July 23, 1999
Volume 1, Issue 30
Midwifery Today E-News
“Cutting the Cord”
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Broaden your education in the United Kingdom and Jamaica!

Make plans now to attend one or both these conferences:

London, England, September 9-13, 1999
Evidence Based Midwifery

Ocho Rios, Jamaica, December 2-6, 1999
Birth Without Borders--Weaving a Global Future
Sponsored by:

Mothering magazine www.mothering.com
Cascade Health Care www.1cascade.com

Exciting plans are shaping up for our Jamaica conference and we hope you will be part of those plans. You will get to meet wonderful midwives from all over the Caribbean and the world. You will go home with many new friends and be rejuvenated for your work. Imagine learning from many experienced midwives who are not from your culture but still speak English. Communication should be strong and many faceted as we express ourselves in research, story, intuition, and song.

Ocho Rios is a safe and beautiful part of the island. The hotel faces a bay on one side and the ocean on the other. It offers an excellent children's program, so consider bringing your family. With the choice of ocean swimming or the pools and shopping right near the hotel, they won't run out of things to do. Plan to come early or stay late and enjoy this amazing island. You will surely make Jamaican friends at the conference and you may want to visit their practice when the conference is over. Plan to take our tour to get to know more about the midwifery situation in Jamaica, have lunch in a Jamaican restaurant, and swim in the Dunn River Falls.

With an early registration deadline coming up on August 1, I want to remind you to get your registration in. The program is in your Midwifery Today 1999 catalog. If you haven't received one, please let us know quickly, and we will fax you the program.

- Jan Tritten, editor

Important Conference Notes:

  • For reduced conference registration prices, postmark your Jamaica conference registration by August 1 or fax it no later than August 1.
  • Students receive price reductions of 25% for Jamaica, 30% for London.
  • Group discounts are available.
  • Subscribe to Midwifery Today magazine and receive a reduced conference price.
  • CEUs for Jamaica are in progress.

For your copy of the printed programs send your full name and postal address to inquiries@midwiferytoday.com. Please mention code 940.

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This issue of Midwifery Today E-News is brought to you by:

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In This Week's Issue:

1) Quote of the Week
2) The Art of Midwifery
3) News Flashes
4) Early or Late Cord Clamping?
5) Question of the Week
6) Question of the Week Responses
7) Switchboard
8) Coming E-News Themes

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1) Quote of the Week: Many of us spend our whole lives running from feeling, with the mistaken belief that you cannot bear the pain. But you have already borne the pain. What you have not done is feel all you are beyond that pain.

- Kahlil Gibran

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2) The Art of Midwifery

A dropperful of angelica tincture in warm water given to a woman who has just birthed helps bring the placenta, often in less than 10 minutes. Repeat if necessary.

- Midwifery Today conference tricks of the trade circle

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3) News Flashes

A study that looked at the outcomes of pregnancies complicated by a multiple nuchal cord entanglement included 8,565 deliveries. A single loop of cord around the fetal neck at delivery was found in 2,191 deliveries, and more than one loop was found in 326 deliveries. Pregnancies with a multiple cord entanglement were more likely to have an abnormal cardiotocograph consisting of persistent variable decelerations in advanced labor. These infants were also more likely to have meconium, a low Apgar score at one minute, and a low umbilical artery pH of <7.10. There was no difference in the rate of cesarean sections, placental abruption and Apgar scores at five minutes between the two groups, and no stillbirths occurred in the cord entanglement group. The study concluded that with multiple nuchal cord entanglement there was no risk of adverse neonatal outcome, and that a multiple cord entanglement is not a contributing factor in intrapartum stillbirth, placental abruption or cesarean delivery.

- MIDIRS, December 1996

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4) Early or Late Cord Clamping?

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.

Because placental transfusion patterns vary widely, it is futile to attempt to give the newborn the "right" amount of blood by clamping at a set time after birth. However, it is extremely likely that the infant will have less-than-optimal blood volume if the cord is clamped before the lungs are ventilated.

In clinical practice, late clamping produces a high hematocrit, high blood pressure, and vasodilatation to accommodate the large volume of blood. These latter two factors should increase tissue perfusion. In searching the literature, I was unable to find any documented case of hyperviscosity syndrome in which the cord was clamped late, although I did find many documented cases of late clamping involving normal newborns with high hematocrits.

There are, however, many documented cases of hyperviscosity syndrome with high hematocrits (e.g., cases involving gestational diabetes or postmaturity) in which the cord was clamped before physiologic cord closure, thus creating low blood volume, low blood pressure, and vasoconstriction coupled with the polycythemia. The inadequate tissue perfusion is blamed on the high hematocrit, when the root cause of the hyperviscosity syndrome is hypovolemic vasoconstriction enforced to the fourth power.

- excerpted from George M. Morley, MB., CH. B, Cord Closure: Can Hasty Clamping Injure the Newborn? July 1998 OBG Management. Submitted by Kathryn Weymouth

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Following are some thoughts and ideas Gloria Lemay, private birth attendant in British Columbia, has gleaned over the years about leaving the umbilical cord to pulse until it stops:

l. Leaving the cord to pulse does no harm and therefore should be encouraged. Think about what nature intended: our ancestors way back before scissors and clamps were invented must have had to wait to deal with the cord/placenta until the placenta was birthed. They probably chewed it, ground it with rocks, or burned it through with hot sticks from the fire. The little teeth on the clamps indicate that traumatizing of the vessels is necessary to quell bleeding.

2. Leaving the cord to pulse slows down the "fire drill" energy that many birth attendants get into after the baby is born. Leaving off the busyness of midwifery for a half hour allows the mother and baby undisturbed bonding time without a "project" going on. The father, too, is undisturbed and able to enjoy this time without focusing on a job at hand.

3. Educator Joseph Chilton Pierce in his book "Magical Child" makes reference to studies that were done on primates who gave birth in captivity and had early cord clamping. Autopsies of the primates showed that early cord clamping produced unusual lesions in the brains of the animals. These same lesions were also found in the brains of human infants when autopsied.

4. In Rh negative women, many believe it is the clamping of a pulsing cord that causes the blood of the baby to transfuse into the bloodstream of the mother, causing sensitization problems.

5. It is interesting that scientists are now discovering that umbilical cord blood is full of valuable T-cells that have cancer fighting properties. A whole industry has sprung up to have this precious blood extracted from the placenta, put in a cooler with dry ice, and taken to a special storage facility to be ready in case the child gets cancer at some time in the future. This is human insanity of the first order. That blood is designed by nature to go into that child's body at birth, not 30 years later!

6. The only time I cut a cord before the placenta comes out is if I have a mother in a water tub and I'm worried about blood loss. Then you have to get both out onto a dry surface quickly and it's easier to hand baby over to an adult while mom is lifted separately. This situation has never happened until after the cord has stopped pulsing.

7. If the baby needs resuscitation, it is important to leave the cord and do all work to help the baby while he/she is on mom's body. Cutting the backup oxygen supply doesn't make any sense at all.

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Learn more from these Midwifery Today issues:
No. 15, Protocols (Regular price, $7.00)
No. 19, Trends vs. Traditions (Regular price: $7.00)
No. 34, Third/Fourth Stage (Regular price: $7.00)
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5) Question of the Week: What steps do you take in your practice to avoid postpartum hemorrhage?

Send your responses or submit a Question of the Week to mtensubmit@midwiferytoday.com

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6) Question of the Week Responses

Question: I would like more information about TENS (Transcutaneous Electrical Nerve Stimulation) for use in labor. The instructions on the units say "PREGNANCY: The safety of [TENS] for use during pregnancy or delivery has not been established." But I know it has been used for this purpose. Is there evidence that TENS works and is it safe?

- Jeanne Batacan, CMA, ICCE, CLE

We use an Obstetric TENS machine in our practice. A lot of women don't want to try it, but those who do generally feel they get some relief from it. The instructions suggest that you should put the pads only on the back and not pass the current through the foetus, but there are no other "warnings" in relation to its use in pregnancy.

I cared for someone only this week who used it throughout her labour (her first) and had 30 mg pethidine IV at about 8 cm dilated. She claimed, at one stage, that the TENS was not working, so her partner and I moved the pads farther down her back so that two of them ended up on her buttocks and the other two were around waist level, and she felt relief again. She said afterward that she had noticed the difference when we moved the pads.

- Jane, Australia

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I used a TENS machine during my labor. I borrowed it from a British friend who used it for all her labors. She benefited greatly from it. I found it very helpful up to a certain point. You hold a little device that you push if you want another "shot" of tensing. When I was at the last point of active labor it started annoying me, so I pulled it off.

But until that point it really helped (this was my third baby so I had done two before without any TENS). It especially helps with posterior birth because it really relieves backache. You have to take it off if you want to take a bath or shower, however, and you have to make sure you stick the little pads on exactly the right places on the back.

TENS has been used in England for a pretty long time now, so maybe there is some literature available there.

- Karen van Loon

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The warning that you mention appears to be a legal requirement in the United States, as the same wording appears on instructions for TENS machines apparently made by a number of manufacturers. I have no medical qualifications, but am aware that TENS is commonly used during labour here in the United Kingdom, and is as far as I am aware uncontroversial.

There's quite a bit of information at www.epemag.wimborne.co.uk/aecctens.htm including a list of indications (which include labour pain) and contraindications (including pregnancy). All are supported by references, which I have not been able to follow up, but which may well include the information you are seeking.

- Dave Seymour, dnsey@aol.com

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I've used TENS during labor for back pain. It is not recommended that it be applied to the abdomen, because the electrical current could interfere with the electrical conductivity of the uterine contractions. So it can't be used for contraction pain. It can be helpful for back pain with contractions, but it is problematic.

The electrodes are applied to the back, and the electrical current is turned up as a contraction starts, and turned down at the end of a contraction. It's very difficult for the laboring woman to do this for herself, because concentrating on turning up the flow at the beginning of a contraction throws her off, so she can't really catch the contraction and go with it--by the time she's turned up the TENS unit, she's at the peak and overwhelmed. We've tried having her signal to someone else when the contraction starts so that person can turn up the unit for her. But then she doesn't have control over how high it's turned up, which needs to be higher for some contractions than for others. So I've found it to be less than satisfactory for that purpose.

TENS is very effective for relieving incision pain after a cesarean section. We used them in a hospital I worked in years ago as a nurse. The woman could control it herself, and could turn it up just before moving or getting out of bed. The amount of pain medication women needed was remarkably reduced. Some women didn't need any at all. I don't know why they aren't used today for that purpose.

- Carla Reinke, CNM, Virginia Mason Midwifery

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7) Switchboard

I have read a lot on the issues surrounding immediate and delayed cord clamping and cutting and the more I read, the more I understand the absolute benefits of doing nothing. I am not a midwife, but a doula who just happens to have witnessed the births of hundreds of calves. We allow the cord to break naturally without clamping and very rarely is a calf ever compromised by infection, even in a pasture that is far less than sanitary.

I was intrigued by a debate on an OB/Gyn list about the benefits of immediate cord clamping or delaying this procedure in babies with low Apgars, and how beneficial giving the mother Narcan is and its almost immediate beneficial effect on the newborn--as well as for meconium and other compromising situations in which babies greatly benefit from the bonus oxygen they receive through the umbilical cord. Kind of makes you think, when meconium protocol dictates immediate clamping and cutting while baby is whisked off to be suctioned aggressively in hospitals!

And finally, something unheard of in hospital births: not clamping or tying the cord at all and severing it only when it has completely stopped pulsating decreases the incidence of umbilical hernia (which I have seen in hospital clients' babies even with delayed clamping).

- Connie Banack,CD,CBE
Mother Care Doula Services, Childbirth Education, Doula/CBE Catalogue
Camrose, Alberta, Canada
momcare@cable-lynx.net
www.cable-lynx.net/~momcare

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According to the textbooks, "late clamping of the cord will result in the transfer of extra blood from the placenta to the baby which may cause hyperviscosity, jaundice and other problems." (Beischer and Mackay, cited in Brown, L.K. (1996) 'Physiology of Childbirth' South Bank University) Is there any hard evidence to support this contention? I would challenge the words "late" and "extra" and question what is meant by "may." Surely evolutionary theory would expect spasms of the umbilical vein to occur sooner, if there should be any advantage in this?

- Dave Seymour. dnsey@aol.com

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In response to the Switchboard question [Issue 28] concerning Hepatitis B and pregnancy: My friend discovered during her first pregnancy 11 years ago that she was a positive carrier for Hepatitis B. Further tests showed she did not presently have an acute infection. She delivered both her children at home with midwives who worked with a consulting MD and with their local health department's infection control nurse or epidemiologist. A series of three immunizations are given in the first 18 months, with the first given right after birth. Gamma globulin was also administered right after birth. Also the baby was washed off with a special soap right after the birth. Financial aid for this fairly expensive treatment was available through the health department.

I attended her second birth and the only thing I did differently was wear long gloves to catch the baby. It was a lovely birth. Her husband and children are free of infection and she is in good health. I had worked with patients in the hospital who were dying of hepatitis and had started IVs on them so I was probably more comfortable with this situation than some people would be.

I know of several people who contracted Hepatitis B from needle sticks and one of my nursing instructors died from this soon after poking herself. So, extreme caution with sharps and the observation of universal precautions are very important, always.

- Kathleen McDonald, CPM Boise, Idaho

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When I was nine weeks pregnant I had an ultrasound that showed a blighted twin pregnancy. Please send me any information you have on this. One of the babies has died and the assumption is that it will just dissolve within the uterus. CDION123@aol.com

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I have just been accepted to train as a midwife in England. Although I am very excited about this prospect I have eczema on my hands, as a form of blistering, and am worrying if I will be accepted after my medical. I would be most grateful if you could give me any details concerning this matter, or know of a midwife who suffers from the same symptoms.

- Gemma Mallett

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A midwife colleague who works in Sydney, Australia will be visiting family in the USA from 10 August till first week of September and is looking for workshops/conferences on midwifery (anywhere in US is feasible) or birth centres to visit.

And does anyone know of workshops/meetings in London UK, 2-9 August? Please respond to Jan Cornfoot capers@gil.com.au

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Share your responses to Switchboard letters with E-News readers! Send them to mtensubmit@midwiferytoday.com

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8) Coming E-News Themes

Coming issues of Midwifery Today E-News will carry the following themes. You are enthusiastically invited to write articles, make comments, tell stories, send techniques, ask questions, write letters or news items related to these themes:

- Ultrasound (July 30)
- Premature labor (Aug. 6)
- International Midwifery (Aug. 13)

We look forward to hearing from you very soon! Send your submissions to mtensubmit@midwiferytoday.com. Some themes will be duplicated over time, so your submission may be filed for later use.


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