Category: Interventions

Released Waters (aka Ruptured Membranes or Water Breaks) and What to Do!

Posted by on in Induction, Interventions, Labour, Safety

Your waters just released – now what?  When you water breaks, it can be released as a few drops at a time or in a gush.  Less than 10 per cent of Pregnant people will experience waters releasing before labour has started.  When this happens, labour usually starts within 24 hours.  The other 92 per cent will release at some point during labour, usually in active labour.  Here is information on self-care and warning signs.

About 75 per cent of those with PROM at term (“premature rupture of membranes” i.e. before labour starts but at full term from 37 weeks on) give birth within 24 hours. This increases to 90 per cent within 48 hours and 95 per cent by 72 hours.  People often worry about infection after waters release.  Note that risk of infection increases with internal exams (cervical checks), fever, and being confirmed GBS-positive.

Warning Signs Regarding Released Waters

If any of these occur, seek medical attention in a timely manner. Contact your medical provider and/or go to hospital – calmly but don’t wait.

  • Waters release before 37 weeks.
  • Fluid is coloured (yellow, green, brown) or has a strong smell.
  • Any signs of fever.
  • Baby isn’t moving normally and doesn’t respond after you’ve had a snack, rested and paid attention.
  • This last one is a 911 call! If you feel a cord between your legs or at the vaginal opening, assume a “child’s pose” with bum in the air (on hands and knees with chest on the ground) and call 911.
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“Child’s Pose” with bum in the air

Self-Care After Membranes Release

  • Nothing inside! That includes internal examinations unless there’s a good reason to do one. There’s a correlation between time on first internal exam and onset of infection; the earlier the initial internal exam, the higher the risk of infection.  Risk of infections goes up with number of internal examinations.
  • Baths in your own tub at home are fine. Once you’re in active labour then baths are also fine in your private birth room.  Use showers instead when in public spaces (e.g. hotel, hospital assessment washroom).
  • Be aware of signs of infection such as fever. Take your temperature every 4-8 hours during awake hours.
  • Stay hydrated. Consider if you’ve had a steady stream of fluid or just that early trickle.  It’s also possible to have a little “high leak” without membranes fully  releasing.  A healthy mama/baby will continue to make amniotic fluid.
  • Take care of hygiene:
    • Wear a clean pad and change it often
    • When using the toilet, one wipe from front to back per tissue
    • Wash hands before and after using toilet or changing pads

Go to Hospital… or Not?

This should be discussed with your midwife or doctor at prenatal appointments ahead of time in case they have specific instructions for you.  If fluid is clear then you may have the choice to stay home or contact your medical care provider for options. Generally there are 3 things assessed at hospital:

  1. Baby’s health (by listening to fetal heart tones);
  2. Maternal health (vital signs and interview); and
  3. Presence (or absence) of amniotic fluid (the “waters”) present, usually by doing a cervical check/internal exam.

If you go to hospital and you’re not in active labour, you will likely be offered a sterile-speculum exam (think PAP test); the purpose being to confirm your waters actually released.  This is optional, although it’s not usually presented as such.  Other ways to determine if waters actually released may included simply asking the pregnant woman or dipping the testing swab into her wet pad.

  • If you previously tested “GBS positive” then your medical care provider may recommend induction.
  • If you previously tested “GBS negative” then may be offered induction but will more likely be sent home to wait for labour to start.  If labour hasn’t started within 24 hours then your medical care provider may recommend induction.

Your Options

  1. Go to hospital for maternal and baby assessment but decline internal examination.
  2. Go to hospital and consent to all of it – sterile speculum exam, maternal and baby assessment.
  3. Stay home and wait for labour to start, barring any warning signs or health complications.  Practice good self-care, be aware of warning signs, and pay attention to your baby’s movements.

Further Info:

This is the best handout I’ve seen for clients – What to do When Your Water Breaks Before Labour. It has graphics and is research based. It’s easy to understand.

Here is an excellent, detailed research article about obstetrical care of women with Premature Rupture of Membranes (PROM) at term (37+ weeks), including discussion of differences in outcomes with GBS positive and negative, options, and when labour typically starts. This document contains studies and stats.

Pregnant Woman by ocean

I teach a variety of Child Birth Education classes and prenatal workshops online for students all over.  I have been a birth doula since 2002, and have helped over 300 mothers with their births and over 1000 through prenatal classes. Learn more about my birth doula services, and contact me with any questions you may have.

Making Informed Choices

Posted by on in Birth Prep, Interventions, Safety

You know informed choice is a legal right but how do you make those choices? Here’s some guidance to help you get information and ask questions, so you can be an active participant in your health care.

In my experience, medical staff usually don’t present things as options the first time around but they are happy to answer questions when asked.

Read More “Making Informed Choices”

Delayed (Optimal) Cord Clamping

Posted by on in Baby Care, Interventions, Umbilical Cord

In spite of a mountain of evidence to support the benefits of leaving the newborn cord intact, immediate cord clamping is still routine care in many hospitals. At the time of birth, up to 40% of the newborn’s blood is in the placenta. Leaving the cord intact for at least 1-3 minutes ensures the baby gets the majority of their blood, including red blood cells, iron and blood volume. Iron deficiency can lead to anemia and neurodevelopmental delays. Adequate oxygenated blood is required to help the baby adapt to life outside the womb, including how their blood circulates and how well they breathe in the first minutes. 

The Cochrane Review, considered the highest standard globally in evidence-based health care information, contains countless articles on the benefits of delayed cord clamping. There are indisputable improved outcomes in babies born at full term and prematurely. 

The placental blood normally belongs to the infant, and his/her failure to get this blood is equivalent to submitting the newborn to a severe hemorrhage at birth.  (DeMarsh, 1941)

Yes, we’ve known since 1941!  Changing practise takes a long time indeed.

6 umbilical cords   Intact cord – birth to 15minutes (Elphanie, 2011)

Benefits of Optimal Cord Care

Benefits and positive effects last well past the newborn period!

  • 40% more blood volume.
  • 45-50% increased levels of red blood cell counts and blood iron levels.
  • Up to 45,000 stem cells (compared to 0 with immediate clamping). Stem cells provide therapeutic benefits to the baby, even into adulthood.
  • Protection from anaemia and iron deficiency for at least 6 months.
  • Better neurological development.
  • More stable vital signs; they thrive better.
  • Preemies are less likely to require blood transfusion, ventilation and oxygen therapy. 
  • Significantly lower rates and less severity of common, major newborn health issues in preemies.

 

What About Jaundice? 

Prevention of jaundice is often cited as the reason to rush the cord clamping. Leaving the umbilical cord intact does not lead to “pathological jaundice” (the kind that makes babies sick). The naturally occurring “physiological newborn jaundice” has no clinical significance, meaning it does not harm the baby. It is normal for healthy newborns to have some jaundice around day 2-3.

Objections by your medical care provider?

The World Health Organization recommends the cord stay intact for 1-3 minutes after the birth (WHO, 2014). 

The Society of Obstetricians and Gynaecologist of Canada (SOGC, 2021) states:  Delaying cord clamping for at least 1-3 minutes after delivery allows more of the baby’s blood to return from the placenta into the baby and is usually advantageous for the baby. Delayed cord clamping (anytime beyond 60 seconds after delivery) has benefits to the baby. This is because delayed cord clamping allows more blood to transfer from the placenta to the infant, which increases the baby’s red blood cells and iron stores, and reduces the risk of anemia.

“The WHO and the SOGC recommend that cord clamping should be delayed by ≥60 seconds in babies who do not require resuscitation, irrespective of the mode of delivery.” (Armson, Allan, Casper; 2018).

The practise guidelines of the Royal College of Obstetricians and Gynaecologists in the United Kingdom are to leave the cord intact for at least 1 minute and up to 5 minutes, and to leave it for longer than 5 minutes if requested by the birth mother (NICE, 2016).

Even the American College of Obstetricians and Gynecologists (ACOG) recommends a delay in umbilical cord clamping for at least 30-60 seconds after birth, “given the numerous benefits to most newborns” (ACOG, 2017).  It’s not enough but is a big step forward for ACOG, notoriously interventionist.

What About Stem-Cell or Cord-Blood Banking?

Delayed cord clamping can not be done with cord-blood banking.  Here’s some food for thought…

In British Columbia the maximum allowable blood draw volume in newborns is 5% of their total blood volume in a 30-day period. Other jurisdictions have the same guidelines. For example, a 7# baby has approximately 275ml of blood. Medical testing allows just under 14ml of that baby’s blood to be drawn and tested, total, in one month.  

The volume collected for cord-blood banking is normally 60-90 ml or more! That’s more than 5x the allowable monthly blood draws, taken all at once in the first seconds of the baby’s life. 

Have you ever noticed all the pamphlets for cord blood banking companies at your Obstetricians’ office? Have you ever seen any information on the benefits of optimal or delayed cord clamping beside those pamphlets?  “All pregnant women should be provided with unbiased information about umbilical cord blood banking options.” Society of Obstetricians and Gynaecologist of Canada (SOGC).

Did you know whoever collects the cord blood (usually a doctor or midwife) gets paid to do so by the blood banking company? 

Did you know cord-blood banking is a very expensive endeavor? You’ll pay for the kit, possibly for the courier, and then pay every year to store the stem cells. 

The Geeky Stuff: Basic Newborn, Placenta & Umbilical Cord Information

  • The placenta is nature’s neonatal life-support system.
  • The placenta will deliver oxygen to the baby until their newborn lungs transition to breathing air (30 to 90 seconds in a full-term infant).
  • Placental transfusion (blood moving from placenta to baby’s body) rate: 50% in 1 minute; nearly 100% over the next 2 to 5 minutes.
  • “Delayed” in research ranges from 30sec – 3min, depending on the researcher and study.
  • Newborns cope well with lack of oxygen for up to 20 minutes (only if the cord is intact) but low blood volume can quickly have catastrophic outcomes.
  • For comparison of the fact that up to 40% of the newborn’s blood is in the placenta, adults may go into shock and receive blood transfusions at 15 to 30% blood-loss.

References

ACOG American College of Obstetricians and Gynecologists. (2017).  Delayed Umbilical Cord Clamping After Birth. Obstet Gynecol 2017;129:e5–10. http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Delayed-Umbilical-Cord-Clamping-After-Birth

Armson, B.A., Allan, D.S., Casper, R.F. (2018). Delayed Cord Clamping and Umbilical Cord Blood Collection.  Journal of Obstetrics and Gynaecology Canada, 40 (2), 155.

Asfour, V., & Bewley, S. (2011). Cord clamping practice could affect the ratio of placental weight to birthweight and perinatal outcomes. BJOG: An International Journal of Obstetrics & Gynaecology., 118 (12), 1539-40.

Chaparro, C. M., Neufeld, L. M., Alavez, G. T., Cedillo, R., & Dewey, K. G. (2006). Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomised controlled trial. The Lancet, 367 (9527), 1997-2004.

CRYO-CELL International Inc. (2019). Cord blood collection instructions. Florida.

De Marsh, Q. B., et al. (1941).”The Effect of Depriving the Infant of its Placental Blood.” Journal of the American Medical Association (J.A.M.A.), 116(23):2568-2573. doi:10.1001/jama.1941.02820230012004

Fogelson, D. N. (2011). Delayed cord clamping grand rounds. USC School of Medicine, A.P. Dept. Obstetrics and Gynecology. South Carolina: Palmetto Health Grand Rounds.

Frye, A. (2004). Holistic midwifery, vol 2, Care during labour and birth. Portland: Labrys.

Garofalo, Milena; Abenhaim, Haim A. (2012). Early Versus Delayed Cord Clamping in Term and Preterm Births: A Review.  J Obstet Gynaecol Can;34(6):525–531.  http://www.jogc.com/article/S1701-2163(16)35268-9/pdf

Greene, A. (2008). How much blood is too much guideline. Retrieved from Dr Greene: http://www.drgreene.com/article/how-much-blood-too-much-guideline.

McAdams, R.M. (2014).  Obstet Gynecol. 123(3):549-52. doi: 10.1097/AOG.0000000000000122.

Mercer, J. S., Vohr, B. R., McGrath, M. M., Padbury, J. F., Wallach, M., & Oh, W. (2006). Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemmorhage and late onset sepsis; a randomized, controlled trial. Pediatrics, 117 (4), 1235-1242.

NICE National Institute for Health and Care Excellence (UK). (2016). Clinical guideline [CG190] Intrapartum care for healthy women and babies.  Pub Dec 2014, revised/updated Nov 2016.  https://www.nice.org.uk/guidance/cg190/ 

Reed, R. (2011). Cord blood collection: confessions of a vampire-midwife. Retrieved from Midwife Thinking: http://midwifethinking.com/2011/02/10/cord-blood-collection-confessions-of-a-vampire-midwife/

Richmond, S., & Wyllie, J. (2010). European resuscitation council guidelines for resuscitation 2010. Section 7. Resuscitation of babies at birth. J. Resuscitation , 1389-1399.

SOGC. (2021). Delayed Cord Clamping. Society of Obstetricians and Gynaecologist of Canada.  https://www.pregnancyinfo.ca/birth/delivery/delayed-cord-clamping/

Tolosa, J. N., Park, D.-H., Eve, D. J., Klasko, S. K., Borlongan, C. V., & Sanberg, P. R. (2010). Mankind’s first natural stem cell transplant. J. Cell. Mol. Med. , 14 (3), 488-95.

University of British Columbia – Children’s & Women’s Health Centre of British Columbia. (2013). Pediatric Blood Draw Guidance. Version 3.2.

Usher, R., Shephard, M., & Lind, J. (1963). The Blood Volume of the Newborn Infant and Placental Transfusion. Acta Paediatrica – Nurturing the Child , 52 (5), 497-512.

WHO. (2014). Guideline: Delayed Umbilical Cord Clamping – for improved maternal and infant health and nutrition. Geneva: World Health Organization.

Angie The Doula – Postpartum Warning Signs for Mother and Baby

Posted by on in Baby Care, Birth Prep, Interventions, Labour, Postpartum, Pregnancy, Recovery, Safety

CALL 811/DOCTOR/MIDWIFE WITH ANY WARNING SIGNS.  CALL 911 FOR EMERGENCY HELP!

If you call 911, have someone clear a path for EMT (halls, stairs etc), turn on outside light, put pets away, unlock door, clear driveway.)

Maternal Warning Signs

  • Vaginal bleeding heavy enough to soak a super-pad front to back in 1/2hr-1hr. Note: if blood starts to pour continuously, lay down immediately and call 911;
  • Foul-smelling bleeding or discharge
  • Passing clots bigger than a toonie
  • Temperature greater than 38C (100.4F)
  • Feeling flu-like
  • Uterus is painful to the touch
  • Uterus feels soft and is at or above the navel, and doesn’t respond to gentle massage
  • Sore, red, hot, tender area on leg or calf
  • Painful, swollen, red breasts or red / hot / lumpy spots
  • Sudden and extreme pain on nipples with feeding (may be thrush)
  • Persistent dizziness (call 911 if accompanied by bleeding)
  • Fainting (call 911 if accompanied by bleeding)
  • Feeling depressed, very anxious, unhappy or are crying without reason and cannot sleep or eat

Baby Warning Signs

  • Blue or grey in the lips, face or chest. Call 911.
  • Temperature of greater than 37.4C (99.3F) or lower than 35C (96.6F) (note: consider environment – e.g. is baby wrapped in layers in a hot room?)
  • Laboured breathing
  • Extra-sleepy and has not fed in the past 6-8 hours
  • Has not urinated or passed meconium (feces) in the first 24 hours
  • Yellow skin in the first 24 hours
  • Red patches, pimples or bumps
  • Vomits after every feed
  • High pitched cry or extremely irritable, inconsolable
  • Lethargic
  • Red, hot area around cord-stump; swelling of stump; discharge of pus, blood or meconium
  • Red blood in urine (note – some girl-babies get a little ‘period’ due to hormones)
  • Bright red diaper rash
  • White spots in mouth that don’t rub off (thrush)

Angie The Doula – Warning Signs During Pregnancy and Labour

Posted by on in Birth, Birth Prep, Interventions, Labour

Unusual sensations and some discomforts are part of normal pregnancies.  It is important, however, that any of the signs listed below be assessed right away.

CALL 811/DOCTOR/MIDWIFE WITH ANY WARNING SIGNS.  CALL 911 FOR EMERGENCY HELP!

If you call 911, have someone clear a path for EMT (halls, stairs etc), turn on outside light, put pets away, unlock door, clear driveway.)

Warning Signs – Seek medical advise soon, at least same day. Do not sleep on any of these or wait for them to go away on their own.

  • Reduced fetal movement that doesn’t respond to stimulation (see below) *
  • Maternal fever and chills
  • Dizziness
  • Persistent and severe mid-back pain
  • Prolonged nausea and vomiting
  • Initial outbreak of lesions or blisters in the perineal area
  • Change from normal urination – suspected bladder infection
  • Vaginal discharge with itching, irritation or a foul smell
  • Signs of bladder infection such as burning or urgent, frequent urination
  • Persistent negative feelings, low moods and/or overwhelming anxiety.
  • Gush of vaginal fluid or suspect ruptured membranes, with nothing felt to be falling out
  • Pinkish, brownish, sparse or suspected vaginal bleeding
  • Signs of labour (regular uterine contractions, waters releasing) before 37 weeks
  • If there’s a colour (yellow, brown, green) or foul odour when waters release

Danger Signs – The symptoms below may indicate a life-threatening condition, and require immediate medical attention.  Get to a hospital right away.

  • Accident or injury such as car accident or a fall (seek medical attention if required)
  • Sudden severe swelling of hands and face
  • Severe continuing headache
  • Visual disturbances (e.g., blurring of vision, spots, flashes of light)
  • Persistent, severe, sudden abdominal or pelvic pain
  • Severe epigastric pain (upper abdomen) – may feel like heartburn but more severe and not relieved by the usual tricks
  • Sudden and severe vomiting
  • Red flowing vaginal bleeding (CALL 911)
  • Persistent thoughts of self-harm, suicidal urges (CALL 911)
  • Convulsions (CALL 911)
  • Gush of vaginal fluid / suspected ruptured membranes, with a cord felt at or outside vaginal opening (cord prolapse) – get on hands and knees with buttocks higher than head (CALL 911)
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* Normal Fetal Movement:  If you’ve been busy or are unsure about movement then relax and have a meal, a small glass of juice or some fruit.  Palpate your baby to induce movement.  Pay attention to the movements.  Babies sleep.  If your blood sugar is low then so is your baby’s.  You should feel at least 10 movements over any 2 hour block and at least 1 in the first hour.   If not then seek medical attention.

Neonatal Resuscitation with Intact Umbilical Cord

Posted by on in Baby Care, Interventions, Umbilical Cord

This paper was published in Midwifery Today, Issue 102, Summer 2012

Click here for video of webinar presented to students at Midwives College of Utah based on this paper.

Abstract

This paper investigates neonatal resuscitation with the umbilical cord intact.  Research confirms numerous immediate and long-term benefits to leaving the cord intact while performing neonatal resuscitation in both term and preterm neonates, while doing no harm.   Current neonatal resuscitation guidelines from around the world are discussed with respect to the cord.  Methods for incorporating an intact cord into standard resuscitation procedures are explored.

Neonatal Resuscitation with Intact Umbilical Cord 

In many birth places, including birth centres, hospitals and home, neonatal resuscitation equipment is set up out of the way of the birth area.  In hospitals, assessment and resuscitation of newborns almost always occurs on a large table across the room and far from mother.  Obviously this requires severing the umbilical cord.  In addition to the physiological advantages of leaving the cord intact, keeping the baby close to mother reduces maternal stress (and surely infant fear too (Strange, 2009)) and helps facilitate bonding (Wright, 2011).  We can do better.  Term and preterm neonates are safer and healthier when neonatal resuscitation includes delayed cord clamping[1].

During pregnancy, the umbilical cord provides oxygen and transfers blood between the placenta and the baby.  Nature has perfectly designed a placental transfusion to carry the blood through the cord and into the newborn baby.  If the cord is intact, then oxygenation continues after birth until the newborn lungs have transitioned to air, a process that takes 30 to 90 seconds in a full-term infant.  If a newborn isn’t breathing independently then the placenta is nature’s neonatal life-support system.   Newborns are not simply tiny adults.  The newborn heart can beat for 20 minutes or longer despite anoxia and the brain can tolerate lack of oxygen for this duration of time (Resuscitation Council (UK), 2001; Frye, 2004; World Health Organization, 1999).  Newborns cope well with hypoxia but struggle with hypovolemia.  At the moment of birth 30 to 50% of the baby’s blood volume is in the placenta.  Immediate clamping deprives the baby of that blood.  Adults are in perilous danger of hypovolemic shock and receive blood transfusions at 15 to 30% blood-loss.

The benefits of delayed clamping are well documented.  Immediate cord clamping is now being compared with blood-letting.  However neonates who are compromised or require resuscitation and desperately need all their blood almost always get their cord severed immediately.  In spite of research saying otherwise, it’s still common practise at most births, usually due to outdated theories or habit.  As more parents request delayed clamping, newborns are more likely to receive their full volume of blood.

As delayed clamping becomes a hot topic there are some aspects that need clarification: time interval, milking the cord, gravity and the myth of causing harm.  “Delayed” isn’t a long time: the rate of transfusion is about half the blood in 1 minute and nearly 100% over the next 2 to 5 minutes.  What about cord stripping?  Parents-to-be may be told that if the cord can’t be left intact then it will be “milked,” implying the benefits are the same.  It’s the time interval of delayed clamping that has clinical benefits, not whether the cord is milked (Fogelson, 2011).

During the first 45 to 60 seconds of life, arterial pressure pumps blood into the neonate, so the height differential between the placenta and baby doesn’t matter.  After that, veins drain blood into the neonate and height matters more.  Full placental transfusion occurs with the baby from 10 centimeters above to 40 centimeters below placenta, which is about the position of baby on mother’s abdomen or lap (Yao & Lind, 1969).

Leaving the umbilical cord intact does not lead to pathological jaundice.  The naturally occurring physiological newborn jaundice has no clinical significance.  Many practitioners believe leaving the cord intact leads to other adverse effects such as tachypnea, grunting, hyperbilirubinemia, polycythemia and hyperviscosity.  If transient these are often not clinically significant issues but rather a normal part of physiological compensation during newborn transition (Tolosa et al., 2010).

Babies with delayed clamping fare better.  They have 40% more blood volume, a 45% increased hematocrit, a 50% increase in red blood cell counts and ferritin is up to 50% higher (Fogelson, 2011).  The benefits are greater in SGA or preterm infants and those born to mothers with low ferritin at birth.  The effects of delayed clamping can be seen well past the newborn period.  Term infants are protected from anaemia and iron deficiency for at least 6 months (Chaparro, Neufeld, Alavez, Cedillo & Dewey, 2006).  This is vital where infant and pediatric anaemia is common, such as impoverished areas.

Mercer et al. (2006) compared data from premature infants that had a 30 to 45 second delay in clamping and intubation, and from those who were immediately clamped and intubated.  There was no statistically significant difference in mortality rates.  The delayed clamping group fared better in common premie health issues, with lower rates of necrotizing enterocolitis, bronchopulmonary dysplasia,  intraventricular haemorrhage (IVH) (14% versus 36%) and sepsis (3% versus 22%).  In addition to the higher rates of IVH, cases were more severe in the early clamping group.  Preterm neonates with delayed cord clamping are less likely to require blood transfusion, ventilation and oxygen therapy, and have lower rates of anaemia at 6 months.  They have more stable blood pressures and thrive better (Asfour & Bewley, 2011).  A 1-minute delay in cord clamping resulted in remarkably elevated red blood cell volume and weekly haematocrit compared to early clamping in neonates of 30 to 36 weeks gestation (Tolosa, Park, Eve, Klasko, Borlongan & Sanberg, 2010).

Of course, if a baby is born flat with a limp, non-pulsing cord then the cord is no longer working.  This is the rare case when immediate clamping and aggressive resuscitation is warranted.

Neonatal resuscitation guidelines in Canada, Australia, Europe and the United Kingdom recommend delayed  clamping for a minimum time range from 1 minute to when the cord stops pulsing in healthy neonates.  These same guidelines cite insufficient evidence to recommend an optimal time of clamping the cord of infants requiring resuscitation.  Not one of them recommends immediate clamping and cutting as part of care, including the American guidelines which say nothing about timing of cord clamping.  The UK and Australian guidelines go so far as to advise waiting 3 minutes in healthy preterm infants for “increased blood pressure during stabilisation, a lower incidence of IVH and fewer blood transfusions” (Resuscitation Council (UK), 2010; Australian Resuscitation Council, 2010).  The UK guidelines also speculate that cord clamping with resuscitation could be delayed until the baby has started breathing.  WHO (1999) advises it’s unnecessary to clamp the cord before beginning resuscitation and to not waste time moving to a special place, as mother’s bed is usually warm and suitable.

The requirements of medicalized neonatal resuscitation are warmth, a firm surface, suction and access to the umbilicus.  Other priorities include comfortable position for staff and the ability to draw umbilical blood for cord-gas analysis.  A warm firm surface can be the bed or surface where baby is born.   In this author’s 2011 poll of 34 midwives from around the world, most reported that they perform resuscitation with the cord intact using the bed, side of a pool designed for water-birth, part of an adult human body (mother or midwife) or a portable board with a warm-pack.

Suction can be from a main hospital line, resuscitation machine or a portable unit such as those used at homebirths.  The umbilicus is accessed to provide drugs and fluids.  If the cord is left intact, then fluids are already being provided.  Drugs are rarely required for resuscitation, and it’s likely they would be required far less often if cords were intact.  Since extensive resuscitation is rarely required can we not be uncomfortable once in awhile, bending over the baby rather than performing resuscitation at our standing height?   Even if one requires cord-gases for medical reasons rather than protection from litigation, they can wait.   Cord-gas results don’t change significantly if taken immediately after birth or after 2 minutes of delayed clamping (De Paco, Florido, Garrido, Prados & Navarrete, 2011; Asfour & Bewley, 2011).

If one prefers a newborn resuscitation table, then there are alternatives to what’s currently being used in most hospitals.  Dr. Andrew Weeks and a team at University of Liverpool designed the award-winning BASICS (Bedside Assessment, Stabilisation and Initial Cardiorespiratory Support) Trolley, a smaller portable neonatal resuscitation table that can be used alongside the mother, even for caesarean birth (University of Liverpool, 2011).  It includes oxygen, suction and heat.  Dr. Weeks says, “It is crazy that the most vulnerable babies are born and whisked off and surrounded by a scrum of doctors” (Wright, 2011).

Many midwives are already doing the good work of leaving cords intact, even for resuscitation.  As further research is available and better equipment is implemented in hospitals, neonatal resuscitation may include nature’s life-line — the full placental transfusion.

 

About the author:  Angie Evans, BSc(Hon), MH is an herbalist, doula and prenatal educator currently enrolled in a Bachelor of Midwifery program.    She’s passionate about the parents’ and baby’s experience of birth and believes good care includes more than simply physical health.   angie@AngieEvans.ca

References

AAP/AHA/CPS. (2006). Neonatal resuscitation textbook (5th ed.). Ottawa: Canadian Paediatric Society.

Alberta Health Services. (2007). Maximum blood draw protocol for pediatric patients.

American Heart Association. (2005, Nov). 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care – Part 13: Neonatal Resuscitation Guidelines. Retrieved Jan 2012, from American Heart Association Journals: http://circ.ahajournals.org/content/112/24_suppl/IV-188.full

Asfour, V., & Bewley, S. (2011). Cord clamping practice could affect the ratio of placental weight to birthweight and perinatal outcomes. BJOG: An International Journal of Obstetrics & Gynaecology,  118 (12), 1539-40.

Australian Resuscitation Council. (2010). Introduction to resuscitation of the newborn infant. Retrieved Feb 2012, from The Australian Resuscitation Council Online: http://www.resus.org.au/

Barret, L. (2008). Resuscitation of the newborn. Retrieved from Homebirth: A Midwife Mutiny: http://www.homebirth.net.au/2008/04/resuscitation-of-newborn.html

Buckley, D. S. (2005). Gentle birth,gentle mothering. Brisbane: One Moon.

Canadian NRP Steering Committee. (2010). Addendum to the NRP provider textbook 6th edition: Recommendations for specific treatment modifications in the Canadian context. Ottawa: Canadian Paediatric Society.

Chaparro, C. M., Neufeld, L. M., Alavez, G. T., Cedillo, R. E.-L., & Dewey, K. G. (2006). Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomised controlled trial. The Lancet , 367 (9527), 1997-2004.

Crews, C. (2007). Clamping of the umbilical cord – Immediate or delayed. Is this really an issue? Retrieved Feb 2012, from Midwifery Services of South Texas: http://www.midwiferyservices.org/umbilical_cord_clamping.htm

CRYO-CELL International Inc. (2011). Cord blood collection instructions . Florida.

De Paco, C., Florido, J., Garrido, M., Prados, S., & Navarrete, L. (2011). Umbilical cord blood acid-base and gas analysis after early versus delayed cord clamping in neonates at term. Arch Gynecol Obstet , 283 (5), 1011-4.

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Kattwinkel, et al. (2010). Special Report Neonatal Resuscitation: 2010 AmericanHeart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics , 126 (5), 1400-1413.

Mercer, J. S., Vohr, B. R., McGrath, M. M., Padbury, J. F., Wallach, M., & Oh, W. (2006). Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemmorhage and late onset sepsis; A randomized, controlled trial. Pediatrics , 117 (4), 1235-1242.

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[1] Clamping refers to clamping and/or cutting the umbilical cord.  Clamping, whether cut or not, immediately halts placental transfusion.  Clients who ask for delayed cord-cutting could be counselled to request delayed clamping.

Cytotec Induction Dangers: What if Viagra Made Penises Explode?

Posted by on in Induction, Interventions, Labour

(There is a connection – stay with me here!)

Cytotec (misoprostol) is a drug for stomach ulcers.  However, it is used “off-label” in the USA, (and has recently been approved in Canada too) to induce labour, per obstetrical guidelines.  It’s not approved by the FDA for such use.  In fact the manufacturer issued a written warning against use of Cytotec for labour induction as it can cause hyper-contraction of the uterus, which can lead to uterine rupture, which can obviously lead to death.

So, when Cytotec is used as directed by the ACOG (American Congress of Obstetricians and Gynecologists), a well documented, possible side effect is uterine rupture.

Ina May Gaskin started a quilt project in which each square represents a woman who died in childbirth.  Many of these squares are dedicated to women who received Cytotec induction.

This issue was raised by some classmates today.  Many good points were made; the most obvious being, why are Cytotec inductions allowed, despite ample evidence to show it’s a dangerous practice.  It was suggested that this demonstrates the extent of disregard for women and their bodies.  My friend and classmate, Kelly Graham, a passionate advocate for women’s health, speculated, “I wonder how many (of these same) doctors would prescribe Viagra if a side effect was penis explosion.”  Or – another analogy – would we use a drug to help asthma if a possible side effect was ruptured lungs?

Enough said.

Want to explore further?