Tuesday, December 2, 2014

A Tale of Two Cords

Dear Readers,

       Over the years I have been very careful to avoid criticism of our local hospitals in my words, and in my blog.  I am grateful to have safe hospitals nearby for those times when we need them.   My intention with this post is to bring to light an issue that is important , and needs to change.  Remaining silent in order to avoid sounding critical does not actually serve mothers and babies.  
     This post is  about  the baby's umbilical cord;   when and why it is clamped and cut, and the implications of that choice for the baby.  I will briefly discuss how my own management of the cord has evolved over the years, give some links to latest research, and then illustrate some important points with a story.
     I was trained in 1995 in a busy public hospital in the Bronx.  My preceptor taught me to always check for a cord around the neck once the head was born, and then "reduce" it,  meaning pull it over the baby's head, or clamp and cut it if it was so tight that I could not.  If option B happened, then we had to hurry to deliver the rest of the baby quickly as the baby's oxygen had just been cut off.  The cord, mind you, is what delivers oxygenated blood to the baby from the placenta in utero, during the birth, and if the cord is left alone, for several minutes postpartum.  During my studies I also learned about the myriad benefits of delayed cord clamping for the baby.  For a detailed explanation of those, please read this . Then I learned that in the hospital, when a baby is born compromised, and not able to start breathing on her own, the cord is cut right away so the baby can be rushed across the room to be resuscitated on the warming bed.
       When I began attending births at home many years later, I quickly realized that home born babies have this brilliant advantage:  If the baby is born compromised and not breathing, the cord is left intact, delivering oxygen to the baby just as it did in utero. The midwives resuscitate the baby right there beside the mother.  The first time I did this, I was amazed at the difference that I saw.  In the hospital, distressed babies are blue or grey in color as they lie on the warming bed, their lifelines severed so that the nurses can work on the other side of the room.  At home, our little non-breathing baby was pink instead of blue, getting her oxygen from both the cord and our ambu-bag until she perked up and could start breathing on her own. 
     Around that time, an article was  published in the ACNM  Journal, questioning the act of even checking for a cord around the neck in the first place.  The  study interviewed midwives in the U.S. and midwives in  New Zealand, comparing  various practices.  Lo and behold, New Zealand midwives don't ever check for a cord, and U.S. midwives always do.  And guess which babies do better?  Neither;  the outcomes are the same.  
       My third year of homebirth practice, I attended a waterbirth for a VBAC (Vaginal Birth After a Cesarean) mama. The head was born in the water, I reached in and checked for the cord, and sure enough there was a very tight cord around the neck.   I realized that  I couldn't possibly clamp and cut it with her in the birthing tub like that, so I just let it be.  That baby was fine.  Better than fine.  He was born, I unwrapped the cord from around his neck, lifted him out of the water and gave his back a little rub, and placed him in his mama's arms, pink and perfect.  I have never cut a tight cord since. It was an "A-ha!" moment.  You don't have to cut a tight cord.  Soon after, I studied detailed intructions on  "The Sumersault Maneuver"  by which the baby's  body can be  sumersaulted past the head to accomodate a tight cord during birth. .  Over the years I have attended births with the cord wrapped once, twice, even four times around the neck, without it ever being a problem for the baby.   And I am always grateful for that lifeline if the baby needs extra help breathing. 
    There has been a lot of research lately to confirm what homebirth midwives already know; babies that need resuscitation do better if the cord is intact.  Read about this promising study of preemies here.  Read about this beneficial practice in the developing world here   Also, there are efforts to develop technologies (like a lightweight board that can be placed beside the mother Wow wow. We use a plastic cutting board at home.)  so that our State of the Art, first-world hospitals can cease cutting cords to rush babies across the room. Read about a pilot program for that here.

Let me quote from these articles :
"When babies aren’t breathing at birth, doctors typically have to cut their umbilical cords and whisk them away from their mothers in an urgent attempt to resuscitate them. The intervention saves lives, but it’s a trade-off. These babies lose nutrient-rich cord blood that can help prevent brain damage and other complications."

“There is no expense and no equipment needed. All the attendant has to do is pause, let the baby breathe and then clamp the cord,”

   I was inspired to write this post by a beautiful birth I attended this week.  Here is the Story, as promised.  Thank you Mary for allowing me to share this.

A Tale of Two Cords.

     For Mary's first birth three years ago, her plan for a home birth changed when she went post dates and we discovered low fluid levels around the baby.  We went in for an induction to her local hospital, and with a little medication she went into labor.  Mary did a tremendous job laboring all night in the shower and on her birth ball.  My assistant and I served as her doula.  In the morning she was close to delivery.  She pushed for a few hours, and fortunately the baby's heart rate sounded terrific the whole time, showing the staff that he was tolerating the labor well.  We got very close to birthing time.  The doctor came in.  The baby's head was born, and there was a cord around the neck.  The doctor clamped and cut it.  Then, everything stopped for a few minutes.  Contractions, pushing, everything.  I felt this terrible sinking feeling when the doctor cut that cord, but now nothing could be done but wait.  Several minutes went by, baby half out, oxygen cut off.   Finally the baby came, grey and limp and in poor shape.  He was rushed off to the NICU .  $64,000 and five days of pokes, pricks, IV's and oxygen masks later, the baby was discharged home, healthy.  Mary said the nurses kept reminding her how wonderful it was, that they saved her baby.  I never said a word to her about that cord, but she knew that that was why her baby had gotten so sick.  "They saved my baby from a mistake the doctor had made, and expected me to be grateful for it.  And I was, but it was really hard." 
    This week, Mary had her second baby, at home, under my care.  She went into labor just after her due date, and her labor progressed quickly.  Her water broke as she approached the final stage of birth, and once again she had scant fluid with meconium.  There wasn't time to transport for this, so we readied ourselves to help the baby at home.  Mary gave birth on soft towels on the bedroom floor.  The head was born, and the little one spit out a mouthful of meconium (which landed on my nose but you didn't need to know that).  I reached a finger in to check the shoulders and felt a tight cord around the neck.  I withdrew my finger and let it be.  Just like last time, it took a little while for the baby's body to come.  Mary got up to a kneeling lunge, and the body slowly emerged.  The baby sumersaulted himself , I unwrapped the cord, and then just watched.  The baby looked around, waved his little fingers about, and then opened his mouth a took a deep breath.  His color went from purple to cotton candy pink.  The cord pulsed away.  This all happened in that silent, timeless moment we call the first minute after birth.  It was my first home birth since my year off in India and I felt honored to witness the perfect design, the perfect physiology, that is the miracle of birth. 
   Folks, don't all our babies here in Butte County deserve this beneficial care, not just the ones born at home?  I think so.  I know so.  Perhaps we can begin bringing awareness to our medical community that it is time to update their practices.  Let's not just stand by shaking our heads.  Some ideas: 

1.  write a letter to the nurse-manager of your local hospital, including copies of these articles I have linked to.
2.  Bring copies of these referenced articles to your next visit with your OB or hospital midwife, and ask to discuss these issues with them.
3. Join the Chico Birth Network, to promote safe and gentle birth;  contact me for info.  I welcome your ideas and input.  

Wednesday, November 5, 2014

A Poem for Mothers


“Where have I come from, where did you pick me up?” the baby asked
its mother.
She answered, half crying, half laughing, and clasping the
baby to her breast-
“You were hidden in my heart as its desire, my darling.
You were in the dolls of my childhood’s games; and when with
clay I made the image of my god every morning, I made the unmade
you then.
You were enshrined with our household deity, in his worship
I worshipped you.
In all my hopes and my loves, in my life, in the life of my
mother you have lived.
In the lap of the deathless Spirit who rules our home you have
been nursed for ages.
When in girlhood my heart was opening its petals, you hovered
as a fragrance about it.
Your tender softness bloomed in my youthful limbs, like a glow
in the sky before the sunrise.
Heaven’s first darling, twain-born with the morning light, you
have floated down the stream of the world’s life, and at last you
have stranded on my heart.
As I gaze on your face, mystery overwhelms me; you who belong
to all have become mine.
For fear of losing you I hold you tight to my breast. What
magic has snared the world’s treasure in these slender arms of

Rabindranath Tagore(India (and Bengal)'s first Nobel laureate)

Saturday, August 16, 2014

Special Announcement: I am back in Chico!

Dear Clients and Readers,

  We have returned from our voyage to India and beyond, and I am now available for midwifery services.  Feel free to call me at 530-828-9435 for information.

Thank you,