Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

Super Comment!: Maternal Death in the U.S., or TOP TEN Ways to Reduce Your Risk For Complications in Pregnancy and Childbirth May 27, 2009

Dear NursingBirth,

I’m a huge fan of your blog! Please keep the awesome entries coming! I am learning so much. I am just a novice birth-junkie rather than a birth professional and so am anxious to eat up all the great information you’re giving out here.

Anyhow…. Our state treasurer’s wife (that’s here in Arizona) died today in childbirth, and their baby is said to be in grave condition. They’re not giving causes or reasons. Here’s the link:

http://www.azcentral.com/news/articles/2009/05/26/20090526treasurers-wife0526-ON.html

Can you think of occurrences in hospital-birth that would end up with a dead mother and a baby in really bad condition? I’d love to hear from someone who knows her stuff. The things that came to mind for me were amniotic fluid embolism, severe uterine rupture, and cesarean gone really wrong.

Keep up the amazing work!!!
Diana

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Dear Diana J.,

 

I just read the story you linked to and my heart goes out to that family.  Unfortunately the story you linked to did not go into any details, including the most important detail which is: Did the treasurer’s wife have a vaginal birth or a cesarean section, as the risks are significantly higher with a cesarean section.  I think your question is a good one and since this story has the potential to make national headlines, I think that it is an important enough question to put as its own post on my site.  I hope, however in posting about your question that moms out there who read my blog are not unnecessarily worried or upset that we are talking about maternal death as it is still a relatively RARE occurrence when you think about all the other causes of death in childbearing women. 

 

Let’s put it into perspective.  As the Arizona Central story stated, “In late 2007, the National Center for Health Statistics, part of the U.S. Centers for Disease Control and Prevention, released a report showing that there were 13 maternal deaths per 100,000 live births in 2004 in the United States.” And since in 2004 there were 4.1 million births in the United States, if you do the math that would make about 533 maternal deaths in 2004.  And don’t get me wrong…that’s 533 deaths to many for sure!  However take a look at this chart published by the Center for Disease Control (CDC) entitled: Leading Causes of Death by Age Group, All Females- United States, 2004.  It shows the following:

 

Leading Causes of Death for 15-19 year old Females, 2004:

1)      Unintentional Injury (51.7%), 2) Suicide (8.8%), 3) Homicide (7.5%), 4) Cancer (7.3%), 5) Heart Disease (3.1%), 6) Birth Defects (2.8%), 7) Pregnancy Complications (0.9%)

 

Leading Causes of Death for 20-24 year old Females, 2004:

1) Unintentional Injuries (40.5%), 2) Homicide (8.4%), 3) Cancer (8.0%), 4) Suicide (7.6%), 5) Heart Disease (4.6%), 5) Pregnancy Complications (2.7%), 6) Birth Defects (1.9%), 7) HIV disease/Stroke (1.4%).

 

Leading Causes of Death for 25-34 year old Females, 2004:

1) Unintentional Injuries (25.3%), 2) Cancer (15.1%), 3) Heart Disease (8.2%), 4) Suicide (7.5%), 5) Homicide (5.8%), 6) HIV disease (4.4%), 7) Pregnancy Complications (2.3%).

 

And for women ages 35-44 years old, pregnancy complications don’t even crack the top 10. 

 

Okay so if you are a pregnant mom please know that dying of pregnancy/childbirth related complications is rare and I don’t want to completely freak you out.  But there is something very disturbing about the United States maternal mortality statistics which shocks most people when they hear it….

 

The United States ranks 42nd in the WORLD for maternal mortality rates, with 1 in 4,800 women dying from pregnancy complications in the U.S. in 2007.  That means that 41 countries other countries in the world have BETTER maternal mortality rates than the United States!

 

Many of our practices and current situations in this country, including our obsession with medically unnecessary labor induction, our over-medicalized maternity care system, the practice of defensive as opposed to evidenced-based medicine, the lack of a universal health care system, large differences in health disparities among different racial/socioeconomic groups, the obesity epidemic, and our skyrocketing cesarean section rate greatly contribute to our country’s maternal death rate. 

 

So what exactly is defined as “maternal death.”  According to the World Health Organization, “A maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.”  Therefore a death of a woman that died from complications arising from a cesarean section a month after she had the baby would be counted in the maternal death statistics where a pregnant woman who died in a car accident or murdered during a domestic violence dispute would not. 

 

Okay, but you are probably thinking Why?  Why are so many women dying in childbirth in an industrialized, developed country like the United States at a much higher rate than other industrialized, developed countries like Japan, many countries in Europe, or Australia? 

 

Ina May Gaskin, midwife and founder of the Safe Motherhood Quilt Project, gives us some insight into the situation in her book Spiritual Midwifery, page 455, written in 2002:

 

“According to the CDC, there has been no improvement in the U.S. death rate (which is nearly twice as high as Canada’s) since 1982.  Sadly, the CDC estimates that the true death rate is as much as three times higher than that which is reported and that half of all the reported deaths could have been prevented through early diagnosis and good care.  Given the situation it makes sense for women to avoid unnecessary surgery while pregnant or in labor.  Women double or triple their risk of dying when they have an unnecessary cesarean.  Medical mistakes do happen, even to people who are well informed about their possibility.”

 

Also Ina May’s Safe Motherhood Quilt Project website also links to a Maternal Mortality in the USA Fact Sheet that is worth checking out!

 

The 2008 documentary Orgasmic Birth (which I highly recommend renting) has a 20- minute movie clip as part of the “special features” section of the DVD that provides some eye opening statistics about maternal and infant mortality rates in the United States as compared to other industrialized countries around the world.  In this short movie clip, entitled Birth By The Numbers, Eugene R. Declercq, PhD, Professor of Maternal and Child Health, Boston University School of Public Health, presents the sobering statistics of birth in the United States today.  It is a MUST WATCH CLIP for anyone who is or cares about a mother.

 

Also, here are some articles from mainstream news sources published in response to the 2007 maternal mortality rankings that provide some insight:

 

1) More U.S. women dying in childbirth: Death rate highest in decades; obesity and C-sections may be the cause  Associated Press, August 24, 2007

2) Maternal Mortality Shames Superpower U.S.  Inter Press Service, October 13, 2007

3) U.S. ranks 41st in maternal mortality  Seattle Post-Intelligencer, October 12, 2007 

 

A flyer published by the medical journal The Lancet in 2006 entitled Causes of Maternal Death: A Systematic Review ranks the top 9 causes of maternal death related to pregnancy/childbirth complications in DEVELOPED countries as the following:

1) Other Direct Causes (21.3%), complication of the pregnancy, delivery, or their management which includes (among other things):

            –Anesthesia Complications* (responsible for about 3% of all maternal deaths by itself and includes:    management of the difficult airway in obstetric patient, aspiration of gastric contents under general anesthesia, local anesthetic toxicity, and high spinal or epidural block which paralyzes the breathing muscles of mother).

2) Hypertensive Disorders (16.1%), includes (among other things):

            –Preeclampsia

            –Eclampsia*

            –HELLP Syndrome*

3) Embolism (14.9%), includes (among other things):

            –Pulmonary Embolism (typically a complication seen post-op surgery)

Deep Vein Thrombosis (DVT) (more likely to develop for women on bed rest or post-op surgery

Amniotic Fluid Embolism (rare and more appropriately known as Anaphylactic Syndrome of Pregnancy)*

4) Other Indirect Causes of Death (14.4%), pregnancy-related death in a patient with a preexisting or newly developed health problem like cardiovascular disease, seizure disorder, respiratory disorder, diabetes, kidney disorder, liver disorder, obesity, etc.

5) Hemorrhage (13.4%), includes (among other things):

  – Obstetrical Hemorrhage (most common causes being uterine atony, trauma, retained placenta, and coagulopathy)

  – Placenta Previa*

            – Placenta Accreta, Increta & Percreta

            – Placental Abruption*

            – True Uterine Rupture*

6) Abortion (8.2%)

7) Ectopic Pregnancy (4.9%)

8.) Unclassified Death (4.8%)

9) Sepsis Infection* (2.1%)  (most likely to occur post-operatively but can occur post-partum or antepartum)

 

*Comes to mind for me as having the potential to cause a critical illness or death for baby as well.

**Please note mothers undergoing cesarean surgery, especially repeat caesarean surgery are MORE at risk for anesthesia complications, pulmonary embolism, obstetrical hemorrhage, placenta previa, placenta accreta, and sepsis/infection than moms undergoing a vaginal birth.**

 

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You are probably thinking, “So what does all of this mean for me?” “How can I reduce my risk?”  Both are GREAT questions.  It is important to remember that I am not claiming that 100% of maternal deaths are preventable or even foreseeable.  No one is.  I also do not want anyone to get the impression that I am blaming mothers or putting unrealistic pressures on mothers to control things that are sometimes just happenings that are an unfortunate and very sad part of life.  For example, who could have predicted a fatal postpartum hemorrhage for a healthy mom after a normal uncomplicated unmedicated singleton vaginal birth?  No one could!  But what about a mom who experienced a fatal postpartum hemorrhage after elective cesarean surgery….well that one doesn’t sit so well with me!   And which do you think is more likely?  If you guessed the latter you are correct…by at least 4 times as much! 

 

So how does a mother reduce her risk of maternal morbidity and mortality related to pregnancy and childbirth complications?  The following is a short list you might want to keep in mind.  (Not surprisingly, many relate back to avoiding unnecessary surgery.)

 

TOP TEN Ways to Reduce Your Risk For Complications in Pregnancy and Childbirth:

1)      Obtain good and thorough prenatal care, keeping all of your appointments, preferably beginning in your first trimester.

 

2)      Make a conscious effort to eat a well balanced diet during conception and pregnancy that includes adequate amounts of fresh fruits and vegetables, healthy fats, and protein.  There are a variety of prenatal nutrition books out there as well as many childbirth books that have a section on prenatal nutrition.  If you don’t have one buy one or borrow one from the library!!

 

3)      If you don’t exercise, start!  Many gyms, community centers, and YMCAs offer low-impact, pregnancy-friendly classes for expectant moms.  Even a 30 minute walk three times a week will do!

 

4)      If you suffer from a chronic disease or illness or are obese, it is important to know that making appointments with health care providers and specialists that can help you to manage your disease and lose weight in a healthy way before and during pregnancy can ultimately help you to reduce your risk of life threatening complications during pregnancy and childbirth.

 

5)      Consider hiring a birth attendant that practices a midwifery model of care.

 

6)      Do NOT agree to a medically unnecessary labor induction.

 

7)      Do NOT agree to a medically unnecessary or elective cesarean section.

 

8)      If you have a history of a cesarean section, seriously consider a vaginal birth after cesarean section (VBAC) if you have no reoccurring or new reasons or medical indications for a repeat cesarean.  If necessary switch to a birth attendant that supports VBAC and has the cesarean statistics to prove it.

 

9)      Seriously consider avoiding interventions in labor that evidenced-based research have shown could increase your risk of a cesarean section, fetal distress, and infection including early amniotomy (breaking of waters), accepting pitocin to stimulate or augment contractions without trying other more natural methods for augmenting labor first, going to the hospital during very early labor, accepting continuous external fetal monitoring as opposed to intermittent auscultation for a normal healthy labor and a normal, reactive, and reassuring fetal heart rate pattern, and requesting an epidural or narcotic pain medication (especially in early labor) before trying all methods of non-pharmacological pain management techniques first.  (Check out my post: Top 8 Ways to Have an Unnecessary Cesarean Section)

 

10)   Empower yourself to make safe, healthy decisions regarding your pregnancy, your labor, your birth, and your baby by doing your own research!!  (Check out my post: Birth Resources EVERY Woman Should Know About).

 

More Risks for Baby With Repeat C-Sections May 24, 2009

A new study entitled Neonatal Outcomes After Elective Cesarean Delivery published in the June issue of Obstetrics & Gynecology (aka “The Green Journal” published by American College of Obstetrics & Gynecology (ACOG)) concluded that:

 

“In comparison with vaginal birth after cesarean, neonates born after elective repeat cesarean delivery have significantly higher rates of respiratory morbidity and NICU-admission and longer length of hospital stay.”

 

The journal article begins with the following introduction:

 

“In 2006, the United States cesarean delivery rate of 31.1% was at an all-time high, making cesarean delivery the most common surgical procedure performed in American women.  This high rate of cesarean delivery is attributed to the rise in primary cesarean delivery rates from 14.6% in 1996 to 20.3% in 2005, an increase of 60%.   With the rates of vaginal births after cesarean delivery (VBAC) at an all-time low of 7.9% in 2005, women who have a primary cesarean delivery have a greater than 90% chance of having a repeat cesarean delivery, only serving to increase the overall cesarean delivery rate.   Almost one half of cesarean deliveries, a rate of 15%, are done electively, before the onset of labor.”

 

This study found that neonates born by intended cesarean delivery were more prone to NICU admission for:

 

1)      hypoglycemia (low blood sugar),

2)      needing higher rates of oxygen supplementation,

3)      needing intubation/ventilator support

 

This study’s findings were consistent with the multiple studies previously done that documented respiratory morbidity in neonates born after elective repeat cesarean delivery, particularly with an increase in:

 

1)      respiratory distress syndrome,

2)      transient tachypnea of the newborn,

3)      persistent pulmonary hypertension,

4)      need for supplemental oxygen

5)      respiratory morbidity related to failure to clear fetal lung fluid related to birth without benefit of labor

 

The authors write:

 

“While the common perception is that conditions such as transient tachypnea of the newborn are benign, self-limiting illnesses, several studies indicate that neonates with such conditions can progress to severe respiratory failure, leading to the need for extracorporeal membrane oxygenation or death.”

 

This study really hits home for me since I had to scrub three, count them, THREE primary elective cesarean sections the other week, all attended by the same physician, for the most outrageous and bogus reasons EVER!  Stay tuned….More on elective primary cesarean section to come!

 

To read the full text of this study click here.

 

To read the Health Day newspaper article on this study check out Yahoo! News.

To learn more about Vaginal Birth After Cesarean (VBAC) and the risks of Repeat Cesarean Section, please visit ICAN’s website.

 

Special THANKS to The Feminist Breeder for alerting me to this study!

 

Response to a Comment, Re: The Deal with Delayed Cord Cutting May 22, 2009

Filed under: Ramblings — NursingBirth @ 12:37 PM
Tags: ,

Posted May 21, 2009 @ 4:02pm  by pinky

Re: The Deal with Delayed Cord Cutting or “Hey! Doctor! Leave that Cord Alone!”

 

Dear NuringBirth

 

Curious? What is your education level? The reason I ask is that you have named every woomeister in the universe. I am surprised you have not mentioned Ghadi, Ina May and Santa Clause.

 

Tina Cassidy is a writer. She is not a authority on birth. I liked her book but I would get myself down to the medical library if you want to print up pros and cons of delayed cord clamping. You may start with the BMJ (British Medical Journal), they have done a few decent studies.

 

From,

Pinky

 

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Dear pinky,

 

I am being very honest when I say that I am a bit frustrated with your question “Curious? What is your education level?” because you have asked me this question before and I was happy to answer it then (see below).  I thought when you asked that question the first time you were merely being inquisitive but now I feel like there is more behind it and you are trying to discredit my post without presenting evidence to the contrary YOURSELF.

 

Here is the comment you wrote in April:

 

pinky Says: April 24, 2009 at 6:44 AM

Henci Goer? I have to wash my eyes out now! You lost me on that one. I did however, like Tina Cassidy’s book. I thought it was fair and accurate. Many books have an agenda, which pisses me off to no end. How long have you been in L&D?

 

Here is my response:

nursingbirth Says: April 24, 2009 at 10:06 AM

Pinky, I’ve been a nurse for three years, in L&D for 2 years. I am curious to why you would ask that question because I have never tried to pretend I am somebody I am not and I feel that whenever someone writes a dissenting comment on my blog, they often ask “how long I have been a nurse for” as if that should somehow discredit all of my experiences and opinions. The fact of the matter is that while experience is an incredibly invaluable resource to have as a nurse and educator, it is NOT all that is important. Education, open-mindedness, drive, passion, commitment, compassion, intelligence, and desire to always keep learning as well as MANY other things play a BIG role too. I value all those who have come before me especially those who have been in the business for many many years, including other nurses, doctors, midwives, doulas, childbirth educators, etc. I also value each mother I work with knowing that they have just as much to teach me as I have to teach them. I also value anyone in my life that has a different opinion than I do, in any area, because I believe we can learn just as much about the world and ourselves from our friends as well as our dissenters. But I have to be honest, valuing only experience over all the other qualities that make up a great nurse is part of the reason why we have a nursing shortage….Nurses eat their young!

You are not alone as an RN who does not like Henci Goer as I have seen many other people in healthcare scoff at her book. But in my opinion she backs up everything she writes about with research, gives pros & cons for each intervention, and from the very beginning of her book she is very honest about the fact that she has an opinion and is not afraid to say it. It’s HER book after all. You may feel her book is pushing her own agenda but there are many OBGYNs, nurses, and midwives who do the same to patients every day in this country, without the evidenced based research to support it!

On page 10 of “Thinking Woman’s Guide” she writes, “The things you are about to read may well worry or distress you or even make you angry. I have not tried to be needlessly alarming, but I haven’t pulled any punches either. This book was written on the same principle as sex education: namely, I would prefer you to be uncomfortable rather than ignorant. My goal is for you never to have cause to say “‘I didn’t know that was an option’ or ‘I never would have agreed if I had known that could happen.’ You can, of course, also leave all or most of your decisions up to your caregiver. That is a perfectly valid choice. The important thing is that it be a conscious choice, not one you felt constrained to make.”

All in all I appreciate everyone’s opinion who comments on my blog and I am humbled that anyone is even reading my words. I am grateful for all that I learn from all of my readers and I hope you will continue reading.

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Pinky, I find it quite amusing that you thought Tina Cassidy’s book was, and I quote, “fair and accurate” in April but now she is just a “woomeister” (whatever that is supposed to mean…)  And for the record I personally admire both Gandhi and the wise Ina May Gaskin and I feel sorry that you do not!  (Maybe it is because I believed in Santa Claus as a small child, a flaw in your opinion!)

 

The fact of the matter is that I do not have nor have I ever had any problem telling people my credentials when they ask.  Perhaps my original response to you about my credentials was not complete enough.  Part of me does not feel like I should have to repeat myself or go into any more detail.  But apparently you insist I go more in depth.  If that is the case then here it goes….

 

I graduated Summa Cum Laude with departmental honors from a large research university in the United States with a Bachelor’s Degree in Nursing.  I spent 5 years in college because for the first year, I was a microbiology major on the pre-med track.  It was a hugely positive change in my life when I switched into the nursing major since I truly feel like nursing is a calling for me.  During nursing school I worked as a nursing assistant/nurse extern on an orthopedic/cardiac floor in a small community hospital for two years.  I was published as an undergraduate my senior year of college in the journal entitled Issues in mental health nursing.  For the honors program I wrote a 50+ page honors thesis and because of it I graduated with departmental honors. 

 

I was inducted into the Sigma Theta Tau International Honor Society of Nursing my senior year.  I arranged my senior internship to be conducted at a large teaching hospital in an Labor, Delivery, Recovery, Postpartum (LDRP) ward where I worked full-time nights, 7pm-7am, three days a week on top of going to school full time, for three months.  After graduation from nursing school I got a job at a large teaching hospital in the medical-surgical float pool on evenings shift, 3pm-11pm.  I worked on the orthopedic/neurology, medical/dialysis, same-day surgery, inpatient surgery, oncology/gyn surgical, and cardiac floors rotating each night to the floor that was the busiest.  Occasionally I also floated to the emergency room, intensive care unit, and pediatric floor.  After a year in the float pool I got a job on the labor & delivery floor where I have been working for two years.  Our L&D ward is the high-risk hospital for cities and towns that span a 3 hour radius around hour city.  I am also a fully oriented peri-operative L&D nurse which means I can work as a circulating nurse, auxiliary nurse, and scrub nurse during cesarean sections. 

 

Through this blog I have been very open about still being a bit green behind the ears as a nurse.  I know that I have a lifetime left of learning as a nurse and learning something new about my job every single day is one of my favorite things about being a nurse!  I love being a nurse because it combines all of my career passions in life including advocacy, outreach, educating, supporting, and caring.  This blog is a hobby for as it is a personal blog.  I am not writing this blog on behalf of any organization or business, and I am not getting paid to write, however I do support a variety of organizations that promote natural childbirth, breastfeeding promotion, the mother-friendly childbirth initiative, and the baby-friendly hospital initiative including but not limited to:

 

The Association of Women’s Health and Neonatal Nursing

BirthNetwork National

Citizens for Midwifery

Coalition for Improving Maternity Services

International Cesarean Awareness Network

La Leche League International

World Health Organization

Childbirth Connection

 

My About NursingBirth page reads:

“This blog follows all HIPPA regulations.  Names, dates, events, and descriptions are altered for the privacy of all who may or may not be involved.  Unless otherwise quoted, all opinions expressed in this blog are my own.  Although this blog should not be used as a substitute for medical or midwifery advice, I try my best to support all facts with the appropriate research and encourage all who stumble upon this site to talk to their midwife or obstetrician about any questions that may arise while reading my posts.”

 

I try to support all of my posts with appropriate research and resources but unlike you, I value different types of sources as long as they are well researched themselves.  I value research published in medical journals and nursing journals however I also often quote various websites, blogs, and books about birth that may or may not (*GASP*) be written by obstetricians!!  I value research and writings from obstetricians, nurses, midwives, pediatricians, nurse practitioners, childbirth educators, doulas, birth advocates, mothers, fathers, and yes EVEN writers and journalists.  Now, I may not think it is appropriate for a journalist who wrote a book about the history of birth (like Tina Cassidy) to be an expert witness during a trial however I think that journalists and writers (again like Tina Cassidy and Henci Goer) have just as much of an ability to do a thorough and appropriate historical review or review of the literature as any other health care professional could.  

 

You also wrote in your comment, “I liked her book but I would get myself down to the medical library if you want to print up pros and cons of delayed cord clamping. You may start with the BMJ, they have done a few decent studies.”

 

However in that very post you are referring to (Super Comment! Re: The Deal with Delayed Cord Cutting)  I referenced two research articles from the Cochrane Collaboration (considered the gold standard of review of the literature and often used to create hospital policy or professional guidelines) which themselves INCLUDE references to the British Medical Journal (BMJ).  You are right however, I did not quote every single research article out there that supports delayed cord clamping.  If I was researching this topic in order to get published, well then yes, I would have referenced every one.  But jeeze, cut me some slack!  This blog, after all, is my HOBBY, not my full time job!

 

Also in that post I referenced the following health care providers that support and have written/spoke out about their support of delayed cord clamping:

 

George M. Morley, MD (retired OB):  http://www.cordclamp.com/

Stuart Fischbein, MD (OB, California)

Sarah J. Buckley, MD (Family Practice/OB):  http://www.sarahjbuckley.com/

Elizabeth Allemann, MD (birth center director): http://www.birthcolumbia.org/

Emmett Miller, MD (mind-body medicine physician): http://www.drmiller.com/

Barbara Herrera, LM, CPM (homebirth midwife): http://www.amamamamidwifery.com/

Gladys McGarey, MD (homebirth & holistic physician): http://www.mcgareyfoundation.com/

Allison Osborn, LM (homebirth midwife): http://www.alisonthemidwife.com/

 

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I welcome hearty debate as a part of this blog and I read and try to respond to every comment that is posted.  However I will not tolerate ad hominem (i.e. “replying to an argument or factual claim by attacking or appealing to a characteristic or belief of the source making the argument or claim, rather than by addressing the substance of the argument or producing evidence against the claim”) or defamatory attacks.  If you continue to post such comments I will have no choice but to delete them, something I do not want to have to do.

 

Of course there is always the obvious, you could just stop ready my blog, or better yet, post your problems or concerns on your own blog which I know you have. 

 

For more information on my personal philosophy please check out: My Philosophy: Birth, Breastfeeding, and Advocacy

 

 I have said my peace and I will no longer take up a post or any of my time to respond to any such comments.

Sincerely,

NursingBirth

 

Super Comment! Re: The Deal with Delayed Cord Cutting May 19, 2009

Many of you might not realize that I personally read every comment that is posted to my blog.  Why you ask?  Because I love reading what the people following my blog have to say!  I love when people engage in great discussions that have been stimulated by something I have written.  I love when women post comments seeking advice, information, or camaraderie and other readers respond!  And I love reading about other women’s birth experiences that they share via this forum.  Often, a reader will post a question to me under the comments section, a question so great that I take hours or days to research and write a response.  And I am such an information/research junkie that if I don’t know the answer, I’ve got to find out!!  Other times a reader will post a comment with some really great information or resources to share with other readers.  Unfortunately, many of these “super comments” often go unnoticed by readers who only read the posts and not each “comments” section.  So I have been inspired to create a new category for my blog entitled “Super Comments” to pay homage to all of the great super comments and questions that my readers post!

 

Today’s Super Comment is in response to May 17th’s post entitled The Deal with Delayed Cord Cutting or “Hey! Doctor! Leave that Cord Alone!”

 

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Dear Nursing Birth,

 

I have a student nurse question. In nursing school we were taught that clamping/cutting the cord stimulates respirations. This comes from our textbook, Maternity, Newborn, and Women’s Health Nursing by Susan Orshan, specifically this quote “…clamping of the umbilical cord affects chemoreceptors sensitive to changes in arterial oxygen and carbon dioxide content, contributing to the onset of respirations.” This sentiment was echoed by our faculty to the tone of *this is why cords are clamped and cut immediately after the birth*.

I guess my question is this: Is the above quote enough to justify swift cord-clamping? Or not?
Thanks so much for this post. I’m enjoying the research you’ve done!

 

Sincerely,

BCB

 

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Dear BCB,

 

That is a really great question!  What you (and I) both learned in nursing school is right on one hand, but wrong on another.  Let me explain a bit further.  I would like to first address the statement you found in your textbook.

 

Your textbook reads “…clamping of the umbilical cord affects chemoreceptors sensitive to changes in arterial oxygen and carbon dioxide content, contributing to the onset of respirations.”  This is true in the fact that clamping the umbilical does stimulate the baby to breathe…BUT the act of clamping the umbilical cord is NOT necessary for the baby to take his first breath!  Clamping of the umbilical cord in a way actually forces the baby to take his first breath!  In the textbook Respiratory Physiology author John B. West writes:

 

“The emergency of a baby into the outside world is perhaps the most cataclysmic event of his or her life.  The baby is suddenly bombarded with a variety of external stimuli.  In addition, the process of birth interferes with placental gas exchange, with resulting hypoxemia and hypercapnia.  Finally, the sensitivity of the chemoreceptors apparently increases dramatically at birth, although the mechanism is unknown.  As a consequence of all these changes, the baby makes the first gasp.  

 

The fetal lung is not collapsed but is inflated with liquid to about 40% of total lung capacity.  This fluid is continuously secreted by alveolar cells during fetal life and has a low pH.  Some of it is squeezed out as the infant moves through the birth canal, but the remainder has an important role in the subsequent inflation of the lung.  As air enters the lung, large surface tension forces have to be overcome.  Because the larger the radius of curvature, the lower the pressures, this pre-inflation reduces the pressures required.”  (page 152, chapter 9)

 

Also (and this is a bit technical so bear with me!) an excerpt from the article “Cord Closure: Can Hasty Clamping Injure the Newborn?” by George M. Morley, MB published in OBG Management in July 1998 tell us:

 

“Very early clamping results in less than physiologic blood volume. The normal, term child routinely survives, but clamping the cord of a compromised child before ventilation is riskier. Initial aeration of the lungs causes reflex dilatation of pulmonary arterioles and a massive increase in pulmonary blood flow. Placental transfusion normally supplies this volume. Clamping the cord before the infant’s first breath results in blood being sacrificed from other organs to establish pulmonary perfusion. Fatality may result if the child is already hypovolemic.”  (Thanks to gentlebirth.org for the reference!)

 

And to answer your second question…

 

Homebirth midwife from Mountain View, CA and author of the website http://www.gentlebirth.org/ Ronnie Falcao, LM MS writes in a post entitled “Some comments about ‘Anatomy of A Fetus: Circulation and Breathing’” :

 

“It is not air hunger that causes the newborn to take a first breath, and it is certainly not necessary for the cord to be cut in order for the baby to start breathing.  …I am quite certain that nature didn’t assume that a birth attendant would be standing nearby, scissors in hand.  In reality, babies start to breathe right away even if the cord is left untouched.  It is not air hunger that stimulates a baby to take its first breath.  It is likely the stimulation that comes from the shock of cold air and the sudden exposure to light and noise.  Even dim lights and low noises seem very startling to a baby who’s only used to life in the womb.

 

Both Williams Obstetrics  and Varney’s Nurse-Midwifery concur: ‘The phenomenon that occurs to stimulate the neonate to take the first breath is still unknown.  It is believed to be a combination of biochemical changes and a number of physical stimuli to which the neonate is subjected, such as cold, gravity, pain, light and noise, which cause excitation of the respiratory center.’

 

Beyond the question of what stimulates the baby to take a first breath, we can look further at the triggers for the changes in the foramen ovale and ductus arteriosus. The delicate process of rerouting the circulatory system depends on the intricate interplay of blood gas levels that occurs naturally as there is a gradual shift from reliance on umbilical cord oxygen to reliance on air breathed into the lungs.  Sudden severing of the umbilical cord is an unnecessary and dangerous meddling with this process. Some people refer to this as premature amputation of the placenta because the baby is still using oxygen carried through the cord from the placenta.”

 

As an L&D nurse, I have witnessed births where the birth attendant practiced early cord clamping and some where the birth attendant practiced delayed cord clamping.  And guess what!?  These normal, healthy, uncompromised babies took their first breath and started to cry whether the cord was clamped early or late!  (When I first personally witnessed a few of the delayed cord clamped babies breathing just fine I started to wonder if the impression that I was given in nursing school (i.e. that babies needed their cord to be clamped to take their first breath) was really totally true.  Both experience and research have shown me otherwise!  Pretty cool huh! 

 

 

Thanks for your great question!

 

Best,

NursingBirth

 

The Deal with Delayed Cord Cutting or “Hey! Doctor! Leave that Cord Alone!” May 17, 2009

Recently I have received a few emails/comments asking me about the pros/cons of delayed cord cutting.  Delayed cord clamping/cutting is the process of waiting until the umbilical cord stops pulsating (approximately 5 minutes) and/or waiting until the placenta is delivered (approximately 30 minutes) before the cord is cut after the baby is born.  In today’s hospitals, obstetricians typically wait no longer than 30 seconds after the shoulders are delivered before they clamp the cord.  Why such a short time?  Author Tina Cassidy in her book Birth: The Surprising History of How We Are Born sheds some light on the subject:

 

“Throughout history, the immediate postpartum period has been as much a victim of fashion and misconception as has labor and birth.  And standard practice still varies among countries, hospitals, doctors, and midwives. 

 

The first act that usually occurs after the slippery baby emerges is the cutting of the umbilical cord.  …The act also forces the newborn to breathe air through its lungs for the first time.  Perhaps because of the symbolism of that moment, cord cutting has been a magnet for drama, ceremony, and superstition.

 

In most hospitals today, cutting the cord is such an uneventful routine that it can pass unnoticed by the overwhelmed mother.  Doctors generally wait about thirty seconds a time period long enough, they believe, for the baby to receive all the blood it needs from the placenta.  …They then apply two clamps, break out the scissors, and often ask the father if he wants to cut between the ligatures.  Doing all of this quickly also allows for the baby to be suctioned, weighed, and swaddled, before it gets cold.  

 

Some childbirth experts argue that, rather than being guided by a clock, it’s best to wait until the cord stops pulsing before cutting, allowing the baby to receive all the blood it was meant to receive from the placenta.  They say it helps the mother as well, because the placenta shrinks as it pumps out extra blood, making it easier to deliver.”

 

Penny Simkin, author of the book The Birth Partner, also writes about this subject:

 

“The cord is often cut immediately, but a recent scientific analysis has found benefit to waiting for at least two minutes or until it stops pulsating—in five minutes or so.  Less likelihood of anemia for as much as six months exists in babies whose cords are cut late.  Until the cord is clamped or stops pulsating, blood passes back and forth between the baby and the placenta.  It goes from placenta to baby when ever the uterus contracts, squeezing blood from the placenta through the umbilical cord to the baby.  Between these contractions, with each beat of the baby’s heart, blood is pumped from the baby through the umbilical cord and back to the placenta.  This transfer stops when the cord is clamped or stops pulsating, which occurs when the blood vessels close down.  The best way to make sure that the baby has the right amount may be to place the baby on the mother’s belly and wait for the cord to stop pulsating.  Exceptions to this are when the baby needs immediate medical attention, when the cord is tightly wrapped around the baby’s neck, preventing delivery, and when you have decided on cord blood removal and storage.”

 

So what can we take from these quotes?  I believe we can take the following two things:

 

#1  Immediate cord cutting is very convenient for today’s hospital staff and birth attendants.  It allows for the birth attendant to begin inspection of the mother’s perineum and stitching up of any episiotomy or tear that may have occurred (or was cut) during delivery.  It also provides an opportunity to use a sponge stick to provide traction on the placenta (a.k.a. slight tugging) to “assist” the placenta in detaching (Note: The majority of obstetricians do this as it is part of “active management of the third stage” which is predominately and widely taught in medical schools and residency programs across the U.S.)  When the cord is cut soon after delivery, it also allows for the nurses/pediatrician to take the baby away from the mother (either in or outside of the room) and weigh it, tag it, footprint it, give it medications like vitamin K shot and erythromycin eye ointment, and swaddle it. (Note: If you think that sounds assembly line-ish, your right!  These practices are based on a desire for modern maternity hospital wards to increase their efficiency!)  Typically mothers are told “Oh this won’t take very long!  You’ll have the next 18 years to spend with your baby!  It’s too hard to hold the baby and get stitched up anyways!  We’ll give her right back…promise.”  I would like to add that it is my personal philosophy that any practice that is done solely or mainly for obstetrical convenience and not for the safety or wellbeing of the mother or baby is a practice that should be re-thought or abandoned!

 

#2  The placenta does not stop working when the baby is born.  In addition, blood continues to flow from the baby to the placenta and back again making the claim that the baby will get “too much blood” a physiological fallacy especially if the baby is placed on the mother’s abdomen skin-to-skin above the level of the placenta which assures that blood will continue to flow, but not to excess.  (Unless, of course, the cord is milked, and by that I mean the practitioner puts the cord between his thumb and forefinger and pushes all the blood in the cord into the baby and then clamps it, a practice which is both outdated and harmful in the fact that it will most surely lead to neonatal jaundice.  This old-school practice of “milking” the cord is probably where delayed cord clamping inaccurately got its bad reputation!) 

 

In my quest for more knowledge on this topic I stumbled upon a YouTube video entitled Better Birth VA – We Can Be Much Kinder” produced by L. Janel Martin. 

 

 

This video was created in part for the Birth Matters Virginia Video ContestIt is a fascinating video that interviews a variety of midwives/obstetricians including:

 

 

This list of birth attendants, both obstetricians and midwives, are practitioners who are in support of delayed cord cutting.  More research into their backgrounds and practice revealed to me that they all believe in, work within, and support a midwifery model of maternity care, a woman-centered model that has been proven to reduce the incidence of birth injury, trauma, and cesarean section and promote empowering, positive birth experiences for childbearing families. 

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Let’s take a moment to learn a little bit more about the research that SUPPORTS delayed cord clamping/cutting:

 

  • Delayed Umbilical Cord Clamping Boosts Iron In Infants (2006): A report of a study conducted by UC Davis nutrition professor Kathryn Dewey that revealed a two-minute delay in cord clamping at birth significantly increases a child’s iron status at 6 months of age.  This study documented for the first time that the beneficial effects of delayed cord clamping last beyond the age of 3 months.

 

  • Early versus delayed umbilical cord clamping in preterm infants (2004): A Cochrane review (considered the “gold standard” of research and evidenced based practice) of studies on babies born prematurely which revealed that delaying cord clamping for greater than 30 to 120 seconds, rather than early clamping as is the current obstetrical practice, seems to be associated with less need for transfusion, less intraventricular haemorrhage, and helped the babies adjust to their new surroundings better.

 

  • Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes (2008): A Cochrane review that showed no significant difference in postpartum hemorrhage rates when early and late cord clamping were compared. The review also reported growing evidence that delayed cord clamping confers improved iron status in infants up to six months after birth, with a possible additional risk of jaundice that requires phototherapy.  (It is important to note however that the act of placing the baby on the mother’s abdomen skin-to-skin above the level of the placenta assures that blood will continue to flow, but not to excess.)

 

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So let’s break it down shall we?!

 

The PROS of Delayed Cord Clamping/Cutting

(This list was written by Marie Berwald, a certified HypnoBirthing practitioner and Yoga instructor from Canada, for a post entitled “Late vs Early Clamping of the Umbilical Cord in Newborn Babies” on her blog Birth Bliss.  Marie supports each one of these points with research so please check her blog out!)

 

1) The blood in the placenta rightfully belongs to the baby, and babies not receiving this blood have the deal with the equivalent of a major blood loss or hemorrhage at birth.  It is estimated that early clamping deprives the baby of 54 to 160 ml of blood, which represents up to half of a baby’s total blood volume at birth.

 

2) There is a significant amount of iron in the cord blood which the baby needs for optimal health and for the prevention of anemia.

 

3) Babies benefit from the increased oxygen available to them from the cord-blood when the taking these first few breathes.  The earlier the cord is clamped, the more likely the incidents of respiratory distress.

 

4) The blood that babies receives through the cord after birth acts as a source of nourishment that protects infants against the breakdown of body protein.

 

5) As an added bonus, delayed cord clamping keeps babies in their mother’s arms, the ideal place to regulate their temperature and initiate bonding and breastfeeding.

 

The CONS of Delayed Cord Clamping/Cutting

 

1)     May increase the baby’s risk for jaundice, a condition that many newborns develop related to the baby’s immature liver that cannot process bilirubin, a yellow byproduct of the breakdown of old red blood cells.

 

It seemed to me that the PROS of delayed cord clamping outweigh the CONS however I feel that it is important to explore the subject of newborn jaundice more…that is, Is it something that parents should be worried about?  Is it serious enough to trump all of the research supported benefits of delayed cord clamping? 

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The answer to my question came from one of the obstetricians featured in the YouTube video featured above, Dr. Sarah J. Buckley.  In an article entitled, Leaving well alone: A natural approach to the third stage of labour  Dr. Buckley writes,

 

“Early clamping has been widely adopted in Western obstetrics as part of the package known as active management of the third stage. This comprises the use of an oxytocic agent- a drug that, like oxytocin, causes the uterus to contract strongly- given usually by injection into the mothers thigh as the baby is born, as well as early cord clamping, and ‘controlled cord traction’- that is, pulling on the cord to deliver the placenta as quickly as possible.

 

While the aim of active management is to reduce the risk of haemorrhage for the mother, ‘its widespread acceptance was not preceded by studies evaluating the effects of depriving neonates [newborn babies] of a significant volume of blood.’

 

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 means 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.

 

Jaundice is almost certain when a baby gets his or her full quota of blood, and is caused by the breakdown of the normal excess of blood to produce bilirubin, the pigment that causes the yellow appearance of a jaundiced baby. There is, however, no evidence of adverse effects from this mild jaundice.  In fact, jaundice, which is present in almost all human infants to some extent, and which is often prolonged by breastfeeding, may be beneficial because of its powerful anti-oxidant properties.

 

Early cord clamping carries the further disadvantage of depriving the baby of the oxygen-rich placental blood that Mother Nature provides to tide the baby over until breathing is well established. In situations of extreme distress- for example, if the baby takes several minutes to breathe-this reservoir of oxygenated blood can be life saving, but, ironically, standard practice is to cut the cord immediately if resuscitation is needed.”

 

I encourage you to read the full text of Dr. Buckley’s article on her website as she not only talks more about the benefits of delayed cord clamping, but she also supports all of her arguments with research.

 

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Are you interested in delaying cord clamping during the birth of your baby?  If you are, know that the research supports you!  If your birth attendant states that she/he does not usually practice delayed cord clamping/cutting but doesn’t automatically shoot the idea down, as her/him if she would be willing to learn more about it.  On the other hand be weary of any birth attendant that discourages this practice, tries to talk you out of it, or outright refuses to participate.  This could be a red flag that she/he will not be wiling to support any other desires in your birth plan.  A regular visitor to my blog recently wrote me this email:

 

Dear NursingBirth,

 

I belong to an online birth club and a fellow mom wrote this post the other day:

 

“I met with my obstetrician yesterday for my 32 week appointment and brought my birth plan with me.  She looked over it and proceeded to tell me all these issues with it…  I want to have a natural/med-free childbirth and mentioned if the labor wasn’t progressing I would like to try nipple stimulation or breaking my water first. She told me no, this it is bad for the baby, and that pitocin is less bad for the baby.  I want to let the baby’s cord finish pulsating before cutting it… she said absolutely not, because it increases the risk for jaundice. Then at the end of the appointment she walked out and I over heard her talking to a nurse about all the issues with my birth plan and how I must have just copied and pasted stuff from the internet.  Maybe I’m being overly sensitive, but it just seemed a little harsh and awkward.  What would you guys do?”

 

Everyone has been writing back to her that she needs to consider finding another doctor but she seems reluctant because she is already 32 weeks along and has had this doctor for her entire pregnancy.  What do you think?

 

Sincerely, 

Concerned Friend

 

My thoughts….this is a RED FLAG to walk right out of that doctor’s office and never look back.  This doctor CLEARLY does NOT practice evidenced based medicine.  Is switching birth attendants during the last few weeks of pregnancy a hassle and nuisance that a mother should not have to go through on top of all the other stresses she is probably experiencing?….ABSOLUTELY!  But is it absolutely imperative that she still switch practices even though it sucks big time….YOU BET IT IS!  I hope that any mother that finds herself in a similar situation truly understands the risk of staying with a birth attendant that does not support her birth plan just because she don’t want to a) hurt anyone’s feelings, b) think she can still have the birth you want without her/his support, c) go through the hassle of finding a new attendant (trust me, I know it is a huge hassle). 

 

The bottom line for me is this:

 

IT’S YOUR BIRTH!!  YOU ARE ONLY GOING TO BE GIVING BIRTH TO THAT CHILD/CHILDREN ONCE IN YOUR WHOLE LIFE!!  YOU, NOT YOUR BIRTH ATTENDANT, ARE THE PERSON THAT IS GOING TO HAVE TO LIVE WITH THE CONSEQUENCES OF A BIRTH THAT IS CONTROLLED BY SOMEONE ELSE!!  YOU HAVE THE RIGHT TO HAVE THE POSTIVE, EMPOWERING, SAFE, AND HEALTHY BIRTH THAT YOU DESIRE!!

 

For help writing a birth plan please check out:

 

 

A Little Bit of Laughter :) May 16, 2009

Filed under: Just For Fun — NursingBirth @ 9:25 AM
Tags: , , ,

My grandmother who has access to the Internet at her job (she’s still working full time at 75 years old!!) always fills my Inbox with silly chain emails.  I feel bad not reading them (because she will often ask me about a particular one!) so instead of deleting them, I usually skim them over, just in case I am “quizzed” later!  Yesterday however she sent me a doozy and I wanted to share it with all of you.  A bit of a “mental health break” to start your weekend off right!  Enjoy!

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Kids Say The Darndest Things!!

 

As I was nursing my baby, my cousin’s six-year-old daughter, Krissy, came into the room.  Never having seen anyone breast feed before, she was intrigued and full of all kinds of questions about what I was doing.  After mulling over my answers, she remarked, “My mom has some of those, but I don’t think she knows how to use them.”

 

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 On the way back from a Cub Scout meeting, my grandson asked my son the question. “Dad, I know that babies come from mommies’ tummies, but how do they get there in the first place?” he asked innocently.  After my son hemmed and hawed awhile, my grandson finally spoke up in disgust.  “You don’t have to make something up, Dad.  It’s OK if you don’t know the answer!”

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Have a great weekend!

 

Research Shows TENS Unit Can Ease Labor Pain May 15, 2009

It’s been waaaaaaaaaaay too long since I have posted!  It’s been really crazy busy at work and I’ve had to work some overtime to help out.  But I’m back in the saddle again!  So here it goes!

 

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Medical News Todayrecently published a press release citing a 2009 review by the Cochrane Collaboration that concluded that women should have the option of using transcutaneous electrical nerve stimulation (TENS) as a non-pharmacological method of pain management in labor.

 

The full report can be found on the Cochrane Collaboration’s website.  The summary reads:

“TENS is a device which emits low voltage currents which has been used for pain relief in labour. The way that TENS acts to relieve pain is not well understood. The electrical pulses are thought to stimulate nerve pathways in the spinal cord which block the transmission of pain. In labour, the electrodes from the TENS machine are usually attached to the lower back (and women themselves control the electrical currents using a hand-held device) but TENS can also be applied to acupuncture points or directly to the head. The purpose of the review was to see whether TENS is effective in relieving pain in labour. The review includes 19 studies with a total of 1671 women. Fifteen studies examined TENS applied to the back, two to acupuncture points and two to the cranium (head). Results show that pain scores were similar in women using TENS and in control groups. There was some evidence that women using TENS were less likely to rate their pain as severe but results were not consistent. Many women said they would be willing to use TENS again in a future labour. TENS did not seem have an effect on the length of labour, interventions in labour, or the wellbeing of mothers and babies. It is not known whether TENS would help women to manage pain at home in early labour. Although it is not clear that it reduces pain, women should have the choice of using TENS in labour if they think it will be helpful.”

 

I think the findings of this study are interesting.  I certainly support pain management techniques in labor that 1) are non-pharmacological, 2) do no harm to mother or baby or to the progress of labor, and 3) increase a mother’s feeling of control during her labor.  So it seems like the use of a TENS unit could be really helpful to some moms.  On the other hand I have never had any experience with a TENS unit, either personally or via any of the moms I have taken care of, so I have little knowledge about it. 

 

Since I have little knowledge on the subject I naturally did an Internet search to learn more.  If you are interested in using a TENS unit for pain management in labor please check out one of these websites:

 

1) Transcutaneous Electrical Nerve Stimulation (TENS) for Labor Pain Relief   By Robin Elise Weiss, LCCE

2) How to Use a Portable TENS Unit for Labor  By eHow Health Editor

 

Here are some quick facts about TENS units to get you started:

 

1) DO learn how to use a TENS unit before labor from a trained professional.  (This can usually be done by a trained doctor, midwife, or physical therapist.)

 

2) DO continue to move with your TENS unit on!  (A TENS unit does not keep you from moving around or assuming various labor positions.)

 

3) DO use a TENS unit beginning early in labor and if you have back pain/back labor.  (Studies have shown that it is most effective in these situations).

 

4) DO NOT use a TENS unit while you are in a tub or shower.  (Although a TENS unit can be used during times when you are not in the water.)

 

5) DO turn up the frequency of the nerve simulations to help with the pain of contractions or push a button to give you a “boost” as needed during labor, then turn down during periods of rest.

 

6) DO try turning the TENS unit off and seeing how your contractions feel if you feel the TENS unit isn’t helping.  (You may find the TENS unit is actually helping!)

 

7) DO learn about, read about, and practice other non-pharmacological pain management techniques for labor even if you are planning on using a TENS unit including: warm water showers/bath/jacuzzi, back massage, leg massage, counter pressure, various labor positions, birthing ball, squat bar, birthing stool, visualization, affirmations, music therapy, aromatherapy, walking, warm packs, breathing & relaxation techniques, doula support, and most importantly, loving undivided attention and care from supportive labor companions.

 

Recommended Reading:  The Birth Partner, Third Edition: A Complete Guide to Childbirth for Dads, Doulas, and All Other Labor Companions  by Penny Simkin

 

Penny Simkin’s book is a MUST read for any woman or labor companion preparing for childbirth (EVEN women who are planning on using pharmacological pain management options including epidural and IV pain medications should read this book!!!)  On page 150-151 Penny describes how to use a TENS unit in labor. 

 

Are you looking to rent a TENS unit for your labor?  Please check out www.babycaretens.com

 

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Have any of you ever used a TENS unit for pain management in labor?  I’d love to hear how it worked for you!