Angie Evans' Pregnancy & Birth Health Notes
Doula, Prenatal Educator & Birth Consultant
Wednesday, May 10, 2017
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All articles have been moved to www.angieevans.ca . You can find current dates there for upcoming classes and events. Thanks!
Sunday, May 17, 2015
Avoiding Postdates, Induction
Post-term
or post-date pregnancy is one that exceeds 42 weeks gestation. Post term refers only to dates and has
nothing to do with fetal condition. If a
woman is healthy and well nourished then her placenta almost always continues
to thrive and nourish the baby at any gestation.
Post-term is not the same as postmaturity, which refers to fetal condition. Postmaturity symptoms include loose skin suggesting weight loss, decreased ability for the skull bones to mold during labour, fetal distress in labour, and presence of meconium. These babies are compromised as they receive insufficient nutrients through the placenta. Therefore continuing the pregnancy is not safe.
Studies vary on
outcomes of post-date pregnancies. Common
belief is that post term leads to large, compromised babies, and that the
placenta stops working. Macrosomia (large baby: >4000g / 8.8lb) occurs in 10% of post term
births; 1% are > 4500g (9.9lb) (Fraser, Cooper, &
Fletcher, 2003). SOGC reports current studies regarding
pregnancy past 40 weeks don’t differentiate between healthy and complicated
pregnancies and are too small to be accurate (Delaney & Roggensack,
2008). Canadian
guidelines are to offer induction during the 41st week of
pregnancy. By far the number one
reason for induction is post-term pregnancy.
Women have the right to accept or refuse this intervention and are
encouraged to ask enough questions to partake in shared decision making with
their care-provider.
Reasons Your Pregnancy May Last Longer than 40 Weeks
·
Inaccurate dates
·
That’s just normal
for you
·
Malpositioned
foetus e.g. facing the wrong way or head not flexed well
·
Anything that
interferes with optimal release of labour hormones e.g. fear, lack of privacy,
conflict, lack of support
·
Not being “ready” to
receive the baby – birth-supplies, home, work responsibilities, too many
friends or family around, calendar too full, waiting for someone
·
Emotional issues –
fear, needing to hold on
Ensuring Placenta Develops Normally and Remains
Healthy – Avoiding Postmaturity Syndrome
All the
things that contribute to a healthy pregnancy and baby, including:
·
Good nutrition,
including healthy salt and fat intake, minimizing or avoiding sugar and junk /
processed foods
·
Proper hydration
·
Pregnancy tea (see
handout)
·
Avoid smoking
(including second-hand smoke), alcohol and drugs
·
Avoid antacids,
cheap or poor-quality vitamins and calcium supplements as these all contain
calcium that humans don’t assimilate.
This calcium builds up in placenta, decreasing function.
·
Discuss any health
issues with care-provider. Some
conditions lead to inadequate hormone activity, circulation problems or
malnutrition.
·
Good prenatal care,
including monitoring blood pressure and health of mother, foetus, placenta
·
Time for relaxation
and some light to moderate exercise daily
·
Manage stress
·
Surroundings –
healthy environment including the people with whom you interact
Is Your “Due Date” Accurate for You and Your Baby?
·
Review your
estimated due date (EDD) with your practitioner and how it was determined
·
Obstetrical history
– some women tend to gestate longer than others
·
Your mother’s
obstetrical history – does it include “late” babies
·
SOGC
recommendations for determining accurate EDD (Delaney &
Roggensack, 2008):
o
Ultrasound (u/s)
between 11-14 weeks
o
If dates determined
by 1st trimester u/s and LMP vary more than 5 days then u/s is used
as EDD
o
If dates determined
by 2nd trimester u/s and LMP vary by more than 10 days then u/s
should be used as EDD
o
If u/s was done in
1st and 2nd trimester, then EDD is determined by earlier
u/s
·
Ultrasound accuracy
for estimating EDD decreases as gestation increases. Accuracy is within 3-5 days in the first
trimester, within 7-10 days in the second trimester, and decreases to within
2-3 weeks after 26 weeks (Varney, Kriebs, & Gegor,
2004)
Tips to Help Avoid Post-Term Pregnancy
There
may be nothing to be done about post-term pregnancy as some babies just take
longer than others. Like roses opening
on a bush, they don’t all happen at the same time. However the following can help prepare you
and the baby for labour. If they don’t
bring your baby faster they will contribute to a healthier, more comfortable
and efficient birth experience.
·
Herbal
“pregnancy-tea” blend through pregnancy as desired; 3 cups daily in last
trimester
·
Homeopathic Actea
racemosa Complex or a similar homeopathic labour-prep blend from your midwife
or homeopath – 2 doses daily from 36 weeks on
·
Massage therapy by
a practitioner who understands pregnancy and the female pelvis
·
Osteopathy to
address any structural issues
·
Webster, a
chiropractic technique to help prepare pelvis for labour and achieve optimal
fetal positioning (Pistolese, 2002)
·
Acupuncture helps
prepare the body for labour and decreases need for pharmaceutical induction;
can be used to induce labour (Winder, 2012)
·
Hypnotherapy or
other counselling techniques to help resolve fears or emotional issues that may
be holding back progress
·
Ripen the cervix
o
Sexual activity –
female orgasm produces oxytocin, semen contains prostaglandins which act on the
cervix
o
Evening Primrose Oil capsules orally and/or vaginally
beginning at 36 weeks: 1500 mg daily
orally, and/or insert 2 caps to the cervix before bed
·
In one practice
guideline the SOGC recommends membrane
sweeping beginning at 38-41 weeks (Delaney & Roggensack,
2008),
while in another they state the procedure doesn’t change neonatal or maternal
outcomes (Crane, 2001)
o
Hill et al. (2008)
found no benefit to membrane sweeping, and no decrease in induction rates. In fact they found this procedure can lead to
risk of membranes releasing before onset of labour.
o
This invasive
procedure ranges from uncomfortable to very painful for the client
Induction – Holistic / Natural Methods
If induction
is necessary or unavoidable then there are a few methods possible. Please contact your midwife before beginning
any of these to facilitate a discussion for shared decision making.
·
Herbs such as black
and blue cohosh – seek a qualified herbalist
·
Homeopathic
remedies such as Caulophyllum, Actea
racemosa, Pulsatilla - your midwife or homeopath will have strong dilutions
·
Castor oil drink
with Lemon Verbena
·
Acupuncture helps
prepare the body for labour and decreases need for pharmaceutical induction;
can be used to induce labour (Winder, 2012)
·
Massage 2 drops of Clary
Sage essential oil with any carrier oil – can be used for acupressure
treatments; stimulates hormones
Induction – Medical Methods
·
Pharmaceutical
induction with cervical ripening agents and/or drugs to stimulate contractions
·
Studies are mixed
regarding outcomes with routine induction based on dates alone. SOGC (Delaney & Roggensack,
2008)
recommends offering induction at 41+0 to 42+0 weeks, claiming a decrease in
perinatal mortality and no change in caesarean rates. Many other studies such as (Grivell, Reilly, Oakey, Cahn, & Dodd,
2012)
found increased rates of caesarean birth and complications with induction. Menticoglou
& Hall (2002) present evidence that the original research was flawed, and
that routine induction based on dates does more harm than good.
References
Crane, D. J.
(2001). SOGC Clinical Practice Guideline No. 107: Induction of labour at term. J
Obstet Gynaecol Can , 23 (8), 717-28.
Delaney, M., & Roggensack, A. (2008). SOGC Clinical
Practice Guideline #214: Guidelines for the management of pregnancy at at 41+0
to 42+0 weeks. J Obstet Gynaecol Can , 30 (9), 800-10.
Dudley, N. J. (2005). A systematic review of the ultrasound
estimation of fetal weight. Ultrasound Obstet Gynecol , 25 (1),
80-89.
Fraser, D., Cooper, M., & Fletcher, G. (Eds.). (2003). Myles
textbook for midwives (14th ed.). Toronto: Chruchill Livingstone.
Frye, A. (1998). Holistic midwifery vol 1; Care during
pregnancy. Portland, OR: Labrys.
Grivell, R., Reilly, A., Oakey, H., Cahn, A., & Dodd, J.
(2012). Maternal and neonatal outcomes following induction of labor: a cohort
study. Acta Obstetricia et Gynecologica Scandinavica , 91 (2),
198-203.
Pistolese, R. (2002). The Webster Technique: A chiropractic
technique with obstetril implications. Journal of Manipulative and
Physiological Therapeutics , 25 (6), E1-E9.
Tayler, R. (2000). Homeopathy for Pregnancy and
Childbirth. Ottawa: Ottawa School of Homeopathy.
Varney, H., Kriebs, J. M., & Gegor, C. L. (2004). Varney's
Midwifery, 4th Ed. Toronto: Jones and Bartlett Publishers.
Winder, K. (2012). Naturally Inducing Labour – Natural
Induction Methods. Retrieved from BellyBelly:
http://www.bellybelly.com.au/birth/natural-induction-methods
Monday, June 11, 2012
NEONATAL RESUSCITATION WITH INTACT UMBILICAL CORD
This paper was published in Midwifery Today Magazine, Issue 102, Summer 2012
Click here for video of webinar presented to students at Midwives College of Utah based on this paper.
Click here for video of webinar presented to students at Midwives College of Utah based on this paper.
Abstract
This
paper investigates neonatal resuscitation with the umbilical cord intact. Research confirms numerous immediate and long-term
benefits to leaving the cord intact while performing neonatal resuscitation in
both term and preterm neonates, while doing no harm. Current neonatal resuscitation guidelines from
around the world are discussed with respect to the cord. Methods for incorporating an intact cord into
standard resuscitation procedures are explored.
Neonatal
Resuscitation with Intact Umbilical Cord
In
many birth places, including birth centres, hospitals and home, neonatal
resuscitation equipment is set up out of the way of the birth area. In hospitals, assessment and resuscitation of newborns almost
always occurs on a large table across the room and far from mother. Obviously this requires severing the umbilical
cord. In addition to the physiological
advantages of leaving the cord intact,
keeping the baby close to mother reduces maternal stress (and surely infant fear too (Strange, 2009)) and helps
facilitate bonding (Wright, 2011). We can do better. Term and preterm neonates are safer and
healthier when neonatal resuscitation includes delayed cord clamping[1].
During pregnancy, the umbilical cord provides oxygen and
transfers blood between the placenta and the baby. Nature has perfectly designed a placental
transfusion to carry the blood through the cord and into the newborn baby. If the cord is intact, then oxygenation
continues after birth until the newborn lungs have transitioned to air, a
process that takes 30 to 90 seconds in a full-term infant. If a newborn isn’t breathing independently
then the placenta is nature’s neonatal life-support system. Newborns
are not simply tiny adults. The newborn
heart can beat for 20 minutes or longer despite anoxia and the brain can
tolerate lack of oxygen for this duration of time (Resuscitation Council (UK), 2001; Frye, 2004; World Health Organization, 1999). Newborns cope well with
hypoxia but struggle with hypovolemia. At
the moment of birth 30 to 50% of the baby’s blood volume is in the
placenta. Immediate clamping deprives
the baby of that blood. Adults are in
perilous danger of hypovolemic shock and receive blood transfusions at 15 to 30%
blood-loss.
The benefits of delayed clamping are well
documented. Immediate cord clamping is
now being compared with blood-letting. However
neonates who are compromised or require resuscitation and desperately need all their
blood almost always get their cord severed immediately. In spite of research saying otherwise, it’s still common practise at most
births, usually due to outdated theories or habit. As more parents request delayed clamping,
newborns are more likely to receive their full volume of blood.
As delayed clamping becomes a hot topic there are some
aspects that need clarification: time interval, milking the cord, gravity and the
myth of causing harm. “Delayed” isn’t a
long time: the rate of transfusion is about half the blood in 1 minute and
nearly 100% over the next 2 to 5 minutes.
What about cord stripping? Parents-to-be
may be told that if the cord can’t be left intact then it will be “milked,”
implying the benefits are the same. It’s
the time interval of delayed clamping that has clinical benefits, not whether
the cord is milked (Fogelson, 2011).
During the first 45 to 60 seconds of life, arterial
pressure pumps blood into the neonate, so the height differential between the
placenta and baby doesn’t matter. After
that, veins drain blood into the neonate and height matters more. Full placental transfusion occurs with the baby
from 10 centimeters above to 40 centimeters below placenta, which is about the
position of baby on mother’s abdomen or lap (Yao & Lind, 1969).
Leaving the umbilical cord intact does not lead to
pathological jaundice. The naturally
occurring physiological newborn jaundice has no clinical significance. Many practitioners believe leaving the cord
intact leads to other adverse effects such as tachypnea, grunting,
hyperbilirubinemia, polycythemia and hyperviscosity. If transient these are often not clinically
significant issues but rather a normal part of physiological compensation
during newborn transition (Tolosa et al., 2010).
Babies with delayed clamping fare better. They have 40% more blood volume, a 45%
increased hematocrit, a 50% increase in red blood cell counts and ferritin is
up to 50% higher (Fogelson, 2011). The benefits are greater in SGA or preterm
infants and those born to mothers with low ferritin at birth. The effects of delayed clamping can be seen
well past the newborn period. Term
infants are protected from anaemia and iron deficiency for at least 6 months (Chaparro, Neufeld, Alavez, Cedillo & Dewey, 2006).
This is vital where infant and pediatric anaemia is common, such as
impoverished areas.
Mercer et al. (2006) compared data from premature
infants that had a 30 to 45 second delay in clamping and intubation, and from those
who were immediately clamped and intubated.
There was no statistically significant difference in mortality rates. The delayed clamping group fared better in common
premie health issues, with lower rates of necrotizing enterocolitis,
bronchopulmonary dysplasia, intraventricular haemorrhage (IVH) (14% versus 36%) and sepsis (3% versus 22%). In addition to the higher rates of IVH, cases
were more severe in the early clamping group.
Preterm neonates with delayed cord clamping are less likely to
require blood transfusion, ventilation and oxygen therapy, and have lower rates
of anaemia at 6 months. They have more
stable blood pressures and thrive better (Asfour & Bewley, 2011). A 1-minute delay in cord clamping resulted in
remarkably elevated red blood cell volume and weekly haematocrit compared to
early clamping in neonates of 30 to 36 weeks gestation (Tolosa, Park, Eve, Klasko, Borlongan & Sanberg, 2010).
Of course, if a baby is born flat with a limp,
non-pulsing cord then the cord is no longer working. This is the rare case when immediate clamping
and aggressive resuscitation is warranted.
Neonatal resuscitation guidelines in Canada,
Australia, Europe and the United Kingdom recommend delayed clamping for a minimum time range from 1
minute to when the cord stops pulsing in healthy neonates. These same guidelines cite insufficient
evidence to recommend an optimal time of clamping the cord of infants requiring
resuscitation. Not one of them
recommends immediate clamping and cutting as part of care, including the
American guidelines which say nothing about timing of cord clamping. The UK and Australian guidelines go so far as
to advise waiting 3 minutes in healthy preterm infants for “increased blood
pressure during stabilisation, a lower incidence of IVH and fewer blood
transfusions” (Resuscitation Council (UK), 2010; Australian
Resuscitation Council, 2010). The UK guidelines also speculate that cord
clamping with resuscitation could be delayed until the baby has started
breathing. WHO (1999) advises it’s
unnecessary to clamp the cord before beginning resuscitation and to not waste
time moving to a special place, as mother's bed is usually warm and suitable.
The
requirements of medicalized neonatal resuscitation are warmth, a firm surface, suction
and access to the umbilicus. Other
priorities include comfortable position for staff and the ability to draw
umbilical blood for cord-gas analysis. A
warm firm surface can be the bed or surface where baby is born. In this author’s 2011 poll of 34 midwives from
around the world, most reported that they perform resuscitation with the cord
intact using the bed, side of a pool designed for water-birth, part of an adult
human body (mother or midwife) or a portable board with a warm-pack.
Suction can
be from a main hospital line, resuscitation machine or a portable unit such as
those used at homebirths. The umbilicus
is accessed to provide drugs and fluids.
If the cord is left intact, then fluids are already being provided. Drugs are rarely required for resuscitation,
and it’s likely they would be required far less often if cords were
intact. Since extensive resuscitation is
rarely required can we not be uncomfortable once in awhile, bending over the
baby rather than performing resuscitation at our standing height? Even if one requires cord-gases for medical
reasons rather than protection from litigation, they can wait. Cord-gas results don’t change significantly if
taken immediately after birth or after 2 minutes of delayed clamping (De Paco, Florido,
Garrido, Prados & Navarrete, 2011; Asfour & Bewley, 2011).
If one prefers a newborn
resuscitation table, then there are alternatives to what’s currently being used
in most hospitals. Dr. Andrew Weeks and a
team at University of Liverpool designed the award-winning BASICS (Bedside
Assessment, Stabilisation and Initial Cardiorespiratory Support) Trolley, a
smaller portable neonatal resuscitation table that can be used alongside the
mother, even for caesarean birth (University of Liverpool,
2011). It includes oxygen, suction and heat. Dr. Weeks says, “It is crazy that the most
vulnerable babies are born and whisked off and surrounded by a scrum of
doctors” (Wright, 2011).
Many midwives are already doing the good work of
leaving cords intact, even for resuscitation.
As further research is available and better equipment is implemented in
hospitals, neonatal resuscitation may include nature’s life-line -- the full
placental transfusion.
About the author: Angie Evans, BSc(Hon), MH
is an herbalist, doula and prenatal educator currently enrolled in a Bachelor
of Midwifery program. She’s passionate
about the parents’ and baby’s experience of birth and believes good care
includes more than simply physical health.
angie@AngieEvans.ca
References
AAP/AHA/CPS.
(2006). Neonatal resuscitation textbook (5th ed.). Ottawa: Canadian
Paediatric Society.
Alberta Health
Services. (2007). Maximum blood draw protocol for pediatric patients.
American Heart
Association. (2005, Nov). 2005 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular Care - Part 13:
Neonatal Resuscitation Guidelines. Retrieved Jan 2012, from American Heart
Association Journals:
http://circ.ahajournals.org/content/112/24_suppl/IV-188.full
Asfour, V., &
Bewley, S. (2011). Cord clamping practice could affect the ratio of placental
weight to birthweight and perinatal outcomes. BJOG: An International Journal
of Obstetrics & Gynaecology, 118
(12), 1539-40.
Australian
Resuscitation Council. (2010). Introduction to resuscitation of the newborn infant.
Retrieved Feb 2012, from The Australian Resuscitation Council Online:
http://www.resus.org.au/
Barret, L. (2008). Resuscitation
of the newborn. Retrieved from Homebirth: A Midwife Mutiny:
http://www.homebirth.net.au/2008/04/resuscitation-of-newborn.html
Buckley, D. S.
(2005). Gentle birth,gentle mothering. Brisbane: One Moon.
Canadian NRP
Steering Committee. (2010). Addendum to the NRP provider textbook 6th edition:
Recommendations for specific treatment modifications in the Canadian context.
Ottawa: Canadian Paediatric Society.
Chaparro, C. M.,
Neufeld, L. M., Alavez, G. T., Cedillo, R. E.-L., & Dewey, K. G. (2006).
Effect of timing of umbilical cord clamping on iron status in Mexican infants:
a randomised controlled trial. The Lancet , 367 (9527),
1997-2004.
Crews, C. (2007). Clamping
of the umbilical cord - Immediate or delayed. Is this really an issue?
Retrieved Feb 2012, from Midwifery Services of South Texas:
http://www.midwiferyservices.org/umbilical_cord_clamping.htm
CRYO-CELL
International Inc. (2011). Cord blood collection instructions . Florida.
De Paco, C.,
Florido, J., Garrido, M., Prados, S., & Navarrete, L. (2011). Umbilical
cord blood acid-base and gas analysis after early versus delayed cord clamping
in neonates at term. Arch Gynecol Obstet , 283 (5), 1011-4.
Fogelson, D. N.
(2011). Delayed Cord Clamping Grand Rounds. USC School of Medicine, A.P.
Dept. Obstetrics and Gynecology. South Carolina: Palmetto Health Grand Rounds.
Frye, A. (2004). Holistic
midwifery, Vol 2, Care during labour and birth. Portland: Labrys.
Greene, A. (2008). How
much blood is too much guideline. Retrieved from Dr Greene:
http://www.drgreene.com/article/how-much-blood-too-much-guideline
Kattwinkel, et al.
(2010). Special Report Neonatal Resuscitation: 2010 AmericanHeart Association
Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
Pediatrics , 126 (5), 1400-1413.
Mercer, J. S.,
Vohr, B. R., McGrath, M. M., Padbury, J. F., Wallach, M., & Oh, W. (2006).
Delayed cord clamping in very preterm infants reduces the incidence of
intraventricular hemmorhage and late onset sepsis; A randomized, controlled
trial. Pediatrics , 117 (4), 1235-1242.
Morley, D. G.
(2011, July). Neonatal resuscitation: Life that failed. Retrieved Jan
2012, from UBM Medica:
http://hcp.obgyn.net/fetal-monitoring/content/article/1760982/1911275
Reed, R. (2011). Cord
blood collection: confessions of a vampire-midwife. Retrieved from Midwife
Thinking:
http://midwifethinking.com/2011/02/10/cord-blood-collection-confessions-of-a-vampire-midwife/
Resuscitation
Council (UK). (2010). Newborn life support guidelines. London: Resuscitation
Council (UK).
Resuscitation
Council (UK). (2001). RESUSCITATION AT BIRTH, The Newborn Life Support
Provider Course Manual (2nd ed.). London, UK: Resuscitation Council (UK).
Richmond, S., &
Wyllie, J. (2010, Aug). European Resuscitation Council guidelines for resuscitation
2010. Section 7. Resuscitation of babies at birth. J. Resuscitation ,
1389-1399.
SOGC. (2012, Feb). Clinical
Practice Guidelines. Retrieved Feb 2012, from SOGC (Society of
Obstetricians and Gynaecologists of Canada): http://www.sogc.org/guidelines/index_e.asp
Strange, K. (2009,
Jan). NRP for midwives certification class. Seattle, WA.
Tolosa, J. N.,
Park, D.-H., Eve, D. J., Klasko, S. K., Borlongan, C. V., & Sanberg, P. R.
(2010). Mankind’s first natural stem cell transplant. J. Cell. Mol. Med.
, 14 (3), 488-95.
University of
Liverpool. (2011, June). City experts develop life-saving trolley for
newborn babies. Retrieved Nov 2011, from University of Liverpool University
News: https://news.liv.ac.uk/2011/06/17/city-experts-develop-life-saving-trolley-for-newborn-babies/
Usher, R.,
Shephard, M., & Lind, J. (1963). The blood volume of the newborn infant and
placental transfusion. Acta Paediatrica - Nurturing the Child , 52
(5), 497-512.
Weaver, P., &
Evans, S. (2007). Practical skills guide for midwifery (4th ed.). Wasilla,
AK: Morningstar
WHO. (1999). Basic
newborn resuscitation practical guide - Revision. Geneva: World health
Organization Safe Motherhood Unit.
Wright, A. (2011,
June). BASICS: Bedside Assessment, Stabilisation and Initial
Cardiorespiratory Support. Retrieved Feb 2012, from Liverpool Women's NHS
Foundation Trust:
http://www.lw.nhs.uk/Library/news_centre/Life_Saving_Trolley_Basics_Case_Study.pdf
Yao, A., &
Lind, J. (1969, Sep). Effect of gravity on placental transfusion. The Lancet
.
[1] Clamping refers to clamping and/or
cutting the umbilical cord. Clamping,
whether cut or not, immediately halts placental transfusion. Clients who ask for delayed cord-cutting
could be counselled to request delayed clamping.
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