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Health Care by Participation

No matter where babies are placed as they are born, there is little question that U.S. obstetricians and midwives will change current practices from immediate cord clamping to optimal cord clamping; it is just a question of when. I fully anticipate that within a decade, immediate cord clamping will no longer be a routine of third stage labor regardless of whether the baby is premature, full term, born vaginally or by cesarean. The evidence against this practice is too strong.  Dr. Alan Greene is more optimistic and is calling for an end to immediate cord clamping, like, today!  He says we can accomplish this with public health by participation. Please participate by asking your midwife or doctor to practice optimal cord clamping for your child and by sharing this information with your healthcare provider and your social network.

Editorial: Time to Implement Delayed Cord Clamping

In a strongly worded editorial published in Obstetrics and Gynecology, the journal of the American College of Obstetricians and Gynecologists (ACOG), Dr. Ryan McAdams recommends that babies should be held at the level of the introitus for vaginal births and on the mother’s thighs above the level of the uterus during cesarean births while waiting two to three minutes to clamp the umbilical cord. Dr. McAdams writes, “In term neonates, delayed cord clamping has been associated with decreased iron-deficient anemia and increased iron stores with potential valuable effects that extend beyond the newborn period, including improvements in long-term neurodevelopment.” He cautions that, “Failure to adopt beneficial practices, especially evidence-based ones, may constitute unnecessary harm. Reluctance to implement delayed card clamping nationally may place thousands of children born this year at unnecessary risk for neurodevelopment delays, cerebral palsy, and behavior problems.”He concludes, “For those privileged enough to participate in the birth of neonates, there is a need for increased appreciation and awareness of which precious minutes may count most.”

Birthing Violet

My mother had died six months earlier as I lay on my bed in Brooklyn and began to time my contractions.

I had never needed her more than during my labor. I wanted living proof that this was possible. I didn’t believe I held enough power or knowledge, enough female strength to do this alone. But she had gone, so I had hired a mother, a doula, to be my guide.

My doula, Mary-Esther Malloy, arrived at three in the morning while I was in the shower. I had taken natural birth classes with her, determined to recreate my late mother’s labor.

“I don’t know what all the fuss is about,” my mother said, whenever someone on television gave birth, screaming and grunting towards motherhood. I did not want to be one of those women my mother scoffed at. With her gone her words were all I had, and so I opted for a natural birth.

I imagined I would give birth exactly as my mother had: silently, gracefully, powerfully; with wide hips and long hair stuck to my forehead. But I had neither wide hips nor long hair, and my gait tended more towards function than grace as I carved a path through my house at three-thirty in the morning with my doula at my side.

A lithe woman, Mary-Esther had the presence of a ghost, beautiful with a face that appeared to glow. She walked next to me, quiet, a sandy haired shadow. Just as I had held my mother’s hand through her illness acting as an anchor while her body performed unimaginable feats of destruction, Mary-Esther held my hand while my body performed unimaginable feats of creation.

Birth is, in every way, the opposite of death, but what common ground the two share is their proximity to not-life: That time before life truly begins or after life inevitably ends. Being close to either of those states it is prudent to have a hand to hold. I had held my mother’s for six weeks and Mary-Esther held mine for what would turn out to be twenty-seven hours. She was my anchor. She offered the conviction that I could do this. Her quiet energy flowed down her thin arms, radiating into my hands. This will be okay, your body can do this, she seemed to be saying.

Dawn came and I asked my husband to draw the curtains. I didn’t want to know how long this was taking. I moved around my apartment leaning on one thing and then another. Mary-Esther, forever at my side, said little; she knew words were not what I needed. I was beyond language. Instead of speaking she joined me in that distant place that labor carves out as its own.

I wanted the birth of my daughter to be a joyous occasion. I had had enough sadness. In an attempt to ensure joy, my husband and I had attended classes in natural birth. But trying to prepare for birth was like trying to learn how to be tall. All childbirth classes could offer me was a sense of preparedness. My husband and I had practiced with me rocking on all fours while he pressed tennis balls into my back. I’d sat atop yoga balls while he massaged my feet. We had squatted and counted and eaten ice chips. I had exercised my Kegels on the subway, secretly clenching my vagina while trying not to appear stressed.

My labor lasted for twenty-seven hours, during which time I barely spoke. Not because of the pain, but because I was doing something no one else could and it was demanding enormous effort: I was birthing Violet. I had imagined feeling deeply close to my husband during labor but he seemed little more than a shadow of face, dark hair and eyes as he stood next to me. Labor focused my mind and body in a way that little else could rival. Anything that was not essential became irrelevant. It was me, my uterus and Mary-Esther Malloy.

My husband and Mary-Esther urged me to eat and drink between contractions which were coming hard and closer together. I had given up timing the pains hours ago. With the curtains closed I had given up time altogether. I sat on the toilet with my knickers on just to rest. Mary-Esther held my bare legs, fastening me to reality. The flickering of the scented candle she’d lit made me feel sick; I kicked it over with my foot. We sat, my doula, my husband and me, and waited.

I was on my toilet in Brooklyn having my legs held by Mary-Esther Malloy. My mother was dead, my sister was in Scotland, my friends were at work and my husband was a man. In that moment I loved Mary-Esther Malloy as much as I’ve ever loved anyone. In the dark bathroom that smelled of smoke and wax, she held on quietly reminding me that my grandmother had done this six times, my mother had done this, as had her mother, and in the pull of my womb I was drawn back hundreds of years to women in linen nightgowns, sweaty and medieval, the king praying for a son; women in jungles, brown and naked squatting in the leaves; women before there were diagrams or videos about how to breathe or about hypno-birthing or hot tubs. I would be one among them.

The pain intensified and the noises coming from within me changed tenor as I was guided by my husband and Mary-Esther Malloy into the living room. A large blue yoga ball was placed in front of me and I was lowered onto it. My knees apart, my belly hanging like a hammock of baby, my chest resting on the ball, I bobbed like a ship lost at sea. The baby was coming. I held onto the ball as if it were a life raft.

Then it was time to go to the birthing center, but I was stuck. My ankles had seized, my knees were pinned, and downwards was the only way my body wanted to go. Mary-Esther Malloy and my husband gently pulled me up.

The short walk from my door to the car took half an hour. Every few shuffles I gripped Mary-Esther and groaned. Her strength seemed without limit. In the car I closed my eyes and imaged my way through the Brooklyn dark.

At the birthing center we were met by our midwife. I sat in a rocking chair in the homey room designed to look non-medical. My blood pressure was slightly high so I was told I’d be moved to labor and delivery. Mary-Esther stepped in front of me with the bravado of a mother and told them to take it again in ten minutes. Then she crouched close to me and spoke in a soft voice. I do not remember what she said but her words conjured images of softness, of submerging in cool water, of returning to calm. I listened and my blood pressure turned downwards. I registered the surprise on the nurse’s face when she took the second reading.

I was helped into a wet tub. The water was warm and I lay back, glad of its suspension. I don’t know how long I was water-bound, but soon I heard hard, groaning noises. As the noises changed from moan to grunt the nurse helped me out of the tub and onto the bed. I was so close to birth that I barely felt the hand that examined me. Then I was told it was time to push. My waters broke and everything was warm.
With the next contraction the midwife told me to push. I did, and then I stopped pushing, afraid of my own power. I looked at the midwife and at Mary-Esther, feeling panic, but they both smiled encouragingly.

I lay on the bed, my side to the mattress, one leg on Mary-Esther Malloy’s shoulder, my husband at my head, my chin on my chest, following what my body told me to do. I didn’t really believe a baby could come out of me until I tried to lower my leg for a rest and felt something large and hard in the way. “It’s the head,” said the midwife at the look of surprise on my face. A head between my legs? Surely not, but I pushed on. I felt something pop out of me and then in one slippery moment out my daughter flew, onto my chest, and like that, I was a mother!

Her warmth at that moment of birth was as real to me as the coldness of my mother at the moment of her death. And the baby looked like my mother had – bald and helpless — but she wriggled up my chest, and gray and slippery, lay against me. Life! I had birthed Violet, and both she and I – mother and daughter — were full of life.

Why does it matter when we cut the cord?

Oxygen

Allowing the placental transfusion has immediate, as well as longer term, benefits for your child. One of the most time-sensitive and critical jobs a newborn must accomplish is to make the switch from gas/cord oxygenation to lung breathing. An understanding of newborn transitional physiology is emerging that stresses the importance of the blood volume and increased red cell supply provided by the placental transfusion to the start of lung breathing (Mercer, 2002; see also Goer and Romano, 2012, page 403). Furthermore, while this transition to lung breathing is underway, the oxygen-rich blood flowing to the baby provides a potentially helpful secondary source of oxygen for the baby during the delicate process of switchover (van Rheenen, 2011).

Iron

“Anaemia is now a recognized complication of early cord clamping”
—(Downey and Blewly 2012).

Researchers are now connecting the dots between the global public health problem of anemia in young children worldwide and the practice of early cord clamping.  The authors of a recent, well-designed study found that delayed cord clamping significantly improves iron status and reduces anemia and iron deficiency to 4 months of age (Andersson, et al, 2011).  Others have followed the benefits of improved iron stores to 6 and 7 months (Chapparro, 2006; Mercer, 2010).

Interestingly, this time frame tracks with the general period recommended for exclusive breastfeeding. And, curiously, as perfect a food as breast milk is, it does not supply iron to our babies. Could it be that nature has designed it such that a few minutes of blood transfusing at the time of birth ensures the necessary iron for the baby’s development for the first half-year? It would appear so. Unfortunately, this means that if cords are clamped according to current practices, our breastfed babies are at the highest risk for iron deficiency.

Iron deficiency, the primary cause of anemia, is of concern because it can negatively impact a child’s cognitive and motor development (Andersson, 2011).  With a quarter of the world’s population experiencing anemia, a simple shift in practices at the time of birth may potentially help our next generation, especially those who are exclusively breasted for their first months, to start life on the outside with iron levels that support optimal brain development.

Stem cells

This is no ordinary blood we are discussing. It is chock full of stem cells, those immature, self-renewing cells that can turn into a variety of tissues. The authors of a recent study published in the Journal of Cellular and Molecular Medicine suggest delaying cord clamping in order to realize “mankind’s first stem cell transfer”:

“Nature’s first stem cell transplant occurs at birth when the placenta and umbilical cord start contracting and pumping blood toward the newborn… This phenomenon occurs in most placental mammals and this transfusion of blood is allowed to end physiologically in most species except in human beings. Human beings manipulate the transition from foetal to neonatal life by early clamping of the umbilical cord, meaning that nature’s first stem cell transplant is curtailed, thus depriving infants of additional stem cells” (Tolosa et al., 2010).

They describe the essential role stem cells play in the development and maturity of many organ systems including the central nervous, respiratory, cardiovascular, haematologic, immunologic and endocrine systems. They write:

“…the artificial loss of stem cells at birth could potentially impact later development and predispose infants to diseases such as chronic lung disease, asthma, diabetes, epilepsy, cerebral palsy, Parkinson’s disease, infection and neoplasm” (Tolosa et al., 2010).

Thus, a simple delay in cord clamping may permit an inborn stem cell therapy that can “promote acute benefits in the case of neonatal disease, as well as long-term benefits against age-related diseases” (Tolosa et al., 2010). It is possible that the greatest health benefit to a newborn when we delay clamping the cord may come from the increased volume of stem cells whose value we are only starting to understand.

Aside from a healthier baby, there are benefits for the mother as well. Allowing the placental blood to drain has been shown to help the placenta detach in a timely and uncomplicated manner (Soltani et al., 2005; Jongkolsiri & Manotaya, 2009).

It makes no sense that this valuable secondary source of oxygen for your baby’s first minutes, important iron for your child’s first months and miraculous stem cells whose impact may last a lifetime, end up in the medical waste bin. This good blood belongs to your baby.  Make sure your child receives it.

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