Tuesday, July 30, 2013

conversation on cord clamping

This week an article Are we cutting umbilical cords too soon? by Sydney midwife, Professor Hannah Dahlen, appeared in The Conversation.

I posted the following comment:
...
I would like to make a point here that the normal physiology of the third stage relies on spontaneous unmedicated progress through the preceding stages of labour. The processes of separation and expulsion of the placenta and cessation of bleeding are finely orchestrated when relying on the mother's hormonal activity.
In the world of spontaneous unmedicated birth, the midwife acts to support the natural physiological processes, and one of the key points is to maintain an intact umbilical cord as the baby is being born. If immediate resuscitation is required, the midwife may instruct the mother to kneel and place her baby on a clean towel on the floor in front of her. The midwife kneels next to the baby, and proceeds with whatever is needed - tactile stimulation, and blowing on the baby's face is often sufficient while assessing heart rate and respiratory effort, but the process may include suction of airways, bag and mask respiratory support, and external cardiac stimulation. As such a baby recovers, the pulsing of the cord is an early sign of resuscitation, ensuring an immediate surge of oxygenated placental blood (with a dash of adrenaline) is delivered with the aid of gravity, to the baby. Then the mother can take her baby to her breast, and wait for the natural completion of the third stage.

My submission attracted a strongly worded response from a person who is identified as a 'public hospital clinician' (presumably a doctor), who considered that I was incorrect in the statement that "the pulsing of the cord is an early sign of resuscitation, ...".  She stated that:
If the midwife conducting resuscitation does not understand newborn physiology, including placental circulation, the baby may well be in better hands in hospital.

I have not tried to defend myself in The Conversation, but will make some comments here here.

I consider the criticism of my statement to indicate a mis-reading of what I have written. In stating that the baby receives oxygenated placental blood, I did not differentiate between arterial and venous blood.

Pulsation of the umbilical cord is in response to the baby's heart action.  The umbilical veins bring blood from the placenta to the baby.  

I can only assume that this criticism came from someone who objects strongly to the very idea of homebirth, and has used criticism of what she understands to be the midwife's knowledge to justify her objection.   She provides further objection to homebirth with the claim that homebirth results "in three times excess mortality for the babies of low risk mothers (compared with birth in hospital)."  This is an unsupportable statistic that has been quoted from time to time, which I think is based on a retrospective report of homebirths in South Australia, published in 2010.  Click here for more discussion and links.

The safety of homebirth is difficult to explain using logic or science.  It makes sense that quick access to all the machines and highly skilled people, if something 'goes wrong', should result in overall better outcomes than being in the woman's home.  Although a midwife is ready and skilled to intervene, and provide neonatal resuscitation, or other life-protecting measures for the baby or mother, the safety of homebirth is not in the interventions: it's in the woman's and baby's own abilities to proceed through the amazing transitions in birth, and the midwife's skill to work with, and not against, those natural physiological processes.

The umbilical cord does not pulse by accident after birth.  It pulses because the link from the newborn baby's heart is open.  This opening will quickly close as breathing becomes established, and the baby's body becomes independent of the mother. 

A recently published (2013) Cochrane Review of 'Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes' states that:

There were, however, some potentially important advantages of delayed cord clamping in healthy term infants, such as higher birthweight, early haemoglobin concentration, and increased iron reserves up to six months after birth.

Those who have seen births in hospitals will know that there is often a great flurry of activity by the accoucheur immediately after the birth of the baby, and that the cutting of the cord and passing the baby to a second person (doctor/midwife) who proceeds with the rituals of drying, and 'resuscitating' the baby, happens very quickly.  These practices need to change. 

I am often the only midwife present at home births.  There is noone to pass the baby to, other than the baby's own mother - cord intact. The woman in her own home is free to choose the place where she gives birth, and the body position she adopts to give birth.  She may be kneeling, lunging, sitting, standing, squatting, or lying.  The baby may be born in water or into air.  My response as the moment of birth approaches is to be ready to take action if required, or to simply be there and witness the wonder of creation in the birth of a child.



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