midwife muse -- a community midwifery bulletin board
Sunday, 28 December 2003
The baby was wonderful -- gave a huge gasp as her head came out of the water; good color and great apgars. But.......... As her head was born, i felt and saw her cord was around her neck; not just "tight" but also limp. Many texts instruct you to cut the cord in these cases - but I believe it's important to deliver with an intact cord whenever possible, so I left the cord -- even though it tightened further -- and hurried the shoulders. She was clearly beginning to show some effects of the pinched cord (wrapped around her neck and under her arm) - and i think that's why she breathed so deeply, so rapidly. Babies usually take about ten to fifteen seconds before they give a full breath like that, but one of the signals telling them to breathe is a rise in carbon dioxide/drop in oxygen. This generaly happens just "after" birth, but it was happening this time during the FAST trip down the birth canal. She was born so quickly, she didn't suffer any harm...but she could have IF the bag of water had been broken earlier!
AS it was -the intact bag protected her cord from being squezed. And the intact cord allowed an additional life-support system if she'd had trouble getting her breathing started. If we had broken her water-bag earlier -- in an effort to speed up labor --this baby might have had some serious problems!
SOmetimes labors like this tempt me. I know that there's a prety good chance the birth will happen quickly if i break the bag (there's the chance it won't of course), but it could dramaticaly speed things up. But then I see something like this --where breaking the bag would likely have changed this birth from a lovely event into a frightening and possibly dangerous one. Possibly even requiring a transfer for surgery -- or a baby who needed resucitatin. Or worse.
It reconfrmed my belief about the wisdom of leaving the bag of waters intact. A birth is not a horse race! There is no prize for a faster delivery! Letting the birth proceed within it's own timing, gave us a healthy baby and a restful, slow, easy labor. A nice combination.
And a wonderful few-days-late Christmas present.
They lived up in the mountains. There was a good bit of snow and we couldn't make it down thier long driveway, so we walked the last bit. It was so quiet, peaceful, lovely to walk in the icy dark -- the reflections of christmas lights being our guide! Yeah, it was a cold walk and slippery, and Tevas sandals arent' the best winter shoes -- even with thick socks-- but the walk just made things that much more memorable! All in all, a lovely birth to a very lovely family!
but, it got me thinking about cords -- and it was amaxingly coincidental that I found an email from someone asking a question about the values of keeping those cords intact, and the benefits of delaying the time of cord clamping.
I'm going to post some references here for public view rather than just in a private email. This information is good to know -- and it's important to be reminded of from time to time (I confess i was tempted to break the bag of waters during this labor. I'm very glad the temptation was resisted!).
These days there are many refferences found online --rather than just in the books on our shelves. The issue of early cord clamping is so important that there are several websites dedicated just to this subject. One of the best is by George M. Morley, M.B., Ch. B., FACOG
who writes about how hypo-volemia from early cord-clamping can be the CAUSE of brain damage after an accident-of-labor -- and that asphyxia can often be reversed by keeping the cord intact.
Dr.Morely argues strongly against cutting cords when they are around the neck. In his words "By relieving the cord compression, (unwinding the cord from around the neck, loosening the true knot) placental circulation reverses the asphyxia and placental transfusion rapidly reverses the hypovolemia. Pulmonary resuscitation with the placental circulation intact will usually result in a pink, crying newborn (with an intact brain) within five minutes. Transfusion of oxygenated placental blood that increases blood volume by less than 50 percent prevents hypoxic, ischemic injury".
He includes a good bit of documentation.
He also reminds us that there is NO DOCUMENTATION -- ever in history -- of any benefit from early cord clamping! He writes. "Not one publication over the past 200 years, peer reviewed or otherwise, endorses the practice of immediate cord clamping; all relevant articles and opinions condemn it," and i think he's correct. I can only find the occasional annecdote or oppinion piece about theoretical benefits -- mainly being an unsupported assumption that early-cord-clamping prevents polycythemia. The lack of data doesn't seem to stop the spread of annecdotes --or cause many to question this routine and dangerous intervention. Immediate cord clamping of a healthy baby has many negative health affects, and clamping the cord of an asphyxiated infant? Well... see Dr Morley's article titled "Neonatal encephalopathy, Hypoxic Ischemic Encephalopathy, and Subsequent Cerebral Palsy: Etiology, Pathology and Prevention" in the Lancet for yourself.
The website http://www.cordclamping.com/ has many intersting articles and links. The evidence for harm from early-cord-clamping is pretty overwhelming.
The evidence showing benefits is pretty overwhelming also. The Journal of Midwifery Womens Health. 2001 Nov-Dec;46(6):402-14,published an article by J.S. Mercer titled "Current best evidence: a review of the literature on umbilical cord clamping."
Here are some excerpts: "Immediate clamping can reduce the red blood cells an infant receives at birth by more than 50%, resulting in potential short-term and long-term neonatal problems... without symptoms of polycythemia or significant hyperbilirubinemia". Listed benefits include: Higher red blood cell flow to vital organs in the first week;less anemia at 2 months; increased duration of early breastfeeding. For preterm infants benefits included higher hematocrit and hemoglobin levels, blood pressure, and blood volume, "with better cardiopulmonary adaptation and fewer days of oxygen and ventilation and fewer transfusions needed". PMID: 11783688 review
Delaying cord clamping has long lasting benefits including reducing infant anemia in the first year of life. The World Health Organisatin is now considering recomending delayed cord-clamping as the preferred routine procedure.
Posted by midwiferyeducation
at 9:37 PM PST
Updated: Sunday, 28 December 2003 9:51 PM PST
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Thursday, 1 January 2004 - 10:37 AM PST
I've always agreed with this - lately I've been asking parents if we can leave the cord attached longer (like an hour or so, just until the newborn exam). I have spoken with a midwife that does this, and she finds she does not have to clamp the cord to cut it, nor does she need to use any ties on the stump.
What do you think about this?
Also, what about women who have had drugs or medications during their labor/birth? Is it better to clamp the cord early to avoid more of that getting to the baby - or is the amount that is going to go to baby already there and not much of an issue after birth?
Thursday, 1 January 2004 - 12:43 PM PST
I commonly leave cords intact untill i get around to cutting them -- often the placenta has been long delivered. I'll cut the cord first only if it's in the way -- unusualy short perhaps -- but only after it's fully stopped pulsing and gone flat and empty. Seems that usualy takes a minimum of five minutes - and sometimes a lot longer.
But -- i always do clamp/tie/or band the cord. I know some don't - but a very long time ago i saw a tie slip off of a cord about an hour after birth, ahnd the baby bled quite a bit. Maybe it's not "supposed" to happen - but it did that time - and i've always felt better if the cord is very securely tied. I usualy use one of those tiny rubber-bands --usually use an averbach but have also used kelly clamps. I like the bands best!
asfar as medications go... i don't really think that's much of a problem nowdays. WIth the old general anesthetics it was - and that's where the whole tradition of early-cord-clamping originated! The docs used a moderage anesthesia until very late second stage and then increased it to 'surgical level" at the end (or when they applied forceps). Every minute - every second --affected the baby and it was an urgent matter to get the kid out quick -- and the cord clamped as soon as possible. It was theorised that the baby might get an "extra large dose" of anesthetic with the natural cord transfusion which occurs in the few minutes right after birth. In that case - it made sense to clamp immediately. (Also, most of those kids were gonna need stimulation or resucitation to initiate breathing. The baby needed to be handed off to someone right away).
But we don't use that type of anesthetics any more, so i don't think it's an issue today.
some use the the full "active management" for third stage which requires a shot of pitocin/syntocinon with the delivery of the shoulders or within the first minute of birth. I don't know if the baby would be affected by the pit given to the mother at that time -- although i know there is some evidence that rates of jaundice might be higher if mom's are given pit in labor. But...if you followed "active management" -- seems to me you could still let the cord stay intact for a few minutes or so -- since -- by definition-- you aren't supposed to begin cord traction until the first strong uterine contraction after birth (although it seems a lot of people don't realise this!). Even if you give pit with the shoulders, there is still usaully at LEAST a several minute delay before the separation contraction (which can be expected 3 to 5 minutes later).
Monday, 12 January 2004 - 7:52 PM PST
Carol Gautschi, midwife
The Midwifery Management Of Neonatal Resuscitation
Taught By: Karen H. Strange, CPM
The Midwifery Management Of Neonatal Resuscitation is an NRP class that is specifically designed and taught for the homebirth and birth center settings. It is also suitable for EMT's, CNM's, CM's, CPM's, DEM's, RN's, doulas, childbirth educators, apprentices, helpers and anyone who may encounter a newborn in distress. The participants will have a thorough understanding of the new guidelines and should purchase the Textbook of Neonatal Resuscitation Textbook 4th Edition copyright 2000 which comes with a CD-ROM. Chapters 1 through 4 and 7 MUST be read before the class. The class is shortened by 1-2 hours if everyone has read the book. If you need Medications and Intubation please inform the sponsor so Karen can bring the extra equipment for testing and be prepared to take the test for chapters 5 and 6. Participants will be taught the practical skills in an easy to recall manner.
You can order the books from AAP/AHA/NRP at 888-227-1770, or through Cascade at 800-443-9942 at Amazon.com or Barnes and Nobles online. They take 3 weeks to receive by mail unless you pay for faster shipping.
About Your Instructor......
Karen H. Strange, CPM was trained at Maternidad La Luz in El Paso, Texas. She worked there as a staff Midwife for many years and as Clinical Director for 2 years. She has also worked as an independent home-based midwife in the Dallas/Ft. Worth area. She has been an instructor for Neonatal Resuscitation since 1992, tailoring her style for those who work in the out-of-hospital setting.
In learning about her own birth and prenatal journey, Karen changed the shape and focus of her class. Her personal journey of discovery explains why she became a midwife and why she teaches neonatal resuscitation. Since this journey began it has become her passion to share what she has learned about the conscious and aware fetus and newborn.
She has come to realize that this perspective can help one appropriately respond to a newborn, especially when they are in distress. Extensive research from the new field of Pre and Perinatal Psychology will be integrated throughout the class.
Karen's workshops are very unique and in demand around the country as one of the few instructors teaching NRP in the apprenticeship model of midwife teaching midwife and from the perspective of the conscious newborn.
Karen is on the Texas Department of Health Midwifery Board, and is chairperson of the Complaint Review Committee. She lectures and teaches on midwifery issues and pre & perinatal psychology.
The AAP/AHA Neonatal Resuscitation Program will be taught in full and all requirements for NRP will be met as well as other information specifically pertaining to the out-of-hospital setting and includes up to date information pertaining to subject.
? I WILL TEACH what is appropriate in resuscitating a newborn.
? I WILL TEACH how to feel comfortable using your equipment.
? I WILL TEACH you the counts in an easy to recall manner.
? You WILL LOVE this class when you are done.
Cost of the class
First time taking Karen?s Class:
? Paid in full by 3 weeks prior to scheduled class: $125.00
? After 3 weeks or at the door: $135.00
Renewing with previous class taken from Karen:
? Paid in full by 3 weeks prior to scheduled class: $115.00
? After 3 weeks or at the door: $125.00
Please bring a dish to share for pot-luck lunch.
Please contact the sponsor in your area to register for the class and get directions. If you have specific questions about the class you can contact Karen directly at firstname.lastname@example.org.
?When: Feb 1st
?Where: Bellevue, WA (exact location TBA)
?Contact Person: Heather Shelley
~Phone: 425-401-8643 or 425-246-2097 cell
Monday, 12 January 2004 - 8:03 PM PST
You go Gail! Thanks again for speakin for so many of us!
I use averbach bands. Had one break once - since then, launch two of them babies on them cords. All it takes is once. Caught it before it bled, phew.
love you, c