the number of saturated pads, or
by weighing of packs and sponges used to absorb blood; 1 milliliter of blood weighs
approximately one gram)

 pulse rate and blood pressure measurement

 hematocrit (red blood cell count)

  clotting factors in the blood

Treatment for postpartum hemorrhage:

Specific treatment for postpartum hemorrhage will be determined by your physician based on:

 your pregnancy, overall health, and medical history

 extent of the condition
 your tolerance for specific medications, procedures, or therapies
 expectations for the course of the condition
 your opinion or preference

The aim of treatment of postpartum hemorrhage is to find and stop the cause of the bleeding as
quickly as possible. Treatment for postpartum hemorrhage may include:

 medication (to stimulate uterine contractions)

 manual massage of the uterus (to stimulate contractions)

 removal of placental pieces that remain in the uterus

 examination of the uterus and other pelvic tissues

 packing the uterus with sponges and sterile materials (to compress the bleeding area in
the uterus)

 tying-off of bleeding blood vessels

 laparotomy - surgery to open the abdomen to find the cause of the bleeding.

 hysterectomy - surgical removal of the uterus; in most cases, this is a last resort.

Replacing lost blood and fluids is important in treating postpartum hemorrhage. Intravenous (IV)
fluids, blood, and blood products may be given rapidly to prevent shock. The mother may also
receive oxygen by mask.

Postpartum hemorrhage can be quite serious. However, quickly detecting and treating the cause
of bleeding can often lead to a full recovery.