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. Sources 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.
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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 britt@blossomingbelliesbirth.com.** In my classes, I've been finding that women have been diagnosed with Gestational Diabetes (GD) with, what seems to me, some frequency. I'd like to take a look at some great resources that I often share with clients to help them see the broader view of things, in addition to pointing out a fantastic new resource. But, to begin, let's take a look at nutrition.
Truly nourishing the body is one of my greatest passions. We could even expand that to discuss nourishment in body and mind but, for tonight's purpose, we will keep the scope more localized. Real nutrition is the backbone to a healthy lifestyle and strong immune system (which could stem many more tangential topics - hopefully ones that I will address in later posts!). I hesitate to use the words "good" or "excellent" when discussing nutrition because it's not quite as clear as "good" and "bad." Nourishing the body really boils down to having a broad understanding of what the body needs to be fueled optimally and function at it's peak. It's not about deprivation or indulgence but about moderation and optimization. Unfortunately, many OBs and midwives offer only a very generalized view of nutrition basics, if any at all. I will never forget when I asked a midwife during my first pregnancy if a recommendation she was making in regards to pregnancy could be applied to general nutrition and she told me she did not know. That was unacceptable to me. It may have been one of the first glimpses I had into the divide between holistic midwifery care and conventional "midwifery." How could someone giving advice about nutrition not be able to see things in the larger scheme? It only lent fuel to my fire of wanting to learn more, more, more about truly nourishing the body. True nourishment follows a "diet" very similar to that which is recommended when diagnosed with gestational diabetes. Unfortunately, it is quite often only after this diagnosis is made that women are actually taking part in discussions with care providers about how they are caring for their bodies and their babies. Nutrition is rarely discussed in visits with hospital-based midwives and obstetricians and is only covered in bare bones with birth center midwives. In my mind, a one hour visit, focused solely on optimum nutrition throughout pregnancy, is crucial to gaining even just a minimal understanding of the basics of solid nourishment. Finding a guide or support person - doula, midwife, childbirth educator, prenatal nutritionist - who will spend this time with you in pregnancy can be paramount in supporting the informed and empowered birth you may desire. Before opening up about some great nutrition resources, understand the research behind the diagnosis of GD. Check out here the research analyzed by medical analyst and birth advocate Henci Goer. This should not be the ultimate in decision making but can hopefully provide you with a bit more information and analysis to further your decision making. Also, check out this post, citing Anne Frye, Varney, and Hart. Both great reads. I won't spend a whole post here talking about the ins and outs of nourishment in pregnancy (maybe I will do that in the future) but I'd love to share a few resources. Aviva Jill Romm's "The Natural Pregnancy Book" is a fantastic holistic resource for nutrition. Full of nutritional information, along with herbal and alternative recommendations, this book is a great guide to supporting the natural pregnancy. "The Vegetarian Mother's Cookbook" is also great, whether vegetarian or not. Recently, I had a momma in my birth class who was really committed to understanding GD and the changes in nourishment that could help support a healthy pregnancy. She became so passionate about what she was learning that she dedicated an entire blog to it. I highly recommend checking out her info, recipes, and insights at http://www.okthedietstartstomorrow.blogspot.com. As is the basis for holistic nutrition in general, remember to eat the colors of the rainbow, explore seasonal local foods, eat what is as close to or in it's natural state as possible, and aim for foods that you could catch, hunt, or grow. For more nutrition guidance or to set up a one-on-one prenatal nourishment workshop, contact Britt at britt@blossomingbelliesbirth.com. What better way to initiate a blog than with a few quotes I find especially inspiring. I'd like to say that they are focused on life in general yet, as many of us realize, "As we live life, so we birth..." (now if I only I can remember where I read that) so I imagine they can be well applied to birth also.
A favorite for the day - one that struck me as particularly powerful: "I long so much to make beautiful things. But beautiful things require effort - and disappointment and perseverance." - Vincent Van Gogh And one that never loses its beauty: "Rain, after all, is only rain; it is not bad weather. So also, pain is only pain; unless we resist it, then it becomes torment." - the I Ching And how can we not end a birth worker's blog post on quotes without mentioning a famous one by Ina May Gaskin: "Babies get big. And their mothers get bigger." Love that. |
AuthorAs 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. Archives
February 2021
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