Jan 302013
 

“It may not be healthy for the baby because then the baby will have too much blood.”- OB to mother when discussing the mother’s preference for delayed cord clamping.

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 January 30, 2013  OB, placenta  Add comments

  45 Responses to ““…The Baby Will Have Too Much Blood.””

  1. Ah yes, the “umbilical cord as hose” theory!

    Welcome to “Cord Clamping: A Procedure In Search Of A Reason To Live.” For our first class, we’ll write down all the reasons you’ve been told the cord must be clamped immediately. List all dire consequences to the baby, mother, father, and father’s office-mate’s dog’s fleas. After we’ve filled the whiteboard with them, we’re going to try synthesizing them all into one theory that involves babies having too much blood AND too little blood at the same time, gravity, mothers bleeding to death, and fleas seeking out the extra-sanguinated newborn because he tastes better than other babies. The second class covers the research on the subject, but since that class will be held on Superbowl Sunday, we’re going to skip that and go right to lesson three, “Saying This Stuff With A Straight Face.”

  2. LIAR! LIAAAR! This ob apparently used to work for the king but the unicorns stole his job so he doesn’t have the confidence to do his job anymore. That’s why he drives his patients away with blatant lies.

  3. It’s a circulatory system. Not a broken fire hydrant. I’m pretty sure it can regulate itself.

  4. This kind of statement really calls into question the OB’s medical training and judgment, but at least it is better to find out how poorly trained your OB is early in the process instead of during labor. So bravo physician, here’s your sign.

  5. Because it would . . . unbalance his humors, or something? Seriously, what–?

  6. Sounds like someone slept through “The Shift from Fetal to Adult Circulation” at med school…which is interesting because I had to write a freaking PAPER on this as part of my monitrice/midwife’s assistant certification. ::head/desk::

    • Yes, but that was not at (cue the ethereal music) **med school**, so it’s not valid.

      • I had “The Shift from Fetal to Adult Circulation” in my mid-exam in med school, but they mentioned NOTHING about the hypothetical difference of early/late/no cord clamping. They did mention that preemies benefit from all extra blood they get, so you “milk out” the cord before clamping it. (They still clamp it fast so they can quickly cart baby off to neo resus or whatever they want to do). Med school definitely needs a class made as midwife cooperation to bring everyone on the same page! (Not that there aren’t ignorant midwives/nurses around… an idiot is an idiot no matter what profession they choose!)

        • You guys didn’t have to do culture competency or inter-professional classes? We do, we covered all sorts of beliefs about health and wellness and learning how to negotiate with patients in respect of their cultural/traditional/religious beliefs about health, when they are in opposition to the medical care we want to provide. We also have to meet with people from the other health professions to learn respect for the other professions.

  7. I think all docs should be required to watch this video. It’s awesome!
    http://www.youtube.com/watch?v=Cw53X98EvLQ

  8. This one is mine. I actually thought he was joking at first so I said oh yeah its like a gas pump that will just keep filling the baby up with blood right? heehee…..but yeah he was serious. He has been supportive of all of my natural birth plans up to this point so this definitely made me uneasy.

    • When the time comes, ask the nurse to give you the clamps and the scissors so your husband can “do the honors.” If the doctor doesn’t have them he can’t use them. Grab the episiotomy scissors off the tray while you are at it.

      • What is with the whole, lets steal the supplies thing? I have heard this so many times on various boards and things. It sounds like people saying “lets hide the scissors and and hope this is the only pair in the world thing!”

        • I read that advice from a doctor, actually! He said that because the L&D unit only prepped one sterile pair of scissors per birth, he’d drop the sterile scissors on the floor and then whoopsie, the mom would give birth without an episiotomy. The doctor apparently was working in a hospital with a 95% episiotomy rate, and he’d gotten in trouble for not cutting them often enough, but he said being clumsy and dropping the scissors gave the mother enough time to give birth. I believe eventually the L&D nurses got used to the idea that he wasn’t going to cut and left him alone as some kind of medical aberration. He’d proven his point: most of these episiotomies were unnecessary.

          In neither case is anyone stealing the supplies, though. In one case they’re in the father’s hand, and in the other, they’re on the floor. :-)

        • If a patient doesn’t consent to the use of those tools, there isn’t any reason for a doctor to have them at hand. I agree with you that it shouldn’t fall on the patient to rid the room of those tools, it should be done by the hospital as a matter of policy when the patient has not consented to their use and failing that the doctor should take the initiative.

          If I didn’t consent to the use of blood products, should they keep a bag hanging on my IV pole just in case they saw the opportunity to slip some in while I was in too much pain to fight them off? What kind of message would that send to the patient? Would that kind of “care” increase or decrease patient trauma?

          I have read that some hospitals (not in the US) have taken the scissors out of the standard kit in labor rooms with great results for mothers and babies. If a doctor or midwife feels an episiotomy is necessary he or she has to ask for a pair to be brought to the room. I imagine that this could cut some of the PTSD symptoms for new mothers and possibly even the suicide rate since it would be pretty much impossible to cut an episiotomy without the patient being aware of the procedure before it happens, and the delay would give the patient the opportunity to get an explanation and consider the procedure first. Of course unwanted medical procedures are not the only thing that cause so many new mothers to suffer from PTS symptoms and depression, but removing the scissors takes a step towards creating a culture where the patient matters and is part of the decision making process which is better for everyone involved.

          • Yep, most (if not all) public and many private hospitals do not have scissors on the tray. When I gave birth in a hospital, the scissors were in a drawer, in a cupboard across the room. They were still available in case of real emergency, but there was a requirement for a verbal request and then a physical act to get them. This gives enough time for a mother / father to question or doc / midwife to explain without compromising a true emergency.

            And Goldilocks….it was the midwives and registrars who instigated the idea. And by the way, if you insist on patronising the people who frequent this board, expect that we will actually cease to listen to your experience. If you want to have a hope in hell of changing our minds on some things, then try speaking to us with a modicum of respect.

          • Thank you Carolyn, I’m so tired of be condesecneded to by a pipsqueeck younger than my own daughter who knows less about childbirth than my own daughter just because she happens to think she knows something based on being in medical school. The point of taking the supplies is to slow down Dr. Auto-pilot. I think the only thing Goldilocks has ever contributed to this board is to explain that they use those rude words because those were the words they were taught to use – then she refused to acknowledge that the words were rude and new ones are needed. Heck of a contribution there!

          • While I do disagree with the wording of her question, I can see why she might feel that way, and I didn’t mean to come across so disrespectfully to Goldilocks. I sincerely apologize to her for that. It does (on its surface) sound like something a crazy person would do; hiding obstetrical tools from the board certified OBGYN or midwife that you hired to safeguard your life and the life of your unborn child during a time when you and the baby are at your most vulnerable. However, after being mistreated and permanently injured by an OBGYN using those tools against my will, it will be the first thing I “take care of” if I’m ever in labor in a hospital again no matter how much I trust my care provider because I trusted the last one too.

            I’ve seen several people comment here that if the patient didn’t fight them off hard enough then she implied her consent (even while drugged or otherwise incapacitated, and even if the patient based that implied consent on blatantly false information), and according to hospital policies and the forms we sign when we are admitted, that’s often true. Even when there’s never a word about risks, benefits or alternatives, HCPs are still under the mistaken impression that the patient properly consented to the procedure/medication/surgery if she’s not screaming her head off and attacking people. In an environment like that, how can you not expect the patient to “steal the scissors”? Maybe Goldilocks will come to understand our thinking after she is out of med school and has been practicing a while. From what I’ve observed, most doctors don’t blatantly abuse their patients in front of a room full of students. She likely won’t witness this kind of abuse and the severe psychological trauma and sometimes lasting physical injuries that come with it firsthand until after she’s been practicing for a while.

      • I don’t think that would work. They generally don’t hand the clamps to the dad anyway and start clamping without asking or waiting.

    • Wow, talk about getting your medical degree from a generic Cracker Jack box! It amazes me that people who will look down their noses at us mere mortals for not having the education they have will spout such junk as gospel truth that is obviously nonsense to us, the UNeducated. You know, it just makes me wish I could go around the country re-educating people in the medical profession. It also makes me so glad to have recently met physicians in a couple of specialties who are very PRO evidence-based medicine, and look down on those who are against it. I feel much safer knowing those MDs are in my corner. Best of luck in the birth of your baby and to your support team in snatching the clamps/scissors while your OB is distracted. That really does make sense if you’ve got an OB whose use of such routine procedures would cause him to forget at that crucial moment.

    • Soon2B3

      This article may help you to understand your OBs position on delayed cord clamping and help inform your discussions.

      All the best

      http://cord-clamping.com/2012/11/22/a-response-to-an-obstetricians-opinions-on-delayed-cord-clamping/

  9. At least this OB is up front about it. OB at my daughter’s birth clamped her cord immediately. When my husband protested that we planned delayed cord clamping/cutting OB responded, “Oh yeah… I don’t do “that.” Wish she’d told us that before, like maybe when discussing our birth preferences.

  10. I have seen where delayed cord clamping of more than 3-5 minutes does result in a polycythemic baby that needs a partial exchange transfusion in NICU (and leads to hypoglycemia and other problems)…

    just saying. :)

    So… this OB is not crazy, haha. But also clamping and cutting immediately can result in a hypovolemic/anemic baby… and that’s even worse.

    3-5 minutes (not “milking”) before clamping is ideal.

    • Does that result in actual bad outcome for the baby or just numbers “out of wack with normal” based on the numbers of baby’s whose cords are normally prematurely clamped? If your chart says the baby is out of normal range, but the chart is based on another set of circumstances then who cares? Did I make myslef clear? It is like using the sem growth chart for breastfed and formula fed babies. Doesn’t make sense; doesn’t matter because it doesn’t actually indicate a harmful condition.
      Or it could be confirmation bias on your part. Because I’ve seen stuff that says the number are different but the result are better with delayed cord clamping. The only problem I’ve seen reported is from milking the cord.

    • or you can just wait till the baby gets all its blood back and everyone will be happy…. what you mentioned must be incredibly rare or baby was premmie and had the cord milked, or the baby was put on the floor below mum because ive never heard of that happening. out of my 2 sons the one who didnt have his cord clamped was fine, the one who had it clamped and cut right away had jaundice, i have a few more examples but no time, but as above said the only problem is when the cord is milked… just saying

      • No, actually, I’ve seen it quite a few times. I am a neonatal nurse at a busy urban hospital. (not a premmie, not a milked cord, baby was on mom’s chest (not below level of the placenta)… I was in the delivery room for some of these babies and followed their care up in the nursery.

        As far as the jaundice in your one son with immediate cord clamping– neonatal jaundice is caused by lots of different factors (ABO incompatibility is the biggest risk factor– something that could have existed in your one son and not in the other, regardless of cord clamping method). Polycythemia (or excess red blood cells) is just one of the risk factors.

        Again…. I AM going to wait 3 minutes before my homebirthed daughter gets her cord clamped. I am in favor of this practice. BUT… It is NOT without SLIGHT risk in extreme circumstances.

        As a homebirthing “crunchy” mom and a neonatal nurse, I have a pretty balanced perspective– not every natural practice is necessarily beneficial and completely “good” and not every mainstream medical practice is harmful and completely “bad.” Everything needs to be weighed out with careful attention to risk perception.

        It states in one of the articles, that about 6% of babies gets polycythemia. I am unaware offhand of the number of times that “delayed” cord clamping contributes to this; all I know is that most babies with very high hematocrit requiring treatment that I personally have cared for at the hospital had “delayed” cord clamping. Not all, but most.

        Just something to think about… just trying to give a balanced perspective on this practice. In MOST cases, “delayed” (or “normal” as Jane would like me to say) cord clamping is beneficial to increase a baby’s iron stores to 6 months of age, etc…

        • The avoidance of cord clamping until complete transition to pulmonary circulation and physiological cord closure equals normovolemia.

          It is interesting that studies of cord clamping have not determined whether arbitrary and premature cord clamping can be responsible for hypervolemia or hypovolemia.

          Science has also not distinguished between the causes of symptomatic polycythemia in normovolemic infants and describes the “normal” blood volume as a cause.

          What about maternal smoking, gestational diabetes, IUGR or small for gestational age, chromosomal abnormalities or other conditions known (or currently unknown) that causes erythropoiesis in the fetus and excess RBCs in the neonate.

          It may very well be that modification of blood volume by timing of cord clamping may help to prevent serious polycythemia in vulnerable newborns – however we would also need to fully understand the short and long term impact of the loss of volume, stem cells, immune cells, clearance of accumulated acids at birth etc on a infant with higher viscosity etc.

          We still don’t know what the impact is for healthy infants.

  11. Yes… it can cause harm to the baby…

    “As the central Hct level increases, viscosity increases. The arterial oxygen content also increases. Changes in blood flow are observed in some organs; this is due to changes in viscosity or changes in arterial oxygen content. The change in blood flow may influence oxygenation and may influence the delivery of substances to organs that are dependent on plasma flow, such as glucose”

    Polycythemia is also common in infants who have experienced delayed clamping of the umbilical cord.

    Neonates with polycythemia may have the following findings:

    Lethargy
    Irritability
    Jitteriness
    Tremors
    Seizures
    Cerebrovascular accidents
    Respiratory distress
    Cyanosis
    Apnea

    Delayed cord clamping allows for an increased blood volume to be delivered to the infant. When cord clamping is delayed more than 3 minutes after birth, blood volume increases 30%.”

    from: http://emedicine.medscape.com/article/976319-overview

    With that said, I am 33 weeks pregnant and plan to have my baby’s cord clamping delayed at least 3 minutes… It is good (obviously) for the baby to get the blood that she needs… but too much blood *can* be a bad thing. :)

    • oh… and the risk for jaundice increases, too, with the excess RBCs breaking down.

      • jaundice – that is what it was- the jaudince number are bogus. The numbers they use to determine jaundice need to be adjusted when a baby’s cord is left alone. The study which was on Dr. Nick’s medical rounds video said that the scale for jaundice needed to be adjusted because bad outcomes did not occur at the same levels when the baby got full blood volume.

      • as my above comment states, in my experience, baby whose cord was clamped immediately got jaundice, baby whose cord was left till placenta was delivered, no jaundice
        i would also like to say that newborn jaundice is a normal state and not at all related to other forms of jaundice,

    • I find this interesting:

      Delayed cord clamping allows for an increased blood volume to be delivered to the infant. When cord clamping is delayed more than 3 minutes after birth, blood volume increases 30%.”

      The interesting thing is that the sentences above make the assumption that immediate cord-clamping is the norm, and delayed cord clamping is the aberration.

      If you make the presumption that delaying cord clamping (for about three minutes, as you said) is the norm, then that statement would read more like “Immediate cord clamping decreases the blood volume delivered to the infant. When cord clamping is not delayed for three minutes after birth, blood volume is decreased 30%.”

      I believe it would be within reason to say that for most humans, across all countries, cultures and timeperiods, the cord was not immediately clamped after birth. The norm really should be leaving the thing alone, so when we have studies or recommendations in favor of delayed cord clamping, the language should reflect that. It’s really only our recent bias that the cord should be clamped.

      If you were to ask most doctors if a 30% blood loss was acceptable in their patients, they’d say no. We need to phrase it that way when talking about this issue with our caregivers.

      • That math isn’t right. If full blood volume is 130 units and mmediate clamping gives the baby 100 units. The the loss of 30 units over 120 units is a 25%. Whereas 30 extra over 100 is a 30% increase. It depends on what you consider normal and what you put on the bottom of the fraction. Just a math fact, but one that a sharp doctor who believes in immediate clamping will use to distract you.

        • I knew the math wasn’t right, but the point is still that we need to talk in terms of aberration from the actual norm, not the real norm’s aberration from the aberrant norm.

        • Blood volume and impact of cord clamping

          The total blood volume of fetal-placental circulation contains 110-115ml/kg. For a 3kg baby, this volume is 330-345ml total.

          While the total blood volume in a neonate varies, one factor that will have a profound effect on the ‘fixed’ blood volume is the timing of umbilical cord clamping (Chaparro, 2011).

          Using indirect methods, Yao and colleagues measured that term infants with immediate cord clamping have approximately 70ml/kg of blood at birth, while those with the cord left intact for 3 minutes have approximately 90ml/kg or more (Yao, Moinian & Lind, 1969).

          For a 3kg baby (7 lb. baby), the difference is 210ml of blood with immediate clamping versus 270ml when the cord is left intact.

          This study showed the infants in the intervention group with immediate cord clamping had 30% less blood volume than babies with a physiologic transition at birth.

          Using direct methods of weighing the infants, Farrar and colleagues measured the mean volume of blood distributed to the baby with the cord left intact was between 83 and 110ml, equivalent to 24-32ml/kg (Farrar, Airey, Law, Tuffnell, Cattle & Duley, 2010).

          This study confirmed that the distribution of blood in the minutes after birth (placental transfusion) represents between one-third to one-quarter of the babies normal blood volume at birth.

  12. “It is vital that clinicians seek to provide evidence-based care. This ensures better care for the women and babies we serve, and emphasizes a culture of attentiveness to clinical evidence. Based on currently available published studies, we conclude that delayed clamping of the umbilical cord should be routinely considered for all women. Waiting 1 to 3 minutes (or until pulsations stop) to cut the umbilical cord has been shown to have numerous benefits for the newborn without additional risk to either the newborn or mother.”

    The key here is the 1-3 minutes part. :)

    from: http://www.medscape.com/viewarticle/708616

    I guess I didn’t come across clear before… I AM in favor of “delayed” cord clamping… but I wanted to demonstrate that it *is* possible (in a LOW percentage of babies) for potential negative effects.

    • “The World Health Organization states the “optimal time to clamp the umbilical cord for all infants regardless of gestational age or fetal weight is when the circulation in the cord has ceased, and the cord is flat and pulseless (approximately 3 minutes or more after birth).”

      From cord-clamping dot com’s faq page

    • Thanks, Judah. You provide some really good information and I appreciate your manner of doing so.

    • Don’t worry, Judah, I think we all understood that you’re FOR delayed/normal cord clamping altogether. And it’s so refreshing to hear from someone who cares for neonates who believes in evidence-based medicine, so points surely go to you for that!! :) It’s just the timing that everyone seems to be debating. I DO like that what you quoted above stated 1) that premature clamping is is not in a baby’s best interests and 2) that it states 1-3 minutes and in parentheses “or until pulsations stop,” which indicates potentially *longer* than 3 minutes, should the parents and medical provider believe that is in the child’s best interests. Now THAT makes full sense to me.

      Also, congratulations on the upcoming arrival of your little one! I wish you all the best in your homebirth, and I hope that you will let us all know how everything went. :)

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