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Cord around the neck – what parents & practitioners should know
This article shares information about the common practice of checking for a nuchal cord during the second stage of labour, and unlooping or cutting the cord – interventions that are not evidence-based and can cause birth trauma.
It is important women are informed about nuchal cord ‘management’ and how it may affect their birth. Prior information can assist with birth planning; promote discussion with care providers and birth support; and help to avoid iatrogenic injury.
A nuchal cord is when the umbilical cord is ‘coiled’ around the baby’s neck.Most nuchal cords are single coils and loose. Less common are tight, double or multiple coils. (1,2,3)
Various studies have shown nuchal cord to occur:
- in 10% – 37% of all births;
- more commonly in male babies;
- during pregnancy or labour;
- progressively with longer gestation. (1,2,3,4)
Maternity care providers should expect to encounter nuchal cords regularly in their practice. (2)
Baby Tyler born with a tight x4 nuchal cord. Babe was pink and breathing spontaneously within a minute, cord intact
NUCHAL CORD RARELY THE CAUSE OF HARM
Nuchal cords are rarely found to be the cause of adverse outcomes in studies of pregnancy and birth. Several authors have concluded nuchal cords “ordinarily do no harm”. (5,6,7)
Some studies have associated nuchal cord with an increased rate of variable fetal heart rate decelerations during labour, and tight nuchal cords to a higher proportion of fetal distress and low Apgar scores. (3,4,8) However, in these retrospective studies the definition of tight nuchal cord were those ‘clamped and cut before delivery of the shoulders’ – therefore short-term morbidity was more likely caused by the interventions rather than the presence of nuchal cord. (3)
(To learn more about nuchal cords, how babies can and are born with loose/tight/multiple nuchal cords, and why they are disproportionately associated with risk and adverse outcomes, please read Nuchal Cords: the perfect scapegoat.)
RITUAL AND ROUTINE
Many birth practitioners are trained to routinely ‘check’ for a nuchal cord during the second stage of labour, and if present, intervene further by pulling to unloop the cord, or clamping and cutting.
Textbook recommendations to intervene in case of nuchal cords (for normal and emergency births) are based on unevaluated medical literature and lack any references to scientific evidence – they are ‘ritualised’ practices. (1)
The rituals advocated in medical textbooks are:
- To conduct a vaginal examination once the baby’s head is born, to feel and check for a nuchal cord.
- To pull andunloop the cord over the baby’s head before ‘delivery’ of the shoulders, if the cord is loose.
- To attempt to loosen the cord or clamp and cut the cord* before ‘delivery’ of the shoulders, if the cord is tight.
* Some textbooks describe the somersault technique as preferable.
While medical literature from the 1840s onward contains cautionary advice about interfering with nuchal cords, ‘revised’ literature since the 1950s does not. (1)Influential nursing and midwifery textbooks that teach nuchal cord ‘management’ also fail to include the findings of research and medico-legal reviews that associate risk, serious injury and malpractice with nuchal cord interventions. (1)
Practitioners should know routinely checking, unlooping or cutting a nuchal cord is unnecessary and can have serious consequences for the baby. Women and practitioners should be aware these interventions are usually performed without consent and are contrary to the midwifery model of care. (1,2,9)
VAGINAL EXAMINATION TO CHECK FOR NUCHAL CORD
A vaginal examination to check for nuchal cord occurs at a vulnerable stage for women, when the baby’s head has just been born. In most cases, women are unprepared for this vaginal exam and have not given informed consent. (10,11)
Vaginal exams can be painful and distressing for women, but even more so after birthing the head may have caused pain and possible trauma to the perineum. One woman described her experience to Australian midwife researcher Rachel Reed as “fingers of broken glass digging in”. (2)
Checking for a nuchal cord can also interfere with the birth, cause unnecessary stress, and shift a woman’s focus away from giving birth to the intervention being performed. (1,2)
No good evidence exists to support the practice of routinely checking for the nuchal cord, yet it is a common medical birth intervention. (9) Jefford and colleagues found it is customary practise in US, UK and Australian maternity units, and taught to students in the UK, US, New Zealand, Ireland, Mexico and Canada. (Interestingly, midwives from Norway and Denmark responding to a survey had not witnessed the practice of checking for nuchal cord). (9)
Students being trained to check for nuchal cord
PULLING AND UNLOOPING A NUCHAL CORD
Pulling and looping a nuchal cord over the baby’s head during birth is a common birth intervention. (12) Just like checking for nuchal cord, it is not based on evidence and there is growing evidence pulling on the cord may be harmful. (4)
For example, evidence indicates that handling the cord stimulates the umbilical arteries to vasoconstrict (reducing blood flow) (13). Pulling on the umbilical cord also creates tension that can risk the cord tearing and “subsequent neonatal bleeding” (6). The effect of pulling on the cord is currently unknown and cannot be predicted– cords have snapped as a direct result this intervention, compromising the baby, mother and practitioner. (2)
An Australian study has found that once midwives from USA, Australia, Ireland, New Zealand and the UK felt a nuchal cord, they “reverted to carrying out the intervention they had been taught during their training: to clamp and cut the cord.” (2,9)
Doctor asks mother to stop pushing and pulls the cord very tight to unloop
CLAMPING AND CUTTING A TIGHT NUCHAL CORD
There is no adequate evidence to support routinely cutting a tight nuchal cord. (1,2,4,9,14) In fact, some of the reasons stated for cutting a tight cord are completely illogical. Surgically clamping and severing the cord does not relieve compression, low heart rate or oxygen – it produces complete, irreversible ligation and amputates the baby from its only source of circulating blood volume, oxygen and oxygen-carrying red blood cells. If the cord is clamped and cut before full delivery has been attempted, there is no evidence the cord is short or preventing the baby from being born safely.
As far back as 1842, medical advice was if a cord was around the neck “so closely as to strangulate the baby”, that it should be loosened, or if impossible “the cord should be left to see if the baby births” – only if the birth is prevented may cutting be required.(1) The Handbook of Obstetric Nursing text from 1898 recommended feeling for a nuchal cord but not to cut if one was found – this advice was continued in midwifery texts until 1930.(1) The 1961 edition of Williams Obstetrics still urged patience after the birth of a baby’s head for the next contractions to ‘deliver’ the shoulders.(15) But from 1976 the same book introduced new ideas (without evidence) that if the umbilical cord is tight around the neck it should be “cut between two clamps and the infant delivered promptly”.(15)
When the normal birth process has been “abruptly terminated” (16) a prompt delivery becomes crucial. This is not always guaranteed however, and there are number of cases documented in research (Mercer et al) and medical journals where cutting the umbilical cord before delivery of the shoulders resulted in iatrogenic injuries including cerebral palsy, Erb’s palsy, global developmental delay and death.(15)
Although other infants may appear to tolerate cutting of a nuchal cord, there is clear evidence that cutting of tight nuchal cords before, or immediately after, birth can result in these serious injuries and even death (1,14,15). Several writers have observed and documented serious risk and outcomes as a direct cause of cutting a tight nuchal cord: life-threatening hypovolemia, anemia, shock, hypoxic-ischemic encephalopathy, cerebral palsy, cognitive deficits and death. (8,13, 14,15,17,18,19,20 )
Clamping and cutting the cord before the shoulders have been born
The risk and harm from cutting a nuchal cord is compounded by the effects of compression on the umbilical cord when the coil is tight.(14) Before clamping, compression from a tight nuchal cord may have produced a loss of blood volume in the baby and acid-base imbalance (14). By cutting the cord, reperfusion and oxygenation of the baby is prevented. In serious cases, babies are born exhibiting “pallor, irregular respirations, low Apgar scores, gasping, tachycardia, weak peripheral pulses, hypotension, and acidemia.” (21) With the cord already severed, these babies are unable to receive placental transfusion and correction of these conditions.
In 1991, the somersault manoeuvre was first described as an option for ‘managing’ a tight nuchal cord without cutting (6). The somersault manoeuvre supports the physiology of birth and leaves the cord intact – which is necessary for placental transfusion and vitally important for the baby born deplete in blood volume.(14)
The Somersault Technique promoted to assist births where the cord is short and/or tight
Routine checking and intervening with nuchal cords, without evidence it is beneficial or required, is in stark contrast to the philosophy of evidence-based practice – and particularly the midwifery model of care of non-intervention in normal physiological birth.
Practitioners that respond clinically, not routinely, to a nuchal cord – and with the least intervention possible – are more likely to protect normal physiology and anatomy and avoid iatrogenic injury.
When practitioners begin to observe babies being born with a nuchal cord without intervention, they will also cease to routinely check for nuchal cord – thus sparing women the indignity, pain and distraction of a vaginal exam as their baby is being born.
Until nuchal cord ‘management’ ceases to be routine practice, women are best advised to discuss these interventions with their care providers. Women can insist upon interventions being performed only when required and where supported by evidence. Birth partners and doulas should also be aware of nuchal cord rituals and have a clear understanding of the woman’s preferences for the second and third stages of her labour.
(1) Jefford E, Fahy K, Sundin D (2009) Routine vaginal examination to check for a nuchal cord Br J Midwifery, 17(4)
(2) Reed R, (2007)Nuchal Cords: Think Before You Check
(3) Lt Col G Singh, Maj K Sidhu (2008)‘Nuchal Cord: A Retrospective Analysis’, MJAFI, Vol. 64, No. 3
(4) Reed, R. Barnes, M. and Allan, J. (2009), ‘Nuchal cords: sharing the evidence with parents’, British Journal of Midwifery, February 2009, Vol 17 (2): 106-109.
(5) Cunningham FG, Leveuo J, Bloom SL, Hauth JC, Gilstrapp III LC,Wenstrom KD (2005) Williams obstetrics 22nd edn. McCraw-Hill Medical Publishing Division
(6) Schorn M, Blanco J. (1991)Management of the nuchal cord. J Nurse Midwifery ;36:131–2.
(7) Steinfield J, Ludmir J, Eife S, Robbins D, Samuels P (1992) Prenatal detection and management of quadruple nuchal cord: A case report. Journal of Reproductive Medicine 37(12): 989–91
(8) Cashmore J. Usher RH. (1973) Hypovolemia resulting from a tight nuchal cord at birth. Pediatr. Res: 7:339.
(9) Jefford E, Fahy K, Sundin D (2009) The Nuchal Cord at Birth: What Do Midwives Think and Do? Midwifery Today 89: 44–6
(10) Coldicott Y, Pope C, Roberts C (2003) The ethics of intimate examinations -teaching tomorrow’s doctors. BMJ 326(7380): 97–101
(11) Lewin D, Fearon B, Hemmings V, Johnson G (2005) Women’s experiences of vaginal examinations in labour. Midwifery 21: 267–77
(12) Jackson H, Melvin C, Downe S (2007) Midwives and the fetal nuchal cord: asurvey of practices and perceptions. J Midwifery Womens Health 52(1): 49–55
(13) Coad J and Dunstall D (2001). Anatomy and Physiology for Midwives, Mosby.
(14) Mercer J, Skovgaard R, Peareara-Eaves J, Bowman, T (2005) ‘Nuchal Cord Management and Nurse-Midwifery Practice’, Journal of Midwifery & Women’s Health 4 (23): 373-79
(15) Iffy L, Varadi V and Papp E (2001). ‘Untoward neonatal sequelae deriving from cutting of the umbilical cord before delivery’. Med Law, 20 (4): 627-624.
(16) Wickham S, (2008) Midwifery: Best Practice Volume 5. London, UK
(17) Dhar K, Ray S, Dhall G. (1995) Significance of nuchal cord. J Indian Med Assoc;93:451–3.
(18) Shepherd A, Richardson C, Brown J. (1985) Nuchal cord as a cause of neonatal anemia. Am J Dis Child;139:71–3.
(19) Iffy L, Varadi V. (1994) Cerebral palsy following cutting of the nuchal cord before delivery. Med Law;13:323–30.
(20) Flamm M D (1999). ‘Tight nuchal cord and shoulder dystocia: a potentially catastrophic combination’. The American College of Obstetricians and Gynecologists, 94 (5): 853.
(21) VanhaesebrouckP, Vanneste K, De Praeter C, Van Trappen Y, Thiery M ,(1987) ‘Tight nuchal cord and neonatal hypovolaemic shock’, Archives of Disease in Childhood, , 62 1276-77
Jackson H, Melvin C, Downe S 2007 ‘Midwives and the fetal nuchal cord: a survey of practices and perceptions’. Journal of Midwifery and Womens Health 52 49-55
Janet D, Larson MD, William F, Rayburn MD, Crosby RSS, Gary R, Thurnan MD. (1995) Multiple cord entanglement and intrapartum complications. Am J Obstect Gynecol 173:1228-31.
Nelson K, Grether J. Potentially asphyxiating conditions and spastic cerebral palsy in infants of normal birth weight. Am J Obstet Gynecol 1998;179:507–13
Melvin C, Downe S 2007 ‘Management of the nuchal cord: a summary of the evidence’, Br J Midwifery 15(10) 617-21
Walsh Downe Evidence for Neonatal Transition and the First Hour of Life, Essential Midwifery Practice: Intrapartum Care pp 85-89
Oxytocin, Pitocin, and Autism: Researchers Wrestle With Links
By Myra Partridge | 1 juli 2007
An imbalance in blood levels of oxytocin(Drug information on oxytocin)
may be associated with certain forms of autism spectrum disorders (ASDs). “I think that this is an important area for future development to understand the underlying root cause of ASDs and develop treatments to help manage symptoms,” said Eric Hollander, MD, chair of psychiatry and director of the Seaver and New York Autism Center of Excellence at Mount Sinai School of Medicine.The oxytocin receptor mediated by certain single nucleotide polymorphisms (SNPs) may be a culprit, according to C. Sue Carter, PhD, professor in the Department of Psychiatry and codirector of the Brain-Body Center at the University of Illinois, Chicago. Use of pitocin to induce labor is also coming under scrutiny.Carter was a coauthor of a study that confirmed a link between the oxytocin receptor and ASDs in white persons in relation to the SNP rs
2254298. Her research was conducted in response to a study of members of the Chinese Han population that showed an association between ASDs and certain SNPs, including rs
2254298.The results of Carter and colleagues’ study were similar to those of the study by the Chinese research team, although only SNP rs
2254298 was implicated and the G allele—rather than the A allele—was found to be overexpressed in probands of the study participants with ASDs. In speaking with Applied Neurology,
Carter also cited research linking low levels of oxytocin to ASDs.Other recent studies led by Hollander showed that oxytocin therapy using intravenous pitocin significantly reduced repetitive behaviors and improved speech comprehension in patients with ASDs for up to 2 weeks. The group is now studying treatment with an intranasal form of pitocin in high-functioning adults with ASDs. “We’re seeing that oxytocin delivered through the nose twice a day over a 6-week period has resulted in a reduction of self stimulatory behaviors and an improvement in social cognition,” said Hollander.“Patterns of oxytocin, even in blood of nonautistic persons, are not well described. We don’t understand the developmental effects of oxytocin very well, and it is possible that the most important effects of oxytocin on ASDs occur in the prenatal or early postnatal period,” Carter commented.Hollander and colleagues have hypothesized that excess oxytocin—perhaps associated with the use of pitocin during birthing—might be a potential cause of ASDs. “In some individuals whose oxytocin system could be genetically vulnerable, a strong environmental early hit while the brain is still developing could down-regulate the oxytocin system, leading to developmental problems. But this is only a hypothesis that has been observed by association,” Hollander said.Empirical work on the relationship between the use of pitocin and ASDs is too scarce to draw conclusions, said Carter. Furthermore, research in this area is challenged, because pitocin is given very frequently during birthing, making it increasingly difficult to find groups that have not been exposed to it.“I think it is often assumed that pitocin does not reach the infant in amounts that would directly affect the baby. Increasing amounts of pitocin are being given in some hospitals, though. In our most recent research in animals, a little extra oxytocin given directly to newborns facilitated certain forms of social behavior, but larger amounts were disruptive,” said Carter.Onderkant formulierREFERENCES1.
Jacob S, Brune CW, Carter CS, et al. Association of the oxytocin receptor gene (OXTR) in Caucasian children and adolescents with autism. Neurosci Lett.
Wu S, Jia M, Ruan Y, et al. Positive association of the oxytocin receptor gene (OXTR) with autism in the Chinese Han population. Biol Psychiatry.
Modahl C, Green L, Fein D, et al. Plasma oxytocin levels in autistic children. Biol Psychiatry.
Green L, Fein D, Modahl C, et al. Oxytocin and autistic disorder: alterations in peptide forms. Biol Psychiatry.
Hollander E, Bartz J, Chaplin W, et al. Oxytocin increases retention of social cognition in autism. Biol Psychiatry.
Hollander E, Novotny S, Hanratty M, et al. Oxytocin infusion reduces repetitive behaviors in adults with autistic and Asperger’s disorders. Neuropsychopharmacology.
Hollander E, Cartwright C, Wong CM, et al. A dimensional approach to the autism spectrum. CNS Spectrums
Pitocin’s untold impact
by Buscando la luz on Wednesday, July 21st, 2010
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Today’s Midwifery Today E-News shared a quote from Michel Odent about synthetic oxytocin and the potentially detrimental impact it can have on a fetus’s oxytocin receptors. Here’s an excerpt:
80% of the blood reaching the fetus via the umbilical vein goes directly to the inferior vena cava via the ductus venosus, bypassing the liver, and therefore immediately reaching the brain: it is all the more direct since the shunts (foramen ovale and ductus arteriosus) are not yet closed. . . . Furthermore, it appears that the permeability of the blood-brain barrier can increase in situations of oxidative stress—a situation that is common when drips of synthetic oxytocin are used during labor. We have, therefore, serious reasons to be concerned if we take into account the widely documented concept of “oxytocin-induced desensitization of the oxytocin receptors.” In other words, it is probable that, at a quasi-global level, we routinely interfere with the development of the oxytocin system of human beings at a critical phase for gene-environment interaction.
Oxytocin is the hormone of love and bonding and human connection. If the oxytocin system is damaged, or a child’s oxytocin receptors become desensitized, the ramifications are huge. A brain and body with an impaired ability to release or detect oxytocin sounds like misery to me. As more and more scientists study oxytocin’s impact, we can see how crucial our body’s oxytocin systems can be for human life, love, and happiness.
Animal research suggests that oxytocin is one of our mind and body’s best defenses against stress, anxiety, and depression:
In a study presented at the 2007 Society for Neuroscience meeting, Grippo, Porges and Carter compared the stress reactions of female prairie voles living for four weeks either in isolation or with a female sibling and found greater levels of stress, behavioral anxiety and depression in those separated from their siblings. The team then gave the animals either oxytocin or saline every day during the last two weeks of the four-week period. The isolated animals treated with oxytocin no longer showed signs of depression, anxiety or cardiac stress. By contrast, oxytocin had no measurable effects on those paired with siblings, suggesting that “the effects of oxytocin are most apparent under stressful conditions,” Carter says. (Tori DeAngelis, “The two faces of oxytocin“)
If Michel Odent is right about prolonged Pitocin exposure desensitizing a fetus’s oxytocin receptors, then it’s possible that these children will grow up with impaired abilities to cope with stress, leading to higher rates of depression and anxiety.
Other research indicates that induction (and cesarean births) may lead to a higher incidence of autism:
A 2004 study out of Australia found that autistic children were twice as likely to have been born without natural labor, either by elective cesarean or induction. (Jennifer Block, Pushed, p. 139)
And that oxytocin administration benefits autistic individuals:
[P]sychiatrist Eric Hollander, MD, of Mount Sinai School of Medicine, and colleagues found that adults diagnosed with autism or Asperger’s disorder who received oxytocin injections showed an improved ability to identify emotional content on a speech comprehension task, while those on a placebo did not. (Tori DeAngelis, “The two faces of oxytocin“)
There are implications for drug addiction as well:
In rats, intravenous self-administration of heroin was potently decreased by [oxytocin] treatment. . . . [Oxytocin] receptors in the [central nervous system]–mainly those located in limbic and basal forebrain structures–are responsible for mediating various effects of [oxytocin] in the opiate- and cocaine-addicted organism. (Kovacs GL, Sarnyai Z, Szabo G, Oxytocin and addiction: a review)
Someone close to me was on Prozac several years ago. He told me that, while it reduced his depression, it also reduced his ability to feel any and all emotions. He felt nothing. Empty. From what I understand, his experience is not uncommon. Perhaps it’s because Prozac (fluoxetine) seems to “inhibit the action of oxytocin” (Cantor JM, Binik YM, Pfaus JG, Chronic fluoxetine inhibits sexual behavior in the male rat: reversal with oxytocin). Could that empty emotional void be what it feels like to live as a child whose oxytocin receptors were damaged at birth? I shudder to think so.
And I haven’t even touched yet on the other potential negative effects of Pitocin. All this from a drug used daily to induce labor for doctor or patient convenience (for which it has not been approved by the FDA) and far too often for less-than-concrete “medical” reasons. Jennifer Block shared these eye-opening statements in Pushed:
A recent ACOG survey found that in 43% of malpractice suits involving neurologically impaired babies, Pitocin was to blame. (p. 137)
Even Williams Obstetrics offers a sobering history: “Oxytocin is a powerful drug, and it has killed or maimed mothers through rupture of the uterus and even more babies through hypoxia from markedly hypertonic uterine contractions.” (p. 138)
The truth is that we really don’t know all the ways synthetic oxytocin might be affecting our children (or ourselves as mothers). There are certainly situations where Pitocin use is warranted and acceptable, but those cases are far less common than current use would suggest. Without a doubt our society has a Pitocin abuse problem. How many women do you know who have been given Pitocin? How many of them do you think are aware of the potentially detrimental impact of that drug? It’s sad, isn’t it?
Formula feeding should be clearly named in research showing its potential health risks to babies, according to a new study.
The study, led by Dr Julie Smith from the Australian Centre for Economics Research on Health at The Australian National University, shows that researchers reporting poorer health among formula-fed children too often shy away from including a mention of formula feeding in their titles or summaries.
“This is not helping properly informed health professionals and mothers,” Dr Smith said. “We looked at the findings of nearly 80 authoritative studies, all of which highlighted that formula-fed babies tend to be at higher risk of poor health than children fed on breast milk.
“Yet the vast majority of these studies did not mention formula feeding in the places that matter most for lasting impressions: headlines and abstracts. Rather than naming formula feeding as a significant risk factor, researchers seem to be treating this subject like Voldemort in the Harry Potter novels, as “He Who Shall Not Be Named.” For example, a study showing a higher incidence of a serious condition in formula fed infants was misleadingly named ‘Breastfeeding and necrotising enterocolitis,” she said.
Dr Smith and her colleagues stress that their research into how formula feeding is referred to in scientific studies was intended to ask an important rhetorical question about cultural attitudes and informed choice, and shows why blaming mothers for not breastfeeding is futile and misguided. They argue that initiatives to improve infant health by increasing breastfeeding have described the importance of accurate language, and the key role that well-informed health professionals play for women to breastfeed successfully.
“How can we expect physicians and other health professionals to be informed and convincing about the importance of breastfeeding if they themselves are not getting the facts on risks of formula feeding presented in a prominent and clear fashion?” Dr Smith said.
“Adopting the ‘Voldemort’ approach to describing the risks of formula feeding in published research harms the ability of physicians and other health professionals to support women, and reduces women’s ability to make informed choices. If a mother seeks support and reassurance that continuing breastfeeding is worthwhile, such non committal research reporting means she may get non committal advice from health professionals, even though the evidence is clear that formula feeding disadvantages infant health.”
Delayed Cord Clamping Should Be Standard Practice in Obstetrics
December 3, 2009
There are times in our medical careers where we see a shift in thought that leads to a completely different way of doing things. This happened with episiotomy in the last few decades. Most recently trained physicians cannot imagine doing routine episiotomy with every delivery, yet it was not so long ago that this was common practice.
Episiotomy was supported in Medline indexed publications as early as the 1920s(1), and many publications followed in support of this procedure. But by as early as the 1940s, publications began to appear that argued that episiotomy was not such a good thing(2). Over the years the mix of publications changed, now the vast majority of recent publications on episiotomy focus on the problems with the procedure, and lament why older physicians are still doing them (3) (4). And over all this time, practice began to change.
It took a long time for this change to occur, and a lot of data had to accumulate and be absorbed by young inquisitive minds before we got to where we are today, with the majority of recently trained OBs and midwives now reserving episiotomy only for rare indicated situations.
Though this change in episiotomy seems behind us, there are many changes that are ahead of us. One of these changes, I believe, is in the way obstetricians handle the timing of cord clamping.
For the majority of my career, I routinely clamped and cut the umbilical cord as soon as it was reasonable. Occasionally a patient would want me to wait to clamp and cut for some arbitrary amount of time, and I would wait, but in my mind this was just humoring the patient and keeping good relations. After all, I had seen all my attendings and upper level residents clamp and cut right away, so it must be the right thing, right?
Later in my career I was exposed to enough other-thinking minds to consider that maybe this practice was not right. And after some research I found that there was some pretty compelling evidence that indeed, early clamping is harmful for the baby. So much evidence in fact, that I am a bit surprised that as a community, OBs in the US have not developed a culture of delayed routine cord clamping for neonatal benefit.
I think that this is a part of our culture that should change. This evidence is compelling enough that I feel like a real effort should be made in this regard. So to do my part in this, I am blogging about it.
As this is Academic OB/GYN, of course I am going to lay out this evidence I speak of. But before I do that, I want to present some logical ideas under which this evidence ought to be considered.
Prior to the advent of medical delivery, and for all time in animals, it has been the natural way of things for a baby to stay on the umbilical cord for a significant period of time after delivery. Depending on culture and situation, the delay in cord separation could be a few minutes or even a few hours. In some cultures the placenta is left on for days, which of course I find excessive and gross (5). But whatever the culture and time on cord, the absence of immediate cord clamping allows fetal blood that was previously in the placenta to transfuse back into the baby. Studies have demonstrated that a delay of as little as thirty seconds between delivery and cord clamping can result in 20-40 ml*kg-1 of blood entering the fetus from the placenta (6).
Considering this data, I have to think about evolution and function. I am a strong believer in evolution, but even under creationist thinking I have to believe that if the system meant for babies to have been phlebotomized of 50-100 cc of blood at birth, we would have been born with higher hemoglobins. Clearly the natural way of things is for this not to happen.
So does this mean that early cord clamping is necessarily harmful? Absolutely not. But what it means is that the burden of proof is on us to prove that early cord clamping, which amounts to planned fetal phlebotomy, is a beneficial thing. Otherwise, all things being equal we ought to give the tykes a few minutes to soak up what blood they can from the placenta before we cut’em off.
So the question is whether or not there is strong data either way.
It is easy to imagine a randomized study of immediate vs. delayed cord clamping, with quantitative analysis of fetal lab values and clinical outcomes. So easy in fact, that it has been done many times – and in just about every study, there is a clear benefit to delaying cord clamping, even if it is just for 30 seconds after delivery. These benefits include important outcomes such as decreased rates of intraventricular hemorrhage and necrotizing enterocolitis in preterm neonates. Furthermore, aside from some intermittent reports of clinically insignificant polycythemia and hyperbilirubinemia in term infants, there appears to be no harm that can be linked to delayed cord clamping. It feels like being a doctor 10-15 years ago looking to see if there is any data about episiotomy, and finding that there’s a lot, and it says we’ve been doing it wrong for awhile now.
So here’s the data:
Randomized 72 VLBW infants (< 1500 grams) to immediate or delayed cord clamping (5-10 vs. 30-45 seconds). Delayed cord clamp infants had significantly less IVH (5/36 in delayed group vs. 13/36 in immediate group, p = 0.03) and less late onset sepsis (1/36 vs. 8/36, p = 0.03).
Randomized 39 preterm infants to immediate clamping vs. 60-90 second delay, and examined fetal brain blood flow and tissue oxygenation. Results showed similar blood flow between groups, but increased tissue oxygenation in the delayed group and 4 and 24 hours after birth.
Randomized 476 infants to immediate or 2 minute delayed clamping and followed them for 6 months. Delayed clamped babies had higher MCVs (81 vs. 79.5), higher ferritins (50.7 vs. 34.4), and higher total body iron. Effects were greater in infants born to iron deficient mothers. Delayed clamping increased total iron stores by 27-47mg. A follow up study showed that lead exposed infants with delayed clamping also had lower serum lead levels than immediate clamped infants, likely due to iron mediates changes in lead absorption.
Infants delivering at 30 to 36 weeks gestation randomized to immediate vs. 1 minute delay. Delayed group had higher RBC volumes (p = 0.04) and hematocrits (p < 0.005), though there was no difference in RBC transfusions. There was a small increase in babies requiring phototherapy in the delayed group (p = 0.03) but no difference in bilirubin levels between groups.
Randomized 60 infants to clamping at 5-10 seconds vs. 30-45 seconds. Delayed clamping infants had higher BPs and hematocrits. Infants < 1500 grams with delayed clamping needed less mechanical ventilation and surfactant. Trend towards more polycythemia in delayed group, but not statistically significant.
And that’s just some of it. I’ll be happy to send you an Endnote file with a pile more of you’d like it. If the burden of proof is on us to prove that immediate clamping is good, that burden is clearly not met. And furthermore, there is strong evidence that delaying clamping as little as 30 seconds has measurable benefits for the infant, especially in premature babies and babies born to iron deficient mothers.
So basically, we should be doing this. I’m going to try to effect some change in my department, but there are a lot of things that need to happen for us to change as a general culture. It can’t just be the OBs. L and D nurses and pediatricians need to buy in as well.
Some people will argue that premature babies need to be brought to the warmer right away for resucitation. I don’t know the answer to this, but it’s worth study. One might think that it is important to intubate a very premature baby right away, but I have to wonder if that intact cord will be better at delivering oxygen to the baby for 30-60 seconds than the premature lungs. Particularly in cases of fetal respiratory acidosis, there is strong logical argument that a baby might be better resuscitated by unwrapping the cord and letting it flow a bit than trying to oxygenate it through its lungs. Until that placenta is detached, you have a natural ECMO system. Why not use it? Certainly there are exceptions to this logical argument, abruption being the biggest one, and perhaps even severe pre-eclampsia and other poor feto-maternal circulation states.
I wonder at times why delayed cord clamping has not become the standard already; why by and large we have not heeded the literature. It is sad to say that I believe it is because the champions of this practice have not been doctors, but midwives, and sometimes we are influenced by prejudice. Clearly, midwives and doctors tend to have some different ideas about how labor should be managed, but in the end data is data. We championed evidence based medicine, but tend to ignore evidence when it comes from the wrong source, which is unfair. It is fair to critique the research and the methods used to write it, but it shouldn’t matter who the author is. In this case, Mercer and other midwives have done the world a favor by scientifically addressing this issue, and their data deserves serious consideration.
To quote Levy et al (12) “Although a tailored approach is required in the case of cord clamping, the balance of available data suggests that delayed cord clamping should be the method of choice.” We ought to heed this advice better. Like episiotomy, this change in practice may take awhile, but we should get it started. I’m going to work on it myself. How about you?
Het essentiele belang van huid op huid
New Research Shows “Kangaroo Mother Care” Reduces Newborn Deaths More than 50 Percent, Proven to be More Effective than Incubators for Stable Preterm Babies
Up To Half A Million Newborn Lives Could Be Saved Each Year
WESTPORT, Conn. (March 26, 2010) — Kangaroo Mother Care is one of the most effective ways to save preterm babies, according to a new meta-analysis released today on the effectiveness of this simple, low-cost intervention in which mothers serve as human incubators for their newborns. The research, led by Dr. Joy Lawn of Save the Children, appears today in a supplement to the International Journal of Epidemiology, which outlines the most effective interventions to reduce newborn and child deaths globally.
A mother practices “kangaroo mother care” with her 11-day-old, premature baby at Gabrielle Traoré Hospital in Bamako, Mali. January 2, 2010. Photo Credit: Joshua Roberts
The review examined 15 studies in eight low- and middle-income countries, including three randomized controlled trials, and found a 51 percent reduction in newborn mortality when stabilized babies weighing less than four pounds (2,000 gm) received warmth and breast milk through continuous skin-to-skin contact on the chest of their mothers. The findings suggest that up to half a million newborn deaths due to preterm birth complications could be prevented each year if Kangaroo Mother Care were available for all preterm babies, particularly in low-income countries, where newborn mortality rates are highest.
“We are more confident than ever that Kangaroo Mother Care works,” said South African-based Dr. Joy Lawn, newborn health expert for Save the Children, and lead author of the analysis. “No matter if babies are born in Lilongwe, London or Los Angeles, preterm babies need extra care to survive. Kangaroo Mother Care is low-cost and feasible, and we now have proof it is one of the most highly effective ways to give more babies the chance to survive and thrive.”
Kangaroo Mother Care has Greatest Impact During First Week of Life
While increasingly accepted in both high- and low-income countries, a previous meta-analysis of studies did not show Kangaroo Mother Care to have a significant impact on newborn mortality because the benefits of the intervention were examined after one week of age. However, Kangaroo Mother Care has the greatest impact during the first week of a preterm baby’s life, when deaths are most likely to occur. Each year at least 1 million of the world’s nearly 4 million newborn deaths (deaths in the first month of life) are due to preterm birth complications.
Some of the poorest countries in the world are discovering that Kangaroo Mother Care can dramatically reduce newborn deaths. The method was first developed in Colombia and is now practiced in many Latin American countries and in several Asian and African countries. In Malawi — where 20 percent of all newborns have low birthweight, and more than 20,000 mothers each year bear the tragedy of their newborn babies dying — the majority of hospitals and many health centers provide Kangaroo Mother Care. A recent BBC documentary, Invisible Lives, showed a baby born 14 weeks early and weighing less than 2 lbs (850 gm) who had survived with Kangaroo Mother Care and no technology. Malawi is not the norm, however, as few countries have managed to bring the practice to scale.
“The review released today provides sufficient evidence to recommend the routine use of this proven intervention in health facilities for all stable preterm babies,” added Lawn. “This is one time when the research from low-income countries is bringing a breakthrough relevant for all countries. For instance, England and Sweden and other high income countries are starting to use Kangaroo Mother Care.”
Low-Cost Intervention Provides Options for Care in Low-Income Countries
The effect of Kangaroo Mother Care is expected to be greatest in low-income countries, where other options for care of preterm babies remain limited with few neonatal care units. Babies may be separated from their mothers, reducing exclusive breastfeeding, and overcrowding of several babies in a bed increases the risk of infection. Kangaroo Mother Care halves the risk of infection compared to incubator care.
According to Lawn, funding for child survival is increasing and it is critical to base those investments on proven solutions that have the greatest impact. The supplement and reviews are focused on the development and use of the Lives Saved Tool, or LiST. This free user-friendly computer program helps guide governments and donors on investments in global child survival programs with the most significant results.
“Evidence-based policy and programming are needed to help save the millions of mothers and children who die from lack of basic care every year,” said Robert Black, MD, MPH, professor and chair of the Department of International Health at Johns Hopkins Bloomberg School of Public Health. “LiST is an easy-to-use program that can help policymakers allocate resources based on the latest and best evidence available.”
Supplement Reviews Five Other Solutions for Reducing Newborn Deaths
The Journal’s special supplement includes five other reviews of interventions with great potential to reduce newborn deaths. For instance, one meta-analysis shows how the simple injection of steroids given to women in preterm labor reduces deaths for preterm babies by 53 percent. Other featured technical reviews on newborn interventions provide new evidence summaries on tetanus toxoid immunization, folic acid for prevention of neural tube defects or spina bifida, and antibiotics for preterm pre-labor rupture of membranes.
“We have only five years left to achieve the Millennium Development Goal of reducing deaths for newborns and children,” urged Lawn. “The findings of this study add new confidence that we have interventions that work even for challenging conditions like preterm birth. There is no doubt this interventions can save lives — but the reality is that babies will continue to die unnecessarily unless we prioritize high-impact care and make sure it reaches those who need it most. This evidence is our wake-up call to bring Kangaroo Mother Care and other proven interventions to scale in low-and middle-income countries.”
Save the Children is the leading, independent organization that creates lasting change for children in need in the United States and around the world. Its Saving Newborn Lives program, supported by grants from the Bill & Melinda Gates Foundation, is a project that aims to reduce newborn deaths and improve newborn survival in high-mortality countries in Asia, Africa and Latin America. Save the Children USA is a member of the International Save the Children Alliance, a global network of 29 independent Save the Children organizations working to ensure the well-being and protection of children in more than 120 countries. Follow us on Twitter and Facebook.
Samen slapen met je baby
Posted by dlende on December 21, 2008
Where a baby sleeps is not as simple as current medical discourse and recommendations against cosleeping in some western societies want it to be. And there is good reason why. I write here to explain why the pediatric recommendations on forms of cosleeping such as bedsharing will and should remain mixed. I will also address why the majority of new parents practice intermittent bedsharing despite governmental and medical warnings against it.
Definitions are important here. The term cosleeping refers to any situation in which a committed adult caregiver, usually the mother, sleeps within close enough proximity to her infant so that each, the mother and infant, can respond to each other’s sensory signals and cues. Room sharing is a form of cosleeping, always considered safe and always considered protective. But it is not the room itself that it is protective. It is what goes on between the mother (or father) and the infant that is. Medical authorities seem to forget this fact. This form of cosleeping is not controversial and is recommended by all.
Unfortunately, the terms cosleeping, bedsharing and a well-known dangerous form of cosleeping, couch or sofa cosleeping, are mostly used interchangeably by medical authorities, even though these terms need to be kept separate. It is absolutely wrong to say, for example, that “cosleeping is dangerous” when roomsharing is a form of cosleeping and this form of cosleeping (as at least three epidemiological studies show) reduce an infant’s chances of dying by one half.
Bedsharing is another form of cosleeping which can be made either safe or unsafe, but it is not intrinsically one nor the other. Couch or sofa cosleeping is, however, intrinsically dangerous as babies can and do all too easily get pushed against the back of the couch by the adult, or flipped face down in the pillows, to suffocate.
Often news stories talk about “another baby dying while cosleeping” but they fail to distinguish between what type of cosleeping was involved and, worse, what specific dangerous factor might have actually been responsible for the baby dying. A specific example is whether the infant was sleeping prone next to their parent, which is an independent risk factor for death regardless of where the infant was sleeping. Such reports inappropriately suggest that all types of cosleeping are the same, dangerous, and all the practices around cosleeping carry the same high risks, and that no cosleeping environment can be made safe.
Nothing can be further from the truth. This is akin to suggesting that because some parents drive drunk with their infants in their cars, unstrapped into car seats, and because some of these babies die in car accidents that nobody can drive with babies in their cars because obviously car transportation for infants is fatal. You see the point.
One of the most important reasons why bedsharing occurs, and the reason why simple declarations against it will not eradicate it, is because sleeping next to one’s baby is biologically appropriate, unlike placing infants prone to sleep or putting an infant in a room to sleep by itself. This is particularly so when bedsharing is associated with breast feeding.
When done safely, mother-infant cosleeping saves infants lives and contributes to infant and maternal health and well being. Merely having an infant sleeping in a room with a committed adult caregiver (cosleeping) reduces the chances of an infant dying from SIDS or from an accident by one half!
In Japan where co-sleeping and breastfeeding (in the absence of maternal smoking) is the cultural norm, rates of the sudden infant death syndrome are the lowest in the world. For breastfeeding mothers, bedsharing makes breastfeeding much easier to manage and practically doubles the amount of breastfeeding sessions while permitting both mothers and infants to spend more time asleep. The increased exposure to mother’s antibodies which comes with more frequent nighttime breastfeeding can potentially, per any given infant, reduce infant illness. And because co-sleeping in the form of bedsharing makes breastfeeding easier for mothers, it encourages them to breastfeed for a greater number of months, according to Dr. Helen Ball’s studies at the University of Durham, therein potentially reducing the mothers chances of breast cancer. Indeed, the benefits of cosleeping helps explain why simply telling parents never to sleep with baby is like suggesting that nobody should eat fats and sugars since excessive fats and sugars lead to obesity and/or death from heart disease, diabetes or cancer. Obviously, there’s a whole lot more to the story.
As regards bedsharing, an expanded version of its function and effects on the infant’s biology helps us to understand not only why the bedsharing debate refuses to go away, but why the overwhelming majority of parents in the United States (over 50% according to the most recent national survey) now sleep in bed for part or all of the night with their babies.
That the highest rates of bedsharing worldwide occur alongside the lowest rates of infant mortality, including Sudden Infant Death Syndrome (SIDS) rates, is a point worth returning to. It is an important beginning point for understanding the complexities involved in explaining why outcomes related to bedsharing (recall, one of many types of cosleeping) vary between being protective for some populations and dangerous for others. It suggests that whether or not babies should bedshare and what the outcome will be may depend on who is involved, under what condition it occurs, how it is practiced, and the quality of the relationship brought to the bed to share. This is not the answer some medical authorities are looking for, but it certainly resonates with parents, and it is substantiated by scores of studies.
Recently, the American Academy of Pediatrics (AAP) SIDS Sub-Committee for whom I served (ad hoc) as an expert panel member recommended that babies should sleep close to their mothers in the same room but not in the same bed. While I celebrated this historic roomsharing recommendation, I disagreed with and worry about the ramifications of the unqualified recommendation against any and all bedsharing. Further, I worry about the message being given unfairly (if not immorally) to mothers; that is, no matter who you are, or what you do, your sleeping body is no more than an inert potential lethal weapon against which neither you nor your infant has any control. If this were true, none of us humans would be here today to have this discussion because the only reason why we survived is because our ancestral mothers slept alongside us and breastfed us through the night!
I am not alone in thinking this way. The Academy of Breast Feeding Medicine, the USA Breast Feeding Committee, the Breast Feeding section of the American Academy of Pediatrics, La Leche League International, UNICEF and WHO are all prestigious organizations who support bedsharing and which use the best and latest scientific information on what makes mothers and babies safe and healthy. Clearly, there is no scientific consensus.
What we do agree on, however, is what specific “factors” increase the chances of SIDS in a bedsharing environment, and what kinds of circumstances increase the chances of suffocation either from someone in the bed or from the bed furniture itself. For example, adults should not bedshare if inebriated or if desensitized by drugs, or overly exhausted, and other toddlers or children should never be in a bed with an infant. Moreover, since having smoked during a pregnancy diminishes the capacities of infants to arouse to protect their breathing, smoking mothers should have their infants sleep alongside them on a different surface but not in the same bed.
My own physiological studies suggest that breastfeeding mother-infant pairs exhibit increased sensitivities and responses to each other while sleeping, and those sensitivities offers the infant protection from overlay. However, if bottle feeding, infants should lie alongside the mother in a crib or bassinet, but not in the same bed. Prone or stomach sleeping especially on soft mattresses is always dangerous for infants and so is covering their heads with blankets, or laying them near or on top of pillows. Light blanketing is always best as is attention to any spaces or gaps in bed furniture which needs to be fixed as babies can slip into these spaces and quickly to become wedged and asphyxiate. My recommendation is, if routinely bedsharing, to strip the bed apart from its frame, pulling the mattress and box springs to the center of the room, therein avoiding dangerous spaces or gaps into which babies can slip to be injured or die.
But, again, disagreement remains over how best to use this information. Certain medical groups, including some members of the American Academy of Pediatrics (though not necessarily the majority), argue that bedsharing should be eliminated altogether. Others, myself included, prefer to support the practice when it can be done safely amongst breastfeeding mothers. Some professionals believe that it can never be made safe but there is no evidence that this is true.
More importantly, parents just don’t believe it! Making sure that parents are in a position to make informed choices therein reflecting their own infant’s needs, family goals, and nurturing and infant care preferences seems to me to be fundamental.
Our Biological Imperatives
My support of bedsharing when practiced safely stems from my research knowledge of how and why it occurs, what it means to mothers, and how it functions biologically. Like human taste buds which reward us for eating what’s overwhelmingly critical for survival i.e. fats and sugars, a consideration of human infant and parental biology and psychology reveal the existence of powerful physiological and social factors that promote maternal motivations to cosleep and explain parental needs to touch and sleep close to baby.
The low calorie composition of human breast milk (exquisitely adjusted for the human infants’ undeveloped gut) requires frequent nighttime feeds, and, hence, helps explain how and why a cultural shift toward increased cosleeping behavior is underway. Approximately 73% of US mothers leave the hospital breast feeding and even amongst mothers who never intended to bedshare soon discover how much easier breast feeding is and how much more satisfied they feel with baby sleeping alongside often in their bed.
But it’s not just breastfeeding that promotes bedsharing. Infants usually have something to say about it too! And for some reason they remain unimpressed with declarations as to how dangerous sleeping next to mother can be. Instead, irrepressible (ancient) neurologically-based infant responses to maternal smells, movements and touch altogether reduce infant crying while positively regulating infant breathing, body temperature, absorption of calories, stress hormone levels, immune status, and oxygenation. In short, and as mentioned above, cosleeping (whether on the same surface or not) facilitates positive clinical changes including more infant sleep and seems to make, well, babies happy. In other words, unless practiced dangerously, sleeping next to mother is good for infants. The reason why it occurs is because… it is supposed to.
Recall that despite dramatic cultural and technological changes in the industrialized west, human infants are still born the most neurologically immature primate of all, with only 25% of their brain volume. This represents a uniquely human characteristic that could only develop biologically (indeed, is only possible) alongside mother’s continuous contact and proximity—as mothers body proves still to be the only environment to which the infant is truly adapted, for which even modern western technology has yet to produce a substitute.
Even here in whatever-city-USA, nothing a baby can or cannot do makes sense except in light of the mother’s body, a biological reality apparently dismissed by those that argue against any and all bedsharing and what they call cosleeping, but which likely explains why most crib-using parents at some point feel the need to bring their babies to bed with them —findings that our mother-baby sleep laboratory here at Notre Dame has helped document scientifically. Given a choice, it seems human babies strongly prefer their mother’s body to solitary contact with inert cotton-lined mattresses. In turn, mothers seem to notice and succumb to their infant’s preferences.
There is no doubt that bedsharing should be avoided in particular circumstances and can be practiced dangerously. While each single bedsharing death is tragic, such deaths are no more indictments about any and all bedsharing than are the three hundred thousand plus deaths or more of babies in cribs an indictment that crib sleeping is deadly and should be eliminated. Just as unsafe cribs and unsafe ways to use cribs can be eliminated so, too, can parents be educated to minimize bedsharing risks.
Moving Beyond Judgments to Understanding
We still do not know what causes SIDS. But fortunately the primary factors that increase risk are now widely known i.e. placing an infant prone (face down) for sleep, using soft mattresses, maternal smoking, overwrapping babies or blocking air movement around their faces. In combination with bedsharing, where more vital normal defensive infant responses and may be more important to an infant (like the ability to arouse to bat a blanket which momentarily falls to cover the infants face when its parent moves or turns) these risks become exaggerated especially amongst unhealthy infants. When infants die in these obviously unsafe conditions, it is here where social biases and the sheer levels of ignorance associated with actually explaining the death become apparent. A death itself in a bedsharing environment does not automatically suggest, as many legal and medical authorities assert, that it was the bedsharing, or worse, suffocation that killed the infant. Infants in bedsharirng environments, like babies in cribs, can still die of SIDS.
It is a shame and certainly inappropriate that, for example, the head pathologists of the state of Indiana recommends that other pathologists assume SIDS as a likely cause of death when babies die in cribs but to assume asphyxiation if a baby dies in an adult bed or has a history of “cosleeping”. By assuming before any facts are known from the pathologist’s death scene and toxicological report that any bedsharing baby was a victim of an accidental suffocation rather than from some congenital or natural cause, including SIDS unrelated to bedsharing, medical authorities not only commit a form of scientific fraud but they victimize the doomed infant’s parents for a third time. The first occurs when their baby dies, the second occurs when health professionals interviewed for news stories (which commonly occurs) imply that when a baby dies in a bed with an adult it must be due to suffocation (or a SIDS induced by bedsharing). The third time the parents are victimized is when still without any evidence medical or police authorities suggest that their baby’s death was “preventable,” that their baby would still be alive if only the parents had not bedshared. This conclusion is based not on the facts of the tragedy but on unfair and fallacious stereotypes about bedsharing.
Indeed, no legitimate SIDS researcher nor forensic pathologist should render a judgment that a baby was suffocated without an extensive toxiological report and death scene investigation including information from the mother concerning what her thoughts are on what might or could have happened.
Whether involving cribs or adult beds, risky sleep practices leading to infant deaths are more likely to occur when parents lack access to safety information, or if they are judged to be irresponsible should they choose to follow their own and their infants’ biological predilections to bedshare, or if public health messages are held back on brochures and replaced by simplistic and inappropriate warnings saying “just never do it.” Such recommendations misrepresent the true function and biological significance of the behaviors, and the critical extent to which dangerous practices can be modified, and they dismiss the valid reasons why people engage in the behavior in the first place.
Possibly related posts: (automatically generated)
This entry was posted on December 21, 2008 at 5:43 pm and is filed under Applied Anthropology, Education, Evolution, Gender, Human variation, Medical anthropology, Relationships. Tagged: Bedsharing, Breastfeeding, Cosleeping, Parenting. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.