Herbs are a part of the wisdom of midwifery care that has been used for many many years during the childbearing year. I recently came across this wonderful blog post with some really helpful and guiding information about herbal use during pregnancy and breastfeeding.
There have been many fantastic posts written in the past few years detailing the errors in judging a pregnancy by it's due date and I won't try to recreate these here. (Although I cite a great one at the bottom of this post "The Lie of the Estimated Due Date" - definitely take a look!). There are also some simply excellent articles written about the problems with induction for going post dates (like this one from Midwifery Today). Check them out.
What instead I'd like to offer are some simple words of reassurance and, possibly, wisdom to those creeping up on or past their "due dates."
First, remember, "due dates" are just averages! Only about 4% of women actually birth on their due date (Simkin) and it is estimated that about 50 to 80% of mothers will go past 40 weeks of pregnancy (Safranski). That said, I am no stranger to the anxiety that settles in as the days continue to go by and the baby continues to stay put and the care providers continue to pressure.
So here are my words of wisdom! They come as a doula but also as a momma of two boys who really liked life in the womb, so much so that they chose to spend a good solid 42 plus weeks in there.
Think of the due date as a day of celebration! A day of "Yay! We have made it, baby and I, forty weeks into pregnancy!" Momma's body and Little One's placenta have grown a healthy and happy baby that is getting more and more equipped for life outside the womb with every moment that passes.
Think of the due date as the due month, rather than one day - such a small moment in the scheme of a full term pregnancy can feel very daunting. When it is generalized to the due month (which is actually far more accurate as about two thirds of women birth within ten days of their due date (Simkin) and up to 19% of women actually reach 42 weeks of pregnancy (Davis), it feels like a space in time where the baby can prepare, where the body can make changes, and where labor can unfold. The due month allows time for the process to take place. A process requires time and space and effort - all of which is far too much to ask of just one day.
Think of the due month as your time to take mental note of your head space. Tie up loose ends, set aside moments for reflection and appreciation. And spend every moment savoring the time and energy that your body and baby are so willing to give to the pregnancy.
The "due date" is no more than one day, nestled in around the end of pregnancy. By reframing a woman's outlook, she can enjoy the last moments of pregnancy and stay calm and centered, allowing the process of labor and birth to unfold in a supported and peaceful space.
Davis, Elizabeth. Heart and Hands. Berkeley: Celestial Arts, 2004. Print.
Misha Safranski. "The Lie of the Estimated Due Date (EDD): Why Your Due Date is Not What You Think." Peaceful Parenting. Peaceful Parenting, 9 Sept. 2009. Web. 17 Oct. 2014.
Simkin, Penny. Prengancy Childbirth and the Newborn: The Complete Guide." New York: Meadowbrook Press, 2001. Print.
Now that we've taken a look at the evidence supporting delayed cord clamping, let's have a chat about incorporating it into the birth wishes and having a discussion with the care provider, if need be. Despite the World Health Organization's strong recommendation for delayed cord clamping at all births ("Delayed Clamping"), many care providers in the greater Philadelphia appear to continue to be quick with the snipping. As we often discuss in birth classes, policies and practices quite frequently get handed down to students without much question about their basis (Gaskin). Unfortunately, many policies are also enforced despite a lack evidence supporting their use (Trochim). Still other practices remain in place because of the desire to keep things moving along in a process that often requires a lot of "just waiting." The lack of delayed cord clamping can fall into all of these categories.
As their is greater awareness about the importance of stem cells, we've begun questioning the practice of immediate cord clamping even more. Is it more important for babies to have these stem cells at birth or more important to save them for a potential sibling down the road? This has brought up other questions related to the benefits of the baby receiving much of his own blood back into his body at the moments following birth. The benefits have been discussed in the prior post so let's assume now that a couple is trying to exert their legal right to evidence-based care in relation to delayed clamping ("The Rights").
It's always helpful to approach a provider about their common practices, whether it be cord clamping, episiotomies, manual rotation of the baby's shoulders at birth, etc. before labor. Despite this being another legal right for a laboring woman, most interventions are not discussed with a couple before birth, unless an out-of-hospital birth class is being taken. Yet, even then, as educators, we are often limited by time and scope in discussing every possible intervention in depth. Anyway, I digress. Back to the point, a conversation during pregnancy can do wonders in terms of helping a couple to assess if they've chosen the right provider for them, if they feel they have a trusting relationship with their doctor or midwife, and what their provider's common practices really are. However, as Sheila Kitzinger states, "...you may have to develop new social skills to create a satisfactory dialogue with those who care for you." (The Complete Book of Pregnancy and Childbirth). Understanding that the answer not only lies in response but in the body language, the willingness to discuss, and the answer to the question "Why?"
Stating your request clearly and concisely (Kitzinger), while fully clothed and seated in an upright position, is key to an open dialogue. If your request is met with reluctance or hesitation, you can simply restate your wishes. It's also never a bad idea to ask a provider for the research they are using to back their practice. I have, unfortunately, had several clients who did just that and were told by their provider that they did not have the research. Waiting until labor to voice requests can put a woman in a very vulnerable position, making it more difficult for her to voice her needs clearly and assertively.
After a discussion with your provider, it's always a great idea to ask about the way that other providers in the practice carry out the same routine. This will help in knowing what to be prepared for in the moment, should a different provider be present during the labor, and also helpful in getting an overall feel for the practice. If your provider has okay'd a request that you've made, it may be helpful to ask them to make note of that in your chart or to have them initial it on a list of your birth priorities.
In the moment, while mom is pushing her baby out or, in the case of a cesarean, while the baby is emerging, partners can take an active role in continuing to advocate for what had been requested. Reminding a provider that delayed clamping is a priority for you can help ensure that things are done the way you'd prefer. A doula or other birth support person can also remind the partner at this point to advocate for the birth wishes.
With clients, I've been in situations where they've requested delayed clamping only to have the doctor or midwife wait 30 seconds before clamping the cord. (On the flip side,I've also been in situations where the provider has asked the client if they were ready for the cord to be clamped before doing anything, which I've found to be very respectful.) One thing that I've found helpful in ensuring that the cord is allowed to finish pulsating is when client's have requested that the cord not be clamped or cut until the placenta is birthed. This provides a bit more insurance that the baby will receive as much blood back into his body as possible.
In a hospital, if there is a concern about the baby's well-being, the baby will be taken to the warmer for the pediatrician or neonatologist to evaluate. In a home birth, the vast majority of the time, the baby is able to be assessed while still on mom, allowing the cord to provide a back-up of blood and nutrients to the baby. Unfortunately, in the hospital scenario, cord clamping does happen immediately so that the baby can be checked out. However, in your average healthy birth, the baby is able to be fully assessed while on mom, cord intact. A move is slowly made towards a family-centered cesarean yet the hospitals in our area still have a ways to go. Unfortunately, at this point, I don't know of any obstetrician who will allow for delayed cord clamping outside of 15 to 30 seconds, during a cesarean section.
The client is the catalyst for change and it's important that we all remember this. The more informed, the more actively participating, and the more knowledgeable a client is, the more opportunity they have to ask questions and request evidence-based care. As much of a fan of the written birth wishes as I am, nothing can replace a face-to-face conversation between a client and their provider. Having a birth in which you are as in control of the process of decision making as possible, quite often makes for a very positive experience. Your birth, your baby, your body.
"The Rights of Childbearing Women." Childbirth Connection. Childbirth Connection. 2006. Web. 14. Oct. 2014.
"Delayed Clamping of the Umbilical Cord to Reduce Infant Anaemia." WHO. n.p. 2014. Web. 5 Oct. 2014.
Gaskin, Ina May. Birth Matters: A Midwife's Manifesto. New York: Seven Stories Press, 2011. Print.
Kitzinger, Sheila. The Complete Book of Pregnancy and Childbirth. London: Dorling Kindersley Limited, 2003. Print.
Trochim, William, Ph.D., Cathleen Kane, M.P.A., Mark J. Graham, Ph.D., and Harold A. Pincus, M.D. "Evaluating Translational Research: A Process Marker Model." CTS Journal 4.3 (2011): 153-162. Web. 14 Oct. 2014
Let's start this with: I have a new favorite blog. I might not love every post and I definitely haven't read every post from the archives. But when it comes to a research-based look at obstetrical procedures, I'm finding this blog far more favorable than not - The Academic OB/GYN, blogger Dr. Nicholas Fogelson. His articles are intended for obstetricians, not for the average person delving into the world of obstetrics for such minor things as having a baby (now I hope you all caught the complete sarcasm there) but his posts are actually research-based and not always in line with ACOG and AAP (which is something I've come to admire as I've learned more about the constraints of the system). Tonight's post is inspired by and largely based on his Grand Rounds discussion from January 2011, at the University of South Carolina School of Medicine (but I promise it will read much more easily than that sounds).
More times than I can count, I've had couples in classes ask "What about delayed cord clamping?" Such a valuable question. What about it?
Delayed cord clamping refers to waiting, an undetermined amount of time, to clamp and cut the baby's umbilical cord after birth. Fogelson has compared the modern procedure of immediate cord clamping and cutting to the antiquated practice of blood-letting, "It's interesting to talk about blood-letting and then talk about immediate cord clamping because I think that you'll see a bit of a parallel." Perhaps one of his most poignant and beautiful points is made in watching the role that cord clamping takes on in births outside of the human realm. The clips Fogelson shows from the births of a cat, a horse, an orangutan, and a dolphin show nothing being done to the cord. That is, the cord is actually simply ignored by the mother for a long while after the birth. The cat and orangutan take their time licking their little ones while the foal figures out it's way onto it's feet. The dolphin in Fogelson's video starts moving it's tail and swims up and with it's mother. It is only in human culture that we've initiated this obsession with cord management.
Cultures around the world have varying traditions surrounding the umbilical cord. In some cultures, a lotus birth is the tradition, where the placenta is left attached to the baby until the cord naturally falls off on it's own (usually a few days shorter than when a "cord stump" dries up and falls off). In other cultures, the midwife calls in another woman from the community to cut the cord. In the islands of Micronesia, the cord is referred to as "the house of the soul" and is preserved in a small box or burred with the placenta near the family's home (Kitzinger, 145). One thing that remains constant, though, is that the need to 'care for' the cord seems to be a distinctly human trait.
The umbilical cord is composed of three vessels. Two vessels (arteries) bring waste products away from the baby back to the placenta and one vessel (vein) brings blood and nourishment to the baby. Until the placenta begins to detach from the mother's uterus, the cord has the potential to continue bringing blood and nourishment to the baby. This means that human umbilical cords will often pulsate for at least ten minutes after birth. In addition, as the cord is exposed to the air, it begins to contract but the first vessels that are closed off are those that bring waste products away from the baby, meaning the vessel bringing blood to the baby continues to pulsate and closes off last. It's theorized that this allows the baby a certain measure of circumstantial control over it's use of this extra blood volume (Buckley). Interestingly, a placenta drained of blood tends to shear away from the lining of the uterus more easily than a placenta swollen with blood (Kitzinger, 145).
I have had several clients whose OB told them that the baby must be held below the mother after birth for gravity to allow the benefits of cord pulsation. Some research does show that holding the baby at or below the level of the uterus until cord pulsation ceases maximizes the blood transfer. In considering this, I remind mommas that birth and the immediate postpartum is a complexity of physiological and emotional responses to the baby's entrance into the world. Having the baby on one's chest while the cord pulsates may not lead to maximum blood transfer from the placenta but will provide the baby with a portion of it's own blood while also providing the benefits of immediate skin to skin contact with mom. According to the World Health Organization, "Trials in which newborns were placed on the mother's abdomen or on the bed where she lay and the cord was clamped only when it stopped pulsating showed that these babies had blood volumes 32% higher than babies whose cords were clamped immediately after birth" ("Review of Evidence"). Thirty two percent higher blood volume paired with skin-to-skin benefits such as lower cortisol levels, assistance in regulating breathing, heart rate, and temperature, elevated blood sugar levels, and colonization of the mother's bacteria ("The Importance of Skin-to-Skin"), to name a few, is a far better deal for most babies than 50% greater blood volume from being held below the level of the mother's uterus and being denied skin to skin with mom.
The clinical indication for keeping the baby at uterus level while the cord is intact really comes into play in the case of a cesarean. After a cesarean, babies are often held at a level several inches higher than the uterus. In this case, gravity can force the blood to remain in the placenta. According to Sarah Buckley, MD, this may cause an increased incidence of respiratory distress in babies born via c-section; several studies have shown respiratory distress can be eliminated in many circumstances by allowing a full transfusion of blood from the placenta.
By delaying the clamping of the umbilical cord, babies gain up to 40% of their own blood volume (Fogelson) and increase their oxygen level (Buckley). This cord and placental blood provides a back-up of blood for use in the rapidly changing pulmonary and organ systems (such as the lungs). When the cord is clamped immediately, other organs sacrifice their blood to the pulmonary system since it requires blood immediately for necessary lung function when the blood-oxygen supply from the placenta is cut off (Morley). Studies have found delaying the clamping of the cord helps raise iron levels, reducing the risk of anemia, in addition to favoring early contact between mom and baby (WHO, "Delayed Clamping"). A frequent question I hear is about the potential for greater jaundice levels due to the increased blood volume. Research does show that jaundice levels can be higher when the cord is clamped later versus earlier with no adverse effects (Morley) and actual antioxidant benefits from the bilirubin (MIreles).
The research that our technology and advances in science and medicine allow us is crucial in aiding our understanding of physiological processes. As professionals, though, information that challenges the accepted norm can be difficult to recognize. As Fogelson noted in his Grand Rounds, it may be comforting for those whom have trouble incorporating new technique into their practice to realize that delayed cord clamping has, in fact, a fairly strong history. Even Erasmus Darwin, grandfather of Charles Darwin, in 1801 recognized the importance of blood flow to the baby:
"Another thing very injurious to the child is the tying and cutting of the navel string too soon; which should always be left till the child has not only repeatedly breathed but till all pulsation in the cord ceases. As otherwise the child is much weaker than it ought to be, a part of the blood being left in the placenta which ought to have been in the child."
Stay tuned for a later post offering up some suggestions as to how you can use this info in your birth, where to go from here, and how to have conversations about topics like these with your care provider.
Buckley, Sarah J. "A Natural Approach to the Third Stage of Labour." Midwifery Today Autumn 2001: 33-36. Print.
"Delayed Clamping of the Umbilical Cord to Reduce Infant Anaemia." WHO. n.p. 2014. Web. 5 Oct. 2014.
Fogelson, Nicholas. "Delayed Cord Clamping Grand Rounds Part 1. Online Video Clip. YouTube. YouTube, 30 Jan. 2011. Web. 4 Oct. 2014.
"The Importance of Skin to Skin Contact." International Breastfeeding Centre. ibc, 2009. Web. 6 Oct. 2014.
Kinmond, S, T C Aitchison, B M Holland, J G Jones, T L Turner, C A J Wardrop. "Umbilical cord clamping and preterm infants: a randomised trial." BMJ Volume 306 16 Jan 1993: 172-175. National Center for Biotechnical Information. Web. 5 Oct. 2014.
Kitzinger, Sheila. Rediscovering Birth. New York: Simon & Schuster, Inc., 2000. Print.
MIreles, L C, M A Lum, P A Dennery. "Antioxidant and cytotoxic effects of bilirubin on neonatal erythrocytes." Pediatric Research 45(3) (Mar. 1999): 355-62. Web. 6 Oct 2014.
Morley, G M. "Cord Closure: Can Hasty Clamping Injure the Newborn?" OBG Management July 1998: 29-36. Print.
"Review of Evidence on Cord Care Practices." WHO. n.p. n.d. Web.
Tomorrow my son turns eight years old. It's so hard to imagine that eight years has gone by since I first held his slippery little body in my arms. Man, did I work hard for that birth. Now, don't get me wrong, I know INCREDIBLY well how hard some women work in labor. And in many ways, my birth with him was not that hard. But it was hard for me. It was not how I planned it to be and I had every ounce of confidence in my body's birthing. And that made things incredibly challenging when I was faced with providers whom felt differently.
Although my birth did not go as I had hoped, I fared better than many in a system that can be intensely totalitarian, patriarchal, and dehumanizing. I escaped (barely) with a vaginal birth and managed to avoid the dreaded episiotomy. I even finagled an incredibly low Pit drip out of the deal. Sounds like a dream. But I knew it could be different. And I knew, somewhere deep within, that birth could be empowering. That it should be empowering no matter how one chooses to attain it.
Throughout my first pregnancy, confidence in my body reigned supreme. Yet my lack of knowledge of the medical model of birth made me subject to many interventions and tests that I may otherwise have questioned, if not fully avoided. This isn't to say that I didn't get excited every time I heard the baby's heart beat or saw the little one on the monitor - it's just to say that I didn't know I could ask questions. Or more appropriately, I didn't know what questions to ask - before, during, or after the procedures. As I learned in my immediate postpartum, telling one's care providers that "I just know it is okay" is not accepted as truth. In fact, in a conventional birth setting, it's often not accepted at all. Unless one realizes that they truly have the power to say "I just know it's okay and you don't have my legal consent to x, y, z..." then things may not work out in their favor. Enter in....the independent birth class.
Perhaps the greatest catalyst in my first pregnancy, in my journey to becoming an experienced and respected birth professional in Philadelphia, and in my path towards embracing the future birth (of my second son, who is now two years old) in a way in which I not only felt empowered but also felt supported, was the independent birth class I took well over eight years ago with the Philadelphia birth legend, Beth Goldberg.
Being as confident as I was that first time around, I "didn't need" a birth class and thought that if I delayed signing up for the class at my birth place, then I could get out of it. What I didn't realize, is that my thinking was completely askew. Side note - what I've learned as a birth worker - perhaps the greatest lesson - is that I will never know all there is to know about birth (or parenting, or the body, or life...). Anyway, by the time I was really being pressured by my provider to take that birth class, there was no more space, I was very late in the game, and I was forced to look elsewhere for classes and forced to - eek! - pay more.
The money I spent on my independent birth class was the best money I may have ever spent in my life. No lie.
And here's why.
An independent birth class will not teach you what to think. It will teach you how to think. It will not teach you how to be a good patient but will teach you how to ask the right questions to get all the information you need about your pregnancy, your birth, your labor and to use that information in making an informed decision. A well-taught independent class will not dictate what you should do but will share with you what your options are, including the often unknown option of refusal. Most importantly, and this may be just the opinion of a seasoned birth worker, a well-taught birth class will not teach you how to give birth but will empower you with the voice, the knowledge, the resources, and the support to seek out your way of birthing and to work your way through it. Let us not forget, labor is work. And work is hard - and rewarding, and challenging, and exhilarating, all at once.
When I finally let go of my ego and realized I didn't know all I needed to know about birthing in our culture, I opened myself to the ability to feel empowered in my body AND my knowledge. Thankfully, this influenced my journey into birth work and heavily influenced my second birth. But the many women whom I work with in my classes who haven't waited until 36 or 37 weeks to seek out information are able to put to great use this instinctual wisdom, intellectual insight, and practical knowledge the first time around. And that leads me to the most important reason to take an independent birth class - the information is usable and will influence the way one approaches their pregnancy, their birth, and their postpartum, whether one chooses to use it right away or chooses to mull it over and let it guide them the next time around.
**I do strongly believe that the information in an independent birth class is crucial for women and their partners regardless of whether they are able to pay the full class fee. In each group birth class that I teach, I do have a spot available for a low income couple to attend. If interested, please contact me at firstname.lastname@example.org.**
As the Philadelphia birth world blooms bigger and brighter, I think it's time I start putting some of the insightful questions I've received and information I've research into a public journal. I hope you'll find this inspiring, empowering, and totally enjoyable.