November 24, 2010
Volume 12, Issue 24
Midwifery Today E-News
“Nuchal Cords”
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In This Week’s Issue:


Quote of the Week

“There is power that comes to women when they give birth. They don’t ask for it, it simply invades them. Accumulates like clouds on the horizon and passes through, carrying the child with it.”

Sheryl Feldman


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attendees_listenAttend the full-day Beginning Midwifery class at our conference in Eugene, Oregon, March 30 – April 3, 2011. You’ll learn the basics of normal pregnancy, birth and postpartum care from Ann Olsen, Elizabeth Davis, Maryl Smith, Sister MorningStar and Eneyda Spradlin-Ramos. This class will also help you decide if midwifery is the profession for you.

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The Art of Midwifery

Q: [from Jan’s Facebook page] Do you check for the cord around the neck after a baby’s head is born? I have found that midwives in many countries don’t routinely check for a cord. Is this just another ritual we haven’t questioned or is there a real need?

A: [reply from Kristi Smith Zittle] Never! I do not ever want to affect the normal transfer of blood and antibodies that are flowing through the cord of the precious baby relying upon them nor do I want to cause any type of startle to the baby by accidently touching them at the critical time in the internal rotation process they are working through. Anytime we touch the cord, we can keep it from working perfectly as it was created to do without our interference. Babies will always come out through them or with them super tight around their little necks—the safest place for them to be. Even in cases of tight cords or short ones—the body, if left alone and NOT encouraged to push but simply to eject baby naturally through normal uterine involution—will prepare itself (the placenta) to release early and immediately if necessary and this often times will cause a baby to come more slowly—but then seem to all of a sudden move out fast and then placenta follows on baby’s heels (many times it will begin to detach as baby’s head is delivering and so blood will be seen along with it)—but baby is nearly out and will be fine.

The problem is we are usually too impatient and the idea of waiting and allowing the baby to do it all on its own pushes most of us beyond our limits and we feel a need to manipulate the cord without concern for what it may do to the baby’s necessary blood and antibody nutrients. This was at one point my mentality as per my training.

Along this line as well, somersaulting is NOT a trick that midwives need to perform—babies will somersault themselves out in the case of a nuchal cord—where else will they go if the head is held near mom’s vaginal opening? I LOVE watching them do it all on their own and then watching mom or dad gently unravel them as they lift baby up without anyone even telling them to do so.


ALL BIRTH PRACTITIONERS: The techniques you’ve perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to mtensubmit@midwiferytoday.com.


Jan’s Corner

Birth on a Desert Island

I love technology. When I started Midwifery Today nearly 25 years ago, publishers had just transitioned from using Linotype machines to lay out their magazines and were beginning to use computers. Though those first few issues were difficult in the face of new technology, it was better than any machine to date. I think about those days now, when I use my amazing iPad. I get my news, learn Spanish and have a blast with this little piece of technology. But when it comes to normal birth, technology needs to take a backseat to what is most needed: love, listening and care. Being involved with the people you serve and hands-on care is best.

Our tradition of midwifery comes from hands-on skills. There were no fetoscopes or bulb syringes used in Catharina Schrader’s day. Schrader was a Frisian midwife in the early 18th century who wrote the memoir Mother & Child Were Saved. [http://www.midwiferytoday.com/reviews/motherandchild.asp] She used her brain, heart and hands in the care she gave. She got babies out that other midwives could not. She was often called to assist when other midwives experienced difficult births.

Could we provide good prenatal and birth care without any of our instruments? Considering that most of us feel 80% of birth is in the brain—or is heavily influenced by the brain—prenatal care, love and counseling are of utmost importance. Washington State midwife Carol Gautschi says the best tools are your brain, heart and faith.

Here’s a question for you: If you were on a desert island with 100 pregnant women in your care, which three tools would you take with you? Carol and I talked about this at length and found it hard to pin down the three most useful tools in a midwife’s bag. I think I have mine. I’ll share them with you in another issue, but please share yours with us and, of course, tell us why you would take those three things. You get to take your brain, heart and faith as freebies, so after those tools, which are the three most important?

Jan Tritten, mother of Midwifery Today

Jan Tritten is the founder, editor-in-chief and mother of Midwifery Today magazine. She became a midwife in 1977 after the amazing homebirth of her second daughter. Her mission is to make loving midwifery care the norm for birthing women and their babies throughout the world. Meet Jan at our conferences around the world, or join her online, as she works to transform birth practices around the world.

Jan’s blog: community.midwiferytoday.com/blogs/jan/default.aspx
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News Flash

Baby Delivered at 37,000 feet
Birth on Korean Airlines on Way to Philippines

by Vicki Penwell

(Click the link to watch a few seconds of post-birth video: http://www.youtube.com/watch?v=byw1KMQKKDw)

Korean Airlines Flight #12 on November 15, 2010, took off from LAX on time with Scott and I on-board, en route to Manila to start a new charity maternity clinic for the poor. We scored the exit row seats in economy, so had plenty of leg room and slept for a few hours.

When I woke up about six hours into the flight, I noticed a flight attendant was bringing a woman to the jump seat in front of us, and she was sitting like she was in pain. My subconscious brain immediately recognized the unique type of squirming and sideways twisting that I had seen thousands of times…but my conscious brain said “No, people don’t go into labor on airplanes except in the movies!” and anyway, in the dark, I could not even tell if she was pregnant. But being medically trained in emergency and primary care as well as being a midwife, and being a generally helpful person, I got up and approached the scene to see if I could lend assistance.

A short history revealed that the woman (a Korean citizen named Jannie, who lived in Los Angles) had boarded the plane feeling fine but had been having stomach pains the past four hours, and had just gone to the bathroom and discovered she was bleeding. This was her third baby, due Jan 1. Her squirming had now turned into low moaning as well, and the steward looked terribly uncomfortable, unsure of what to do. He helpfully approached her with an oxygen mask, which is what you do for heart attacks, but was not much help for this situation. I told the steward we needed to get her to a private place, that she was going to deliver. He looked shocked and in denial and so did the woman. I insisted he think of a plan for a private place…perhaps clear out the back row of seats?

[Please read the rest of this story here.
And come meet this amazing midwife at the Midwifery Today conference in Eugene, Oregon, next spring! Learn what Vicki will be teaching here.]


Research

Survey says bath, shower better than Demerol for pain relief during labor

A recent survey of 510 first-time mothers has found that taking a bath or shower during labor is better for relieving pain than commonly used drugs such as pethidine (commonly known as Demerol) or anesthetic gas. Epidurals ranked highest for pain relief among the new mothers surveyed, but taking a bath or shower beat out some of the most-used pain relieving drugs used in labor wards such as pethidine.

The survey was recently published online at www.news-medical.net.

— Mandal, Ananya, MD. 2010. www.news-medical.net/news/20101010/Bathing-better-than-pethidine-as-pain-relief-during-labor-Survey.aspx Accessed 1 Nov 2010.


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Nuchal Cords Are Necklaces, Not Nooses

In no study was it possible for ultrasound imaging to distinguish between a loose or tight cord on ultrasound, although this has been attempted in at least three studies. Peregrine concludes that ultrasound diagnosis of nuchal cords will only be useful if we are able to diagnose them reliably as well as predict which of those fetuses are likely to have a problem.(1) Since neither of those capabilities exists, looking for a nuchal cord on ultrasound is useless. Ultrasound measurement of the velocity of flow in the cord may be useful in the management of twins and chronically growth-restricted fetuses.

Clapp attempted to find out the rate at which nuchal cords come and go during pregnancy.(2) He recruited 84 healthy, nonsmoking, nonsubstance-abusing women carrying a single fetus, with dates confirmed by 8- to 10-week ultrasounds, before the 20th week of gestation. The women all agreed to four extensive ultrasounds at 24–26, 30–32 and 36–38 weeks gestation and during labor and delivery, evaluating fetal biometry, fetal tone and fetal motion. The ultrasound tests used color flow Doppler imaging to determine whether a nuchal cord was present and also monitored breathing movements, amniotic fluid volume, fetal flow redistribution, and velocity flow profiles from the umbilical artery at the body wall and placental insertion as well as at the origin of the fetal middle cerebral artery. Clapp reports that in 60% of women, a nuchal cord was seen on ultrasound at one of the four evaluations, yet at full term, at most, 35% are born with a nuchal cord. The data suggests that the likelihood of a nuchal cord linearly increases as the pregnancy advances. Larson had similar findings.(3) He found of the 13,895 singleton deliveries he analyzed, a nuchal cord appeared in 6% at 20 weeks to 29% at 42 weeks gestation. It appears that the rate of nuchal cords increases with gestation.

Clapp was the first to blind his physicians to the presence or absence of a nuchal cord on ultrasound when they did clinical evaluations for assessing fetal well-being. Their clinical evaluations found no difference between fetuses thought to have a nuchal cord and those without. Clapp points out that in all research showing a difference in the well-being of fetuses with a nuchal cord, the physician was not blinded to the supposed presence or absence of a nuchal cord.

Considering the well-accepted myth of the danger of nuchal cords, the most surprising outcome of recent research is that nuchal cords are not associated with adverse perinatal outcomes. This was the conclusion of every study since 2000. The largest studies were published in 2005 and 2006. The first study examined 4,426 term deliveries (37–42 weeks) retrospectively, finding 17.5% born with a nuchal cord.(4) There was no significant difference in birth weight, non-reassuring fetal heart rate pattern, need for operative delivery, 5-minute Apgar <7, or admission to the NICU nursery, even in the group with two or more loops around the neck. The babies without nuchal cords had significantly higher rate of cesarean delivery. The next study, which was published in July 2005, looked at 11,748 term (37 weeks or longer) deliveries.(5) Researchers found a rate of 34% nuchal cords in the group that delivered between 37–41 weeks, and 35% had nuchal cords in the group that delivered after 41 weeks. The babies born with nuchal cords had more 1-minute Apgar scores <7, but had no difference in 5-minute Apgar scores and no increase in NICU admissions.

In the third study (the largest study of nuchal cords published), 166,318 deliveries were examined retrospectively. Sheiner, et al., found 14.7% with a nuchal cord at delivery including all deliveries at any week of gestation.(6) Although previous studies have found babies with nuchal cords to weigh 50 grams less than those without, this study found babies with a nuchal cord to weigh 50 grams more on average than those without. Sheiner again found the 1-minute Apgar scores to be significantly lower in the group with a cord, but the 5-minute Apgar scores to be the same. Perinatal mortality rate was significantly lower in pregnancies with a nuchal cord compared to those who delivered without a nuchal cord. Altogether these studies represent the outcomes of 182,492 births, which all showed less morbidity and less mortality associated with having a nuchal cord. Nuchal cords are associated with non-reassuring fetal heart rate patterns, probably leading to higher rates of lower Apgar scores at 1 minute, but not at 5 minutes. In addition to the large studies, two smaller studies performed since 2006 have confirmed these results, one of 202 nuchal cords (7) and one of 512 nuchal cords (8). Both found Apgar scores <7 at 1 minute significantly higher in the nuchal cord group, but Apgar scores at 5 minutes were the same in both groups; admission to the neonatal unit was not more common; and nuchal cord was not associated with adverse perinatal outcome.

References:

  1. Peregrine, E., P. O’Brien and E. Jauniaux. 2005. Ultrasound detection of nuchal cord prior to labor induction and the risk of Cesarean section. Ultrasound Obstet Gynecol 25(2): 160–64.
  2. Clapp, J.F., 3rd, et al. 2003. Natural history of antenatal nuchal cords. Am J Obstet Gynecol 189(2): 488–93.
  3. Larson, J.D., W.F. Rayburn and V.L. Harlan. 1997. Nuchal cord entanglements and gestational age. Am J Perinatol 14(9): 555–57.
  4. Mastrobattista, J.M., et al. 2005. Effects of nuchal cord on birth weight and immediate neonatal outcomes. Am J Perinatol 22(2): 83–85.
  5. Schäffer, L., et al. 2005. Nuchal cords in term and post-term deliveries—Do we need to know? Obstet Gynecol 106(1): 23–28.
  6. Sheiner, E., et al. 2006. Nuchal cord is not associated with adverse perinatal outcome. Arch Gynecol Obstet 274(2): 81–83.
  7. Ghosh, G.S. and S. Gudmundsson. 2008. Nuchal cord in post-term pregnancy—relationship to suspected intrapartum fetal distress indicating operative intervention. J Perinat Med 36(2): 142–44.
  8. Shrestha N.S., and N. Singh. 2007. Nuchal cord and perinatal outcome. Kathmandu Univ Med 5(3): 360–63.

Judy Slome Cohain
Excerpted from "Nuchal Cords Are Necklaces, Not Nooses," Midwifery Today, Issue 93
View table of contents / Order the back issue

Editor’s Note: Midwifery Today does not recommend prenatal ultrasound. For more information, please read the following articles: http://www.midwiferytoday.com/articles/default.asp?q=ultrasound


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Read this article from Midwifery Today, Issue 95, newly posted to our Web site:

  • Beyond Fear, Tension and Panic: Helping Men Enjoy the Birth Experience—by Leah Hazard
    “How many times have you seen a man become overwhelmed by fear as his partner gives birth? Calm enough to begin with, the man who was diligently timing contractions and cracking the odd joke a few hours ago now sits rigid by his partner’s bedside, his eyes wide with panic and his mouth set in a hard expression that is neither a smile nor a grimace.”

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Question of the Week

Q: Share your thoughts on nuchal cords. Do you have a standard procedure for checking for a cord wrap? Why or why not?

— Midwifery Today staff


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.


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Question of the Week Responses

Q: Did you have a postdates pregnancy? Have you helped clients who gave birth after 42 weeks? Tell us about your experiences with postmaturity.

— Midwifery Today staff

A: I have enjoyed extra “in utero time” with all three of my children, with no ill effects. My daughter, born at 43 weeks and 1 day, was a hospital birth so I was monitored weekly by my obstetrician (nonstress and AFI tests). My first son, born at 43 weeks exactly, was a homebirth and fetal kick counts guided my sense of well-being. Our last, born at 42 weeks and 1 day, was unmonitored and not expected for several days. We joke that, at 10 pounds, he’s our premie! I never doubted the wisdom of waiting for nature to take its course. My husband simply tells folks, “We bake them at a lower temperature,” and that’s a good enough answer for me.

— Mandy Harshbarger

Q: I recently had a mom with a Bandl’s ring just above the cervix, which held the baby up high and would close to 5 cm with a strong contraction. [Editor’s note: A Bandl’s ring is an atypical thickening of the normal retraction ring that occurs during an obstructed labor. If a Bandl’s ring is palpable abdominally, it is a sign of imminent uterine rupture.] She had to have a c-section. My question is: Will this repeat with another pregnancy? This was her sixth pregnancy, but the first time she has had a Bandl’s ring. Has anyone had experience with a mother who has had a pregnancy after having had a Bandl’s ring during a previous labor?

— Judy, CPM

A: I knew a mom (a friend, not a client) who had a Bandl’s ring with a homebirth with baby No. 8. She ended up transporting and having a c-section. She did go on to have another baby, but opted for a hospital VBAC and was successful—no Bandl’s Ring.

— Debbie Baisley, doula
Magnolia Birth Services


Responses to any Question of the Week may be sent to E-News at any time. Write to mtensubmit@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.


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