Saturday, August 29, 2009
Delayed Cord Clamping
A common request on birth plans, delayed cord clamping does offer benefits for baby.
Immediate cord clamping is part of routine obstetric procedure in the US. This is part of active management of the third stage (third stage being the time from delivery of the baby to the delivery of the placenta), which is considered optimal for reducing risk of postpartum hemorrhage. The cord is often clamped within 30 seconds of birth. However, there is no practice guideline that indicates when cord clamping should optimally occur. A guideline for what 'delayed' is does not exist either. The various research studies on delayed cord clamping use different time intervals, anywhere from 60 seconds to 3 minutes.
Anywhere from 25% to 60% of the baby's blood volume can be found in the placenta at term. Allowing this blood to return to the baby's circulation after birth can provide the baby with a 30% increase in blood volume and up to a 60% increase in red blood cells. This blood volume increase can contribute as much as 2% of the baby's weight!
The benefits
Immediate cord clamping is part of routine obstetric procedure in the US. This is part of active management of the third stage (third stage being the time from delivery of the baby to the delivery of the placenta), which is considered optimal for reducing risk of postpartum hemorrhage. The cord is often clamped within 30 seconds of birth. However, there is no practice guideline that indicates when cord clamping should optimally occur. A guideline for what 'delayed' is does not exist either. The various research studies on delayed cord clamping use different time intervals, anywhere from 60 seconds to 3 minutes.
Anywhere from 25% to 60% of the baby's blood volume can be found in the placenta at term. Allowing this blood to return to the baby's circulation after birth can provide the baby with a 30% increase in blood volume and up to a 60% increase in red blood cells. This blood volume increase can contribute as much as 2% of the baby's weight!
The benefits
- Waiting 1-3 minutes in term babies has been shown to result in an increase in Hemoglobin and hematocrit, meaning lower rates of anemia in newborns
- The difference in Hemoglobin and hematocrit continued to be significant at 2 months and 6 months after birth
- Ferritin (iron) stores were significantly higher at 2-3 months of age in infants where delayed cord clamping had occurred
- Delayed cord clamping can increase the rate of hematopoietic stem cells to the newborn, which may play a role in reducing certain blood and immune disorders
The down side
- There is potential for polycythemia (the infant's blood becomes overly thick due to the increase in volume). The studies done on this show mixed results. However, of significance is the finding that no polycythemic infants were symptomatic or required treatment
- Several studies again show mixed results regarding hyperbilirubinemia (elevated bilirubin levels cause jaundice and sometimes require treatment with phototherapy).
- Transient tachypnea (faster than normal respiratory rate in the newborn) may occur as a result of delayed lung fluid absorption casued by an increase in blood volume realted to delayed cord clamping. One study showed that no additional respiratory support was necessary in these infants while another study showed that similar numbers from each group (delayed versus immediate clamping) reuired additional support
FYI
- Immediate cord clamping is not formally a component of active management for prevention of postpartum hemorrhage. Research provides no evidence that this practice increases the risk of hemorrhage
- There is some question of where the newborn should be placed to allow optimal transfusion of placental blood. Not much research has been done on this particular topic.
The midwives of Bethany Womens Healthcare routinely delay cord clamping :)
Eichenbaum-Pikser, G. & Zasloff, J. (2009). Delayed Clamping of the Umbilical Cord: A review with implications for practice. Journal of Midwifery & Women's Health, 54(4), p321.
Sunday, August 23, 2009
A Day in the Life of a Midwife
Typically we do 24 hours of call at a time or a whole weekend, however there are occasional 12 hour call shifts also. I was on call for 12 hours recently...and it was very busy!
0700 Call starts - I'm in bed.
0745 The first page of the day from Labor & Delivery (L&D). Someone's water has broken - which is ok because she's supposed to be having a baby anyway.
0747 Get up and help the husband get the kids off to school. Avoid the whole raised-by-wolves-look by actually brushing the girls' hair.
0815 Think about getting dressed.
0816 Lay back down.
0820 Get up, get dressed in my fashionable hospital scrubs. Go play on computer (blogs, email, etc).
0840 Page from L&D, patient #1 is ready to deliver
0933 Patient #1 delivers
0950 Start making rounds on the two other laboring patients and charting on everyone
1100 Head to postpartum to see postpartum patients and chart on everyone
1145 Grab some lunch in the doctor's lounge and head over to the office
1200 Pull into parking lot of office when L&D pages, patient #3 that just came in at 8cms and feeling pushy.
1201 Bang head against steering wheel
1202 Head back to hospital with lunch in hand
1215 Arrive at patient #3's room to find her smiling and contracting every 6-7 minutes.
1216 Contemplate stepping outside of room to bang head against the wall but opt not to as I have a headache already
1216 Discuss labor support, etc with patient #3. She doesn't feel like getting out of bed at this point.
1220 Call office and tell them I will try to be there by 2pm
1240 Patient #2 is complete and starting to push, I proceed to spend most of the next hour and a half working with her, while running next door to check on patient #3, who is planning natural childbirth
1300 Call office to tell them I will try to be there by 3pm
1400 Call office to tell them I ain't coming.
1438 Patient #2 delivers.
1500 Patient #3 is hurting and just generally not having a good time. She's still the same exam
1515 I get her in the tub and I sit on the toilet. With a chux over it which turns it into a chair. I realize how bad that sounded.
1530 the tub works its magic.
1545 Patient #3 delivers
Meanwhile patient #4 is gradually getting into labor, which was the goal.
1605 Admit patient #5 for labor
1609 Sit down and try to catch up on charts, without mixing up deliveries and patients
1630 The doc wants to know if I will take over his patient as he is going off call and a doc from another practice will be covering (if the patient is ok with this). The patient (#6) has met me before and is fine with me taking over. She has also been stuck at 8cms.
1635 Bang head against the wall
1636 Utilize the magic peanut with patient #6
1645 Sit and catch up on charts
1700 Re-check patient #4 to determine the next course of action. She's definitely in labor now so onward and forward
1715 Sit down and do nothing for a few minutes.
1745 Re-check patient #6 - complete and ready to go!
1800 Call Lylaine to give report as she comes on call for the weekend
1815 Patient #6 delivers
1840 Check on patient #5, who is doing well and making progress.
1855 Leave the hospital
1900 Off call
Tiffany
0700 Call starts - I'm in bed.
0745 The first page of the day from Labor & Delivery (L&D). Someone's water has broken - which is ok because she's supposed to be having a baby anyway.
0747 Get up and help the husband get the kids off to school. Avoid the whole raised-by-wolves-look by actually brushing the girls' hair.
0815 Think about getting dressed.
0816 Lay back down.
0820 Get up, get dressed in my fashionable hospital scrubs. Go play on computer (blogs, email, etc).
0840 Page from L&D, patient #1 is ready to deliver
0933 Patient #1 delivers
0950 Start making rounds on the two other laboring patients and charting on everyone
1100 Head to postpartum to see postpartum patients and chart on everyone
1145 Grab some lunch in the doctor's lounge and head over to the office
1200 Pull into parking lot of office when L&D pages, patient #3 that just came in at 8cms and feeling pushy.
1201 Bang head against steering wheel
1202 Head back to hospital with lunch in hand
1215 Arrive at patient #3's room to find her smiling and contracting every 6-7 minutes.
1216 Contemplate stepping outside of room to bang head against the wall but opt not to as I have a headache already
1216 Discuss labor support, etc with patient #3. She doesn't feel like getting out of bed at this point.
1220 Call office and tell them I will try to be there by 2pm
1240 Patient #2 is complete and starting to push, I proceed to spend most of the next hour and a half working with her, while running next door to check on patient #3, who is planning natural childbirth
1300 Call office to tell them I will try to be there by 3pm
1400 Call office to tell them I ain't coming.
1438 Patient #2 delivers.
1500 Patient #3 is hurting and just generally not having a good time. She's still the same exam
1515 I get her in the tub and I sit on the toilet. With a chux over it which turns it into a chair. I realize how bad that sounded.
1530 the tub works its magic.
1545 Patient #3 delivers
Meanwhile patient #4 is gradually getting into labor, which was the goal.
1605 Admit patient #5 for labor
1609 Sit down and try to catch up on charts, without mixing up deliveries and patients
1630 The doc wants to know if I will take over his patient as he is going off call and a doc from another practice will be covering (if the patient is ok with this). The patient (#6) has met me before and is fine with me taking over. She has also been stuck at 8cms.
1635 Bang head against the wall
1636 Utilize the magic peanut with patient #6
1645 Sit and catch up on charts
1700 Re-check patient #4 to determine the next course of action. She's definitely in labor now so onward and forward
1715 Sit down and do nothing for a few minutes.
1745 Re-check patient #6 - complete and ready to go!
1800 Call Lylaine to give report as she comes on call for the weekend
1815 Patient #6 delivers
1840 Check on patient #5, who is doing well and making progress.
1855 Leave the hospital
1900 Off call
Tiffany
Another Benefit of Breastfeeding!
The Breast Cancer Fund published a report showing that formula feeding may be a contributing factor to puberty in girls starting at younger ages. Conversely, breastfeeding contains hormones that may protect against early puberty. See the report for more information!
VBACs Associated with Positive Outcomes
Much controversy surrounds VBAC (vaginal birth after cesarean) today. With an all-time high cesarean section rate of 31.1% nationwide (in 1996, section rates were 14.6%), VBACs are definitely a hot topic. In the 80's and 90's, VBACs occurred at a tremendous rate. Then, true to obstetrical history (where practices are often implemented without adequate research), research was started on this practice. A disturbing trend of complications became apparent, specifically uterine rupture. The VBAC then almost went the way of the albatross, nearly becoming extinct. Doctors and hospitals across the country stopped offering VBACs as an alternative to repeat cesareans due to safety and liability issues.
Uterine rupture is catastrophic if it occurs. It can result in fetal and maternal damage or death. However, the early stages of research included women who had one or more sections, women being induced with prostaglandins (cytotec, cervidil, etc) and/or pitocin. So trully the early research was not an accurate picture of the risk of VBAC. Again, true to obstetrical history, everyone jumped on the bandwagon and stopped offering VBACs.
In the past few years, research has been refined and continues to be improved upon in this area. Now, research tells us that women can safely and effectively VBAC when certain criteria is met. Recently, Obstetrics & Gynecology released a study that yet again found positive outcomes associated with VBACs and negative outcomes associated with elective cesarean. This journal is also known as the 'green journal', and is associated with the American College of Obstetricians and Gynecologists (ACOG).
So research shows us that women having elective repeat cesareans are more likely to have infants with respiratory distress, have less children than women having vaginal deliveries, increased risk of stillbirth, increased risk of placental abnormalities in future pregnancies...not to mention all the risks of having major abdominal surgery (infection, hemorrhage, damage to organs, death). And this is just a brief overview!
For more information regarding cesarean sections and VBACs, check out these links...
Childbirth Connection - Cesarean Sections
Childbirth Connection - VBAC versus Repeat C/S
Navelgazing Midwife
Uterine rupture is catastrophic if it occurs. It can result in fetal and maternal damage or death. However, the early stages of research included women who had one or more sections, women being induced with prostaglandins (cytotec, cervidil, etc) and/or pitocin. So trully the early research was not an accurate picture of the risk of VBAC. Again, true to obstetrical history, everyone jumped on the bandwagon and stopped offering VBACs.
In the past few years, research has been refined and continues to be improved upon in this area. Now, research tells us that women can safely and effectively VBAC when certain criteria is met. Recently, Obstetrics & Gynecology released a study that yet again found positive outcomes associated with VBACs and negative outcomes associated with elective cesarean. This journal is also known as the 'green journal', and is associated with the American College of Obstetricians and Gynecologists (ACOG).
So research shows us that women having elective repeat cesareans are more likely to have infants with respiratory distress, have less children than women having vaginal deliveries, increased risk of stillbirth, increased risk of placental abnormalities in future pregnancies...not to mention all the risks of having major abdominal surgery (infection, hemorrhage, damage to organs, death). And this is just a brief overview!
For more information regarding cesarean sections and VBACs, check out these links...
Childbirth Connection - Cesarean Sections
Childbirth Connection - VBAC versus Repeat C/S
Navelgazing Midwife
Sunday, August 16, 2009
Healthcare Reform
Regardless of where one might stand on healthcare reform, it's an important and hot topic that everyone should be checking out. It can be difficult to weed through all the rhetoric and mis-information on the web. I found a link through Kaiser Family Foundation that offers a side-by-side comparison of various healthcare policies being proposed.
Tiffany
Tiffany
Support Breastfeeding Legislation
I was over on At Your Cervix, reading her newest post on supporting breastfeeding legislation so thought I would hsare here as well. Please click this link and send an email in support of this very important legislation. This will help make breastfeeding in the workplace better supported!
Tiffany
Tiffany
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