The Umbilical Cord
Early cord clamping deprives the baby of 54-160 mL of blood, which represents
up to half of a baby's total blood volume at birth. "Clamping the cord before
the infant's first breath results in blood being sacrificed from other organs
to establish pulmonary perfusion [blood supply to the lungs]. Fatality may result
if the child is already hypovolemic [low in blood volume]".
- Morley, G. (1998, July). Cord closure: Can hasty clamping injure the newborn? OBG Mgmnt: 29-36.
Early clamping has been linked with an extra risk of anemia in infancy.
- Grajeda, R. et al. (1997).
Delayed clamping of the umbilical cord improves hematologic status of Guatemalan
infants at 2 mo. of age.
- Am J Clin Nutr 65:425-431.
Premature babies who experienced delayed cord clamping--the delay was only 30
seconds--showed a reduced need for transfusion, less severe breathing problems,
better oxygen levels, and indications of probable improved long-term outcomes
compared with those whose cords were clamped immediately.
- Kinmond, S. et al. (1993). Umbilical cord clamping and preterm infants:
A randomized trial. BMJ 306(6871): 172-175.
Some studies have shown an increased risk of polycythemia (more red blood cells
in the blood) and jaundice when the cord is clamped later. Polycythemia may be
beneficial in that more red cells mean more oxygen being delivered to the tissues.
The risk that polycythemia will cause the blood to become too thick (hyperviscosity
syndrome), which is often used as an argument against delayed cord clamping, seems
to be negligible in healthy babies.
- Morley, ibid.
Some evidence shows that the practice of clamping the cord, which is not practiced
by indigenous cultures, contributes both to postpartum hemorrhage and retained
placenta by trapping extra blood (about 100 mL) within the placenta. This increases
placental bulk, which the uterus cannot contract efficiently against and which
is more difficult to expel.
- Walsh, S. (1968, May 11). Maternal effects of early and late clamping
of the umbilical cord. The Lancet: 997.
Clamping the cord, especially at an early stage, may also cause the extra blood
trapped within the placenta to be forced back through the placenta into the mother's
blood supply during the third stage contractions. This feto-maternal transfusion
increases the chance of future blood group incompatibility problems, which occur
when the current baby's blood enters the mother's bloodstream and causes an immune
reaction that can be reactivated in a subsequent pregnancy, destroying the baby's
blood cells and causing anemia or even death.
- Doolittle, J. & Moritz, C. (1966). Obstet Gynecol 27:529 and Lapido,
O. (1971, March 18). Management of the third state of labour with particular reference
to reduction of feto-maternal transfusion. BMJ 721-3.
====
The above are excerpts from Sarah Buckley's "A Natural Approach to the
Third Stage of Labour," Midwifery Today Issue 59
====
Several types of cord problems can affect blood flow to the baby and cause fetal
distress. "Cord nipping" means the cord is being pinched between the
head and pelvic bones, causing variable decelerations in the fetal heart tones
(FHTs). During first stage, repositioning the mother usually eases pressure on the cord and brings the FHT to normal, but in second stage nipping may easily
progress to cord compression. One trick for remedying variable decels in second
stage is to gently press on the mother's abdomen where the baby's back is located.
This frequently shifts the baby off the cord and improves FHTs.
Cord compression may be due to occult prolapse, meaning that the cord is low
in the pelvis and is being compressed by the head as it descends with the force
of contractions. If cord compression is severe, bradycardia is likely to develop.
There is also a possibility that the FHT will return to normal if the head moves
past the cord entirely. Persistent bradycardia constitutes a crisis with very
little leeway. Try repositioning the mother and give oxygen by mask at 6 L/min.
Check FHT with each contraction. If there is no improvement after four or five
contractions, transport to the hospital.
Cord entanglement may inhibit descent and you may hear cord sounds over the
FHT. A very tight cord around the neck may also deflex the baby's head. This may
result in persistent bradycardia, necessitating transport.
Complete cord prolapse can occasionally be diagnosed by internal exam in the
last weeks of pregnancy with the discovery of pulsations at the cervix or through
the lower uterine segment that are synchronous with the FHT. This finding necessitates
immediate hospitalization and cesarean section.
If the membranes rupture during labor and the cord prolapses, call the paramedics
and place the mother in a knees-chest position with your fingers inside her cervix,
holding the head up and away from the cord. Place the cord gently back inside
the vagina if it is exposed. If there isn't room, wrap it in gauze or a washcloth
soaked in warm water with a pinch of salt and cover with a plastic bag. Rough
handling of the cord or exposure to air can cause spasm and constriction. If you
must transport the mother yourself, lay a chair back-down on the floor and ease
her onto it, then lift and tip her slightly backward until her head is lower than
her hips. Keep her in this position in the car with fingers inside to alleviate
pressure on the cord until the cesarean is performed.
- Elizabeth Davis, Heart and Hands, Celestial Arts 1997
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To share your thoughts and experience, go to Midwifery Today's Forums.
Question of the Week (Repeated)
Q: As a care provider for women during their childbearing
years, it is also essential to be able to have competent information I can give
to the women who I continue to care for beyond the birthing times of their lives.
What are the signs and symptoms of breast cancer and what is the percentage of
women who breastfeed to those who don't correlate with cancerous tumors in women's
breasts? Can you recommend any books that are informative, honest and coming from
a natural healing perspective?
- Amanda Moore, midwifery student
Send your responses to:
Question of the Week Responses
Q: 1. What is the longest you have waited for a placenta
after the birth of the baby? What was the outcome?
2. What is the longest you have seen from full dilation to the beginning of
pushing - or to the birth of a baby? What were the outcomes?
- Nancy Wainer
We had a client who had a 4-hour 2nd stage. She had a posterior baby with a
very high head and poor uterine contractions. What we did was WAIT patiently.
Whilst waiting, I called her backup doctor who suggested we do an artificial rupture
of membranes. That was not an option as far as I was concerned; I think it courts
trouble. So we hydrated her with "labour-aide," let her rest, and then
began some homeopathic pulsatilla and caullophyllum pellets which increased the
intensity of the contractions. Our lady had to first accept that her cervix was
fully opened and that was all she needed to push her baby out. Once she accepted
this (about 1 hour into 2nd stage) she pushed with all her strength. It was amazing
to watch; she literally pushed that baby from her symphysis to the pelvic floor!
Baby was born 4 hours after full dilation with great Apgars, weight 7 lbs 6 oz.
Although mum had to work really hard, we believe that it was essential that
she came to terms with what she had to do. Also, keeping those membranes intact
gave her more time to push out her baby. So I think that Nancy's client may have
been correct--keep those membranes intact and avoid transfer as much as possible
if baby is OK. Once transferred, a mother's perception of her abilities are greatly
reduced, and feelings of "I can't do this" quickly set in.
- Kathy Neblett, midwife
Barbados
====
Fully dilated and No Urge to Push: This should be the title of a 10-day conference!
I am learning not to call fully dilated "second stage", but to call
fully dilated with an urge to push second stage. I believe the words we use are
what get us and our clients into trouble (Read Jean Sutton's book Optimal
Fetal (Feotal) Positioning"} [available from Midwifery Today].
I am waiting longer and longer over the years for the "urge to push"
part of the definition. Problems occur when you have decreased uterine contractions
and strength of contractions. Then one is tempted to rupture membranes (if not
ruptured already) to get contractions going again. But instead we try every position
change known to womankind, including crawling hands/knees on the floor), drinking
all sorts of fluids, nipple stimulation, herbs (blue and black cohosh), baths,
showers, encouraging her to lie on her left side with her right leg in a 'hurdle'
position and wait wait wait.
I've recently been in above the situation and it took about 6 hours--but some
of my fellow local midwives have stories to tell of over 12 hours. If the contractions
are very regular and strong, it really is a different story: you may end up with
exhaustion and later, maternal/fetal infection. A bolus of IV fluids can help
here as well. Keeping meticulous records of the reactivity of the baby, mom's
vitals, and her verbalization of her wishes ("Yes, I want to keep waiting")
and of the family's is very very important. To bring a woman into the hospital
after such a marathon can be intimidating, so be thorough and careful.
- Annette Manant, CNM
====
I agree with the mother--if the baby was not in danger, then there was not valid
medical reason for the cesarean. I find it sad that some midwives, for all the
lip service they pay to "trusting the process," still feel the need
to limit women by looking primarily to traditional obstetrical standards to guide
them in evaluating the safety and normalcy of a situation. Anything that diverges
from these standards is seen as suspect even though the standards are largely
arbitrary and as such cannot possibly represent the true range of normal.
The notion that the only normal second stage is one in which the mother feels
the urge to push at "full" dilation (even assuming that such a measurement
can be objectively determined) is absolute nonsense. Who is the clever fellow
who decided for us birthing women what "full dilation" and appropriate
physiological action at that point should be? And where are the clinical studies
that back him up?
When we believe we must manipulate the birth process according to an unscientific
standard, we are doing no different and no better than the typical obstetrical
model of birth management, regardless of where the birth takes place and how loving
the hands doing the manipulating.
- Linda Hessel
Switchboard
In last week's E-News, Valerie El Halta said, "There may be psychological
reasons for slowed progress, as well as physiological." Does anyone have
ideas about psychological and physiological reasons for a very fast labor?
- Anon.
====
I don't know of any research on the effect of hemochromatosis on pregnancy and
birth [Issue 3:42], but I can speak from my own experience. I'm a midwife and
when I was thinking of getting pregnant for the first time, my diagnosis with
hemochromatosis was confirmed by a gastroenterologist. I asked him about getting
pregnant (thinking I had to use up some extra iron I had in my blood, and what
better way than pregnancy!), and he said absolutely not, not until I had it under
control. However, I wasn't sick and my iron was not that high, and my liver wasn't
very affected. So I got pregnant, had a perfect pregnancy, never took an iron
supplement, and had a beautiful homebirth. I monitored my hemoglobin and hematocrit
and maybe once my iron or ferritin, just like any pregnant woman, but as they
were within normal range, I never considered myself "high-risk." I always
thought the pregnancy helped control the high assimilation of iron particular
to hemochromatosis. The risk would depend more on any damage done by hemochromatosis
prior to pregnancy. It's very possible to keep it under control and that way organs
won't be damaged. If the liver or heart or any other organ is significantly damaged,
then these factors should be taken into account individually as to their effect
on pregnancy and possible birth risks.
- Marie Tyndall
====
I cared for a woman with hemochromatosis. It is important that she be in the
care of a hematologist/GI specialist. However it does not require consultant OB
care unless the pregnancy or birth become complicated. Uncontrolled hemochromatosis
can lead to liver failure and diabetes. My client had not been in appropriate
care and had a very high serum ferritin level >600 (normal 10-40 depending
on local lab specs). Regular phlebotomies of blood are necessary to keep the serum
iron levels normal. In some jurisdictions the woman can donate the blood rather
than have it wasted. I did not see any studies that linked hemochromatosis with
preeclampsia.
Obviously she will not be at risk for iron deficiency anemia, but she may have
folate and/or B12 deficiencies. Genetic counseling is important and pediatric
assessment to determine if the infant is affected or is a carrier. There are several
consumer oriented organizations that you can find on the web using your search
engine.
References:
Hereditary Hemochromatosis Practice Guidelines Development Task Force of the College
of American Pathologists. Hereditary hemochromatosis. Clin Chim Acta 1996; 245:
139-200[Medline].
Yang Q, et al. Hemochromatosis-associated mortality in the United States from
1979 to 1992: An analysis of multiple-cause mortality data. Ann Intern Med 1998;
129: 946-953[Medline].
Niederau C, et al. Long-term survival in patients with hereditary hemochromatosis.
Gastroenterology 1996; 110: 1107-1119
- Freda Seddon, RN, RM, community midwife
Toronto, Ontario, Canada
====
The News Flash about recent research from the J Pediatrics 2001; 139:380-384
[Issue 3:42], "Maternal and infant use of erythromycin and other macrolide
antibiotics as risk factors for infantile hypertrophic pyloric stenosis"
failed to clarify that the increased risk of pyloric stenosis occurred only when
the route of administration of erythromcyin to the infant was systemic. The research
was specific in its finding that erythromycin opthalmic ointment was not associated
with an increased risk of IHPS. The distinction is important.
- Ann
====
Regarding numbness postpartum [Issue 3:37]: I experienced numbness in the feet
and toes after the birth of my second son. I saw a podiatrist and a neurologist.
The conclusion was swelling compression caused by pregnancy. Because I was breastfeeding
he suggested I wait until I was 3 months postpartum, and if it had not resolved
to see him again. When the 12 weeks was up I had feeling in my feet again.
- Amy
====
More on pertussis [Issue 3:41]: My family and I contracted pertussis in early
June 2000, and my husband and I exposed more than 200 OB/GYN clients at our center.
All were notified and offered prophylactic antibiotics, which some took. Only
one pregnant client contracted pertussis and she had none of the complications
that you mentioned. I don't know of any research on pertussis in pregnancy that
would shed more light, but you might do a Medline search via the nlm.nih.gov (national
library of medicine, national institutes of health).
- Heidi Rinehart, MD
====
I hope to be a midwife some day. Does anyone have advice about fertility or
just helping conceive? I seem to be ovulating regularly but can't get pregnant.
We've been trying and trying. Are there any tricks of the trade I could try?
- J. Nielsen
Seattle
Reply to: ish1221@hotmail.com
====
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mtensubmit@midwiferytoday.com,
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