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midwife muse -- a community midwifery bulletin board
Tuesday, 13 January 2004
Karen has decided to add a THIRD OREGON CLASS in Neonatal Resuscitation For Midwives! There will be an additional class on Wednesday in Portland. See for details -- or contact kate mclachlan to learn more or to sign up!

Karen will also be holding a class in Belleview Washington on February 1st. Contact Heather Shelley for details: Phone: 425-401-8643 or 425-246-2097 cell

or Email:

Posted by midwiferyeducation at 8:32 PM PST
Sunday, 4 January 2004
meconium -- suctioning - bulb versus delee
Several centuries ago, the early midwifery and OB books said that a baby born with thick meconium might be in trouble -- especialy if it was small, or if the labor had been difficult, or if the baby's heart had been slow or erractic during labor. If meconium is light -- what the old books called "coloured waters" - the baby rarely showed any effects. After all these centuries it seems we haven't added much new to this. We have made great progress in the last twenty years in TREATING babies with Meconium Aspiration Syndrom (MAS), and what about prevention? We've developed many new suctioning methods, but do they succesfully prevent MAS?

Here a large study out of Singapore confirming the old knowlege -- that Meconium Stained Amniotic FLuid (MSAF)is not uncommon, yet MAS is rare without the combination of thick meconium and poor Fetal Heart Tones. They found the incidence of MAS with light meconium staining was 0.3%, with moderate it was 5.8%,and thick was 61% -- and that poor heart-tones were a deciding factor. This study had nearly 2000 MSAF babies, and that 3out of a thousand number (for light mec) is rather reasuring, considering the incidence of meconium staining reportedly ranges from about 15% to 28%.

That "range" is interesting, and some study locations report a much higher range than others. Just annecdotally, most midwives see a much lower incidence of MSAF (of course we deal primarily with low risk pregnancies), but many of us have wondered if the rate is increasing. Seems it just might be according to this large 1991 hospital study which concluded "the incidence of meconium-stained amniotic fluid increased 40.9% over the study period, from 18.8% in 1980 to 26.5% in 1986". They give no guess of "Why".....but i personally wonder if the advent of EFM (with supine maternal position) and epidurals might be a factor. Or maybe the rise in rate of induction? Or augmentation? It wasn't all THAT many years ago that pitocin was a rarely used drug -- now it's almost a routine thing.

But, what should we do if MSAF occurs (assuming heart tones are reasuring)? Do we suction? And when? On the perinuem? After delivery, but before the first breath? ANd what do we use if we ARE going to suction? Some midwives are criticised if they use an old-fashioned bulb syrnge instead of a delee suction tube. Is a delee trap any better -- more effective -- than a bulb syrnge or suction tube? The DeLee was adopted without good study. It turns out that a bulb syrnge is probably BETTER than a DeLee, and this study concludes "We recommend the use of bulb suction as routine obstetric practice even in the presence of thick meconium." This one also calls a bulb syrnge the "preferable method" since it is as effective, less expensive, easier to use and safer, than a DeLee.

But does it make any difference if we suction, or when, or with which device? Here is one of many large studies concluding that MAS develops long before we ever see the baby:
"oronasopharyngeal DeLee suctioning at the perineum does not affect the rate of meconium aspiration syndrome. We speculate that meconium aspiration syndrome is predominantly an intrauterine event associated with fetal distress and that meconium in the airways is merely a "marker" of previous fetal hypoxia."

Meconium Aspiration is non-preventable. No matter who attends the birth, no matter where the baby is born and no matter which suctioning method (if any)is used. It occurs within the womb, not on the perineum. It is not predictable. Our only clue may be an poor heart rate pattern. In effect, our oldest textbooks are still accurate. We've made progress is "treating" MAS, but not in "preventing" it.

Posted by midwiferyeducation at 1:36 PM PST
Updated: Sunday, 4 January 2004 5:41 PM PST
Saturday, 3 January 2004
Want the latest link for Neonatal Resucitation ?

Parenting Magazine . They have a nice page with images of the baby in the womb.

Here are wonderful pictures of a lovely

breech birth!

Worried about a big baby? Thinking you might need to induce? WOnder what ACOG thinks about inducing to prevent macrosmia? Here's the dope on that sticky subject.

It almost seems to be some sort of secret that ACOG does NOT advise elective induction or ceserean for big babies. In thier "practice guidline" they reason that diagnosis of fetal macrosomia is imprecise, and that ultrasound is no more accurate than palpation or external estimates, and that induction isn't warranted since it doesn't improve fetal or maternal outcome.
As long as mom doesn't have diabetes -- and baby is expected under 5 kg (11 pounds)-- then a spontaneous vaginal delivery "is not contra-indicated". But read it yourself.

Here's an intersting site. Ever hear of Mayan Massage? It's one of those old folk wisdoms, and seems pretty neat!

Well,ok, this one is a political link and not related to midwifery link. But it's still pretty cool!

Post your "cool links" here!Add a "comment"!

Posted by midwiferyeducation at 5:01 PM PST
Updated: Tuesday, 6 January 2004 12:44 PM PST
What do you do -- or don't do -- for umbillical cords?
Do you put anything on them? Forbid baths? How long do you leave the clamps on? Do you clamp or not? What type of ties/clamps do you use?

I'll start with what "I"do, just to get the ball rolling. (I think it's great to discuss different ideas)

i don't put ANYTHING on cords -- not even alcohol -- although if parents insist on it, I don't forbid it.

I also recomend tub baths from birth onward. It seems to help the cords fall off quickly, limits any foul smell, and doesn't raise the risk of infection(probably actually lowers it).

Re clamping: I really really like the rubber bands!

What do y'all think?

Posted by midwiferyeducation at 4:29 PM PST
organising topics
I'm going to reset this board a bit differently by topic instead of by date.

I'll get started by setting up a list of common topics. Read comments and/or post your own comments by clicking the link at the end of each topic.


Posted by midwiferyeducation at 4:22 PM PST
Thursday, 1 January 2004
happy new year
what a WONDERFUL beginning! We have nearly a half-foot of snow outside! It's a holiday anyway......might as well sit back (somewhere warm) and enjoy the view!
we don't get snow often enough here to dread's just FUN!

Posted by midwiferyeducation at 12:19 PM PST
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 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
Saturday, 27 December 2003
OMC meeting
I had been told the location of the jan 9th meeting was changed, but apparantly that's not so.......It will be held at the usual location --the spiritual center in eugene.

Posted by midwiferyeducation at 1:25 PM PST

well, Christmas has come and gone. I don't know about most folks, but i always feel melancholy this time of year. Seeing freinds and family is wonderful, but it almost points up how fragile are our connections and how short our time together may be. The baby neices and nephews-- the young cousins - grow to be toddlers, kindergardners, teens and college age -- and it all seems to happen so swiftly. (Perhaps i'm feeling this so strongly because this is my sons first year "away" at school -- OSU - and I've discovered the empty nest syndrom is a true malady! It doesn't seem to matter that there are four still left at home-- one is gone! But, the solstice is past! The days are now just a tiny bit longer. Morning comes about ten minutes earlier each day - -and the difference is now noticible! I LOVE IT! On the midwifery front -- did anyone see a recent news article about a possible link between low-selenium levels and pre-eclampsia? It'll take a lot of work to see if there is any true link - and which is cause and which is affect. And whether supplementation works for treatment or for prevention. Butit's interesting to see another theory proposed (there've been so many over the years).

Posted by midwiferyeducation at 1:04 PM PST
Monday, 22 December 2003
I've been busy tweeking the website ( posting pictures of the novemenber conference etc. Having some troubles with the pictures -- some people can see the and some can't and it's probably my fault - but I'll figure it out eventually.
Making some cookies this evening -- that's a christmas tradition almost forced upon us isn't it? I think my kids would feel more deprived if they missed cookies than if they missed gifts!

anyway, i was adding links to the page and added the OMC link - but that webpage is still down and has been for a long time --weeks maybe? Lisa (current president) told me the next meeting is january 9,but the location is different from before?

Posted by midwiferyeducation at 9:42 PM PST

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