October 24, 2001
Volume 3, Issue 43
Midwifery Today E-News
“The Umbilical Cord”
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THIS WEEK'S ISSUE

Contents:

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Quote of the Week:

"Each participant in the birthing process comes into a more valuable state of consciousness through the experience."

- Whapio Diane Bartlett


The Art of Midwifery

During long labor-sitting when the mother is dozing, wear something that jingles so she knows as she drifts in and out of sleep that you are close by.

- Midwifery Today Tricks of the Trade Circle

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News Flashes

Infants who are breastfed for more than 12 months have a very low incidence of hypertension, according to a recently published report. The author believes this protective effect is the result of the breastmilk's polyunsaturated fatty acid profile, which is rich in docosahexaenoic acids (DHA) and arachidonic acid (AA). Likewise, when DHA levels are reduced in animal models, the animals develop hypertension as adults. There is also evidence that when these fatty acids are given to adults who have mild to moderate hypertension, blood pressure returns to normal.

- Hypertension 2001;38:e6-e8


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The Umbilical Cord

Early cord clamping deprives the baby of 54-160 mL of blood, which represents up to half of a baby's total blood volume at birth. "Clamping the cord before the infant's first breath results in blood being sacrificed from other organs to establish pulmonary perfusion [blood supply to the lungs]. Fatality may result if the child is already hypovolemic [low in blood volume]".

- Morley, G. (1998, July). Cord closure: Can hasty clamping injure the newborn? OBG Mgmnt: 29-36.

Early clamping has been linked with an extra risk of anemia in infancy.

- Grajeda, R. et al. (1997).

Delayed clamping of the umbilical cord improves hematologic status of Guatemalan infants at 2 mo. of age.

- Am J Clin Nutr 65:425-431.

Premature babies who experienced delayed cord clamping--the delay was only 30 seconds--showed a reduced need for transfusion, less severe breathing problems, better oxygen levels, and indications of probable improved long-term outcomes compared with those whose cords were clamped immediately.

- Kinmond, S. et al. (1993). Umbilical cord clamping and preterm infants: A randomized trial. BMJ 306(6871): 172-175.

Some studies have shown an increased risk of polycythemia (more red blood cells in the blood) and jaundice when the cord is clamped later. Polycythemia may be beneficial in that more red cells mean more oxygen being delivered to the tissues. The risk that polycythemia will cause the blood to become too thick (hyperviscosity syndrome), which is often used as an argument against delayed cord clamping, seems to be negligible in healthy babies.

- Morley, ibid.

Some evidence shows that the practice of clamping the cord, which is not practiced by indigenous cultures, contributes both to postpartum hemorrhage and retained placenta by trapping extra blood (about 100 mL) within the placenta. This increases placental bulk, which the uterus cannot contract efficiently against and which is more difficult to expel.

- Walsh, S. (1968, May 11). Maternal effects of early and late clamping of the umbilical cord. The Lancet: 997.

Clamping the cord, especially at an early stage, may also cause the extra blood trapped within the placenta to be forced back through the placenta into the mother's blood supply during the third stage contractions. This feto-maternal transfusion increases the chance of future blood group incompatibility problems, which occur when the current baby's blood enters the mother's bloodstream and causes an immune reaction that can be reactivated in a subsequent pregnancy, destroying the baby's blood cells and causing anemia or even death.

- Doolittle, J. & Moritz, C. (1966). Obstet Gynecol 27:529 and Lapido, O. (1971, March 18). Management of the third state of labour with particular reference to reduction of feto-maternal transfusion. BMJ 721-3.

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The above are excerpts from Sarah Buckley's "A Natural Approach to the Third Stage of Labour," Midwifery Today Issue 59

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Several types of cord problems can affect blood flow to the baby and cause fetal distress. "Cord nipping" means the cord is being pinched between the head and pelvic bones, causing variable decelerations in the fetal heart tones (FHTs). During first stage, repositioning the mother usually eases pressure on the cord and brings the FHT to normal, but in second stage nipping may easily progress to cord compression. One trick for remedying variable decels in second stage is to gently press on the mother's abdomen where the baby's back is located. This frequently shifts the baby off the cord and improves FHTs.

Cord compression may be due to occult prolapse, meaning that the cord is low in the pelvis and is being compressed by the head as it descends with the force of contractions. If cord compression is severe, bradycardia is likely to develop. There is also a possibility that the FHT will return to normal if the head moves past the cord entirely. Persistent bradycardia constitutes a crisis with very little leeway. Try repositioning the mother and give oxygen by mask at 6 L/min. Check FHT with each contraction. If there is no improvement after four or five contractions, transport to the hospital.

Cord entanglement may inhibit descent and you may hear cord sounds over the FHT. A very tight cord around the neck may also deflex the baby's head. This may result in persistent bradycardia, necessitating transport.

Complete cord prolapse can occasionally be diagnosed by internal exam in the last weeks of pregnancy with the discovery of pulsations at the cervix or through the lower uterine segment that are synchronous with the FHT. This finding necessitates immediate hospitalization and cesarean section.

If the membranes rupture during labor and the cord prolapses, call the paramedics and place the mother in a knees-chest position with your fingers inside her cervix, holding the head up and away from the cord. Place the cord gently back inside the vagina if it is exposed. If there isn't room, wrap it in gauze or a washcloth soaked in warm water with a pinch of salt and cover with a plastic bag. Rough handling of the cord or exposure to air can cause spasm and constriction. If you must transport the mother yourself, lay a chair back-down on the floor and ease her onto it, then lift and tip her slightly backward until her head is lower than her hips. Keep her in this position in the car with fingers inside to alleviate pressure on the cord until the cesarean is performed.

- Elizabeth Davis, Heart and Hands, Celestial Arts 1997


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Question of the Week (Repeated)

Q: As a care provider for women during their childbearing years, it is also essential to be able to have competent information I can give to the women who I continue to care for beyond the birthing times of their lives. What are the signs and symptoms of breast cancer and what is the percentage of women who breastfeed to those who don't correlate with cancerous tumors in women's breasts? Can you recommend any books that are informative, honest and coming from a natural healing perspective?

- Amanda Moore, midwifery student

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Question of the Week Responses

Q: 1. What is the longest you have waited for a placenta after the birth of the baby? What was the outcome?

2. What is the longest you have seen from full dilation to the beginning of pushing - or to the birth of a baby? What were the outcomes?

- Nancy Wainer

We had a client who had a 4-hour 2nd stage. She had a posterior baby with a very high head and poor uterine contractions. What we did was WAIT patiently. Whilst waiting, I called her backup doctor who suggested we do an artificial rupture of membranes. That was not an option as far as I was concerned; I think it courts trouble. So we hydrated her with "labour-aide," let her rest, and then began some homeopathic pulsatilla and caullophyllum pellets which increased the intensity of the contractions. Our lady had to first accept that her cervix was fully opened and that was all she needed to push her baby out. Once she accepted this (about 1 hour into 2nd stage) she pushed with all her strength. It was amazing to watch; she literally pushed that baby from her symphysis to the pelvic floor! Baby was born 4 hours after full dilation with great Apgars, weight 7 lbs 6 oz.

Although mum had to work really hard, we believe that it was essential that she came to terms with what she had to do. Also, keeping those membranes intact gave her more time to push out her baby. So I think that Nancy's client may have been correct--keep those membranes intact and avoid transfer as much as possible if baby is OK. Once transferred, a mother's perception of her abilities are greatly reduced, and feelings of "I can't do this" quickly set in.

- Kathy Neblett, midwife
Barbados

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Fully dilated and No Urge to Push: This should be the title of a 10-day conference!
I am learning not to call fully dilated "second stage", but to call fully dilated with an urge to push second stage. I believe the words we use are what get us and our clients into trouble (Read Jean Sutton's book Optimal Fetal (Feotal) Positioning"} [available from Midwifery Today].

I am waiting longer and longer over the years for the "urge to push" part of the definition. Problems occur when you have decreased uterine contractions and strength of contractions. Then one is tempted to rupture membranes (if not ruptured already) to get contractions going again. But instead we try every position change known to womankind, including crawling hands/knees on the floor), drinking all sorts of fluids, nipple stimulation, herbs (blue and black cohosh), baths, showers, encouraging her to lie on her left side with her right leg in a 'hurdle' position and wait wait wait.

I've recently been in above the situation and it took about 6 hours--but some of my fellow local midwives have stories to tell of over 12 hours. If the contractions are very regular and strong, it really is a different story: you may end up with exhaustion and later, maternal/fetal infection. A bolus of IV fluids can help here as well. Keeping meticulous records of the reactivity of the baby, mom's vitals, and her verbalization of her wishes ("Yes, I want to keep waiting") and of the family's is very very important. To bring a woman into the hospital after such a marathon can be intimidating, so be thorough and careful.

- Annette Manant, CNM

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I agree with the mother--if the baby was not in danger, then there was not valid medical reason for the cesarean. I find it sad that some midwives, for all the lip service they pay to "trusting the process," still feel the need to limit women by looking primarily to traditional obstetrical standards to guide them in evaluating the safety and normalcy of a situation. Anything that diverges from these standards is seen as suspect even though the standards are largely arbitrary and as such cannot possibly represent the true range of normal.

The notion that the only normal second stage is one in which the mother feels the urge to push at "full" dilation (even assuming that such a measurement can be objectively determined) is absolute nonsense. Who is the clever fellow who decided for us birthing women what "full dilation" and appropriate physiological action at that point should be? And where are the clinical studies that back him up?

When we believe we must manipulate the birth process according to an unscientific standard, we are doing no different and no better than the typical obstetrical model of birth management, regardless of where the birth takes place and how loving the hands doing the manipulating.

- Linda Hessel


Switchboard

In last week's E-News, Valerie El Halta said, "There may be psychological reasons for slowed progress, as well as physiological." Does anyone have ideas about psychological and physiological reasons for a very fast labor?

- Anon.

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I don't know of any research on the effect of hemochromatosis on pregnancy and birth [Issue 3:42], but I can speak from my own experience. I'm a midwife and when I was thinking of getting pregnant for the first time, my diagnosis with hemochromatosis was confirmed by a gastroenterologist. I asked him about getting pregnant (thinking I had to use up some extra iron I had in my blood, and what better way than pregnancy!), and he said absolutely not, not until I had it under control. However, I wasn't sick and my iron was not that high, and my liver wasn't very affected. So I got pregnant, had a perfect pregnancy, never took an iron supplement, and had a beautiful homebirth. I monitored my hemoglobin and hematocrit and maybe once my iron or ferritin, just like any pregnant woman, but as they were within normal range, I never considered myself "high-risk." I always thought the pregnancy helped control the high assimilation of iron particular to hemochromatosis. The risk would depend more on any damage done by hemochromatosis prior to pregnancy. It's very possible to keep it under control and that way organs won't be damaged. If the liver or heart or any other organ is significantly damaged, then these factors should be taken into account individually as to their effect on pregnancy and possible birth risks.

- Marie Tyndall

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I cared for a woman with hemochromatosis. It is important that she be in the care of a hematologist/GI specialist. However it does not require consultant OB care unless the pregnancy or birth become complicated. Uncontrolled hemochromatosis can lead to liver failure and diabetes. My client had not been in appropriate care and had a very high serum ferritin level >600 (normal 10-40 depending on local lab specs). Regular phlebotomies of blood are necessary to keep the serum iron levels normal. In some jurisdictions the woman can donate the blood rather than have it wasted. I did not see any studies that linked hemochromatosis with preeclampsia.

Obviously she will not be at risk for iron deficiency anemia, but she may have folate and/or B12 deficiencies. Genetic counseling is important and pediatric assessment to determine if the infant is affected or is a carrier. There are several consumer oriented organizations that you can find on the web using your search engine.

References:
Hereditary Hemochromatosis Practice Guidelines Development Task Force of the College of American Pathologists. Hereditary hemochromatosis. Clin Chim Acta 1996; 245: 139-200[Medline].
Yang Q, et al. Hemochromatosis-associated mortality in the United States from 1979 to 1992: An analysis of multiple-cause mortality data. Ann Intern Med 1998; 129: 946-953[Medline].
Niederau C, et al. Long-term survival in patients with hereditary hemochromatosis. Gastroenterology 1996; 110: 1107-1119

- Freda Seddon, RN, RM, community midwife
Toronto, Ontario, Canada

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The News Flash about recent research from the J Pediatrics 2001; 139:380-384 [Issue 3:42], "Maternal and infant use of erythromycin and other macrolide antibiotics as risk factors for infantile hypertrophic pyloric stenosis" failed to clarify that the increased risk of pyloric stenosis occurred only when the route of administration of erythromcyin to the infant was systemic. The research was specific in its finding that erythromycin opthalmic ointment was not associated with an increased risk of IHPS. The distinction is important.

- Ann

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Regarding numbness postpartum [Issue 3:37]: I experienced numbness in the feet and toes after the birth of my second son. I saw a podiatrist and a neurologist. The conclusion was swelling compression caused by pregnancy. Because I was breastfeeding he suggested I wait until I was 3 months postpartum, and if it had not resolved to see him again. When the 12 weeks was up I had feeling in my feet again.

- Amy

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More on pertussis [Issue 3:41]: My family and I contracted pertussis in early June 2000, and my husband and I exposed more than 200 OB/GYN clients at our center. All were notified and offered prophylactic antibiotics, which some took. Only one pregnant client contracted pertussis and she had none of the complications that you mentioned. I don't know of any research on pertussis in pregnancy that would shed more light, but you might do a Medline search via the nlm.nih.gov (national library of medicine, national institutes of health).

- Heidi Rinehart, MD

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I hope to be a midwife some day. Does anyone have advice about fertility or just helping conceive? I seem to be ovulating regularly but can't get pregnant. We've been trying and trying. Are there any tricks of the trade I could try?

- J. Nielsen
Seattle
Reply to: ish1221@hotmail.com

====

EDITOR'S NOTE: Only letters sent to the E-News official email address, mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER email addresses will not be considered.


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