Cord Around the Neck

From Susan:

“My first was born by c-section due to brow presentation. I was induced at 41 weeks 4 days. Long labor.

My second was a successful VBAC. I was induced with him also at 41 weeks, 5 days with a Pitocin drip. Contractions didn’t start right away and, after about 3 hours, the doctor broke my water. Things started so slow, but the doctor was very patient and we waited. Finally the contractions were getting a bit heavy and I decided on an epidural. I was given a small amount and was still able to feel the contractions but the peaks had been tapered off. I then dilated quite quickly from 8 to 10 (45 minutes) and had that intense need to push. So I pushed for about 30 minutes and our son was born. But when he came out his cord was wrapped twice real tight around his neck. He was not breathing. His one minute Apgar was 3. He was given oxygen and, within 5 minutes, his Apgar score was up to 8.”

Gloria responds:

Susan, you said- ‘But when he came out his cord was wrapped twice real tight around his neck. He was not breathing, Apgar was 3. Given oxygen and within 5 minutes his Apgar was up to 8.’ Susan, you are making a very common mistake. Attributing your baby’s low 1 minute Apgar to the cord around the neck is not correct. Your baby had a low Apgar at birth because you had an epidural and the pitocin drip was turned up too high. We know this because the second stage was so short. The cord around the neck is the reason the doctors give you so you won’t ask questions about why he was blasted out so quickly.

This kind of pitocin induction is sometimes associated with delayed speech and/or learning difficulties. It depresses the baby’s oxygen levels through the pushing stage. The reason the baby’s Apgar score came up nicely after 5 minutes is because you grew an essentially healthy baby and it was difficult for modern obstetrics to kill him.

So many women are told the baby didn’t breathe or wasn’t pink because of the umbilical cord being around the neck. It is a lie. We don’t see this at unmedicated home births and I have attended births where the cord was tight and up to five times around the neck.

The two most important things with a VBAC are:

1. don’t do anything to increase the strength of the contractions and
2. don’t anaesthetize the woman.

Your former doctor put you and your baby in danger by not following those two protocols. Your uterus was put in unnecessary danger of rupturing by both the Pitocin drip and artificially rupturing the membranes.  In hindsight, the cord was around the neck and, thus, probably out of danger but artificially rupturing the membranes is associated with causing the umbilical cord to prolapse–an obstetric emergency.
Susan replies:

“Gloria, it sounds like you just completely described what happened to me and my son–who does have learning difficulties and developmental delays.”

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

This photo shows a baby born at home in the U.K. who had the cord twice around the neck and was in a breech presentation.  Note his good colour.

Nuchal cord

Added January 2015: I just saw this video of a woman giving birth unassisted. The birthing woman calmly unwraps one loop of cord once the baby is out. Found on www.midwifethinking.com

Here’s a video of a hospital birth. Doctor is busy in the Operating Room. Woman births her baby and unwraps the multi-wrapped cord around the neck.

Insider’s Tip on How to Have a Great VBAC

The following is a post I sent to the ICAN (International Cesarean Awareness
Network) list. It is very, very important information for ALL birthing women
and can make all the difference in a VBAC birth. Read it carefully, copy it,
send it to your clients. One of the ICAN women replies to my post at the
end:

Subject: ICAN: Tip for birth

I wanted to write to those of you who are pregnant to tell you something
that has been running through my mind all day about how you can be
successful with your VBAC births. Many births begin in the night…. woman
will get up to pee, feel her membranes release and then an hour later begin
having sensations fifteen minutes apart. Because we think of birth as a
family/couple experience, most women will wake up their husbands to tell
them something’s starting and then, probably because we all hope we’ll be
the 1 in 10,000 women who don’t experience any pain, we start getting the
birth supplies organized, fill up the water tub, etc. I have seen so many
births that take days and days of prodromal (under 3 cms. dilation)
sensations and they usually begin this way. The couple distracts themselves
in that early critical time when the pituitary gland is beginning to put out
oxytocin to dilate the cervix. Turning on the light, causes inhibition of
the oxytocin release. Many couples don’t call their midwives until they have
sensations coming 5 minutes apart at 7:00 a.m. but they’ve been up since
midnight timing every one of the early sensations. If they had called their
midwife at midnight she would have said “Turn off the light and let your
husband sleep as much as possible through the night. You, stay dark and
quiet. Take a bath with a candle if it helps and call me back when you think
I should come over.”

Secret beginning of birth

Secret beginning of birth

That first night can make all the difference and yet so many couples act
like it’s a party and don’t realize they are sabotaging their births right
at the beginning. Staying up all night in the early part does two things–it
throws off the body clock that controls sleep and waking and confuses the
brain AND it inhibits the release of the very hormone you need to dilate
effectively. You know that it can take days to recover after a night of
partying or after working a graveyard shift. Don’t start your birth with
that kind of stress on your hormone system.

When you begin to have sensations, I urge you to ignore it as long as you
possibly can. Don’t tell anyone. Have a “secret sensation time” with your
unborn baby and get in as dark a space as you can. Minimize what is
happening with your husband, family and the birth attendants. What would you
rather have–a big, long dramatic birth story to tell everyone or a really
smooth birth? You do have a say over your hormone activity. Help your
pituitary gland secrete oxytocin to open your cervix by being in a dark,
quiet room with your eyes closed. Gloria Lemay, Vancouver

Pam wrote:

“I really loved what Gloria had to say here. For me, it’s all about what
went wrong at my first birth (stayed up all night timing
contractions…stupid, stupid, stupid, and was totally wiped out by morning),
and could have been improved at the second, when I lacked a place to stay
dark and quiet. I printed it out for my husband to read, and am putting it in my
file of important things to remember when labor starts, within the next
couple of weeks.”

Who is the Best of the Birth Blogs this Week? Moi!

It’s thrilling to have my blog be recognized.  Here’s what they are saying at the International Cesarean Awareness Network (ICAN) website:

Best of the Birth Blogs – Week ending August 30th
Your weekly one-stop for highlights from the birth blogosphere. Visit weekly for the latest on childbirth, especially related to cesarean prevention, recovery, and VBAC. To nominate a blog post to be featured here, email me at blogican-online.org


Gloria Lemay – Eating During the Birth Process: Many in the blogosphere commented this week on ACOG’s new recommendation stating that women should now be allowed to drink clear liquids during labor. Gloria discusses eating during labor, including her own experiences in labor and as a birth attendant. Bottom line, says Gloria: “I pity the powers that be at ACOG that they think they can make protocols, rules, and guidelines that will cover all births. A better goal would be to have clinicians who could think for themselves, distinguish complications from a normal birth, relax when things are taking a while, and really observe the consistently fascinating process of human birth.”

I was also selected by ICAN on Aug. 16, 2009 for my post:

“A Proven Method for Reducing the Cesarean Rate”:   Gloria reviews a successful, but sadly abandoned, effort to reduce the cesarean rate at a British Columbia Hospital.

So, there’s my brag for the day.  Thanks for the acknowledgement, beautiful goddesses at I.C.A.N., it means a lot to me.
 
 

 

You Had to be There or you wouldn’t believe it Department

We transported the young mother to hospital because the baby had passed a lot of meconium.  Every midwife does this a few times and then realizes that the worst place to be with a meconium stained baby is a hospital.  As soon as we arrived, (granted,  there was no paperwork, no history,  no pre-registration) the nurse on duty wanted to do an exam and, as she was doing it, I realized that she already had an opened scalp monitor in her hand and was about to screw it into the baby’s scalp.  I raised my voice and said “Don’t put that in the baby’s head without the parent’s permission.”  She threw it aside, glowered at me and announced that the mother was fully dilated.  The doctor was on his way but things were proceeding pretty quickly. 

As the baby’s head crowned–the moment when the perineum is stretched beyond all possibility and the mother is deeply focused inside just barely hanging in with all the strange sensation–that same nurse said “Do we have a name for this baby?”  What possesses people to come out with a question that is completely inappropriate to what is happening?  Fine question, completely weird timing.

Another similar moment of disbelief at a hospital birth:  Woman pushing her VBAC baby out in a lovely darkened room, everyone calm, serene, peaceful, in complete awe and admiration of birthing woman.  New nurse comes through the door, walks past the birth bed and says “That’s a big baby in there!”  Whole atmosphere in the room disintegrates into fear and apprehension.  Now, think about it, at that moment in history can we make that baby smaller?  Is the baby that is being pushed out of that vagina the absolute perfect size?  YES, it is because it’s the only size it can be at that moment.

I wasn’t there for this next one, but one of my friends told me what happened when she was being stitched after her cesarean.  Her husband knew she was very disappointed and so he said to her, “Honey, don’t worry next time it will be a vaginal birth.”  The surgeon who was stitching her said “Not unless she’s having a two pound baby, she won’t.”  When she had her seven and a half pound VBAC baby without problems, I asked her to write to the surgeon and remind him of what he had said.

I’ve been guilty of saying dumb things to birthing women, too.  I’m grateful that women have told me some of the insensitive things that disempowered them so I could become more aware and spare others.  There seems to be lots of blogposts on the net right now about what not to say to pregnant and birthing women and I hope it helps people to think before inserting giant foot into mouth.

Words are so important and they can make or break an experience.  I remember one of my friends telling me about her lovely homebirth with a registered midwife and she said “Linda (her midwife) said me and my baby are a match made in heaven.”  Now, that is something she will always remember.  My own midwife, Judy Loyer, said after my youngest daughter’s birth “Every baby should be born that way.”  Thanks for that treasured gift, Jude.

A Proven Method for Lowering the Cesarean Rate

Another article in my local newspaper last week bemoaned the fact that the cesarean rate keeps rising and physicians are concerned not only about the high rate of surgery but also the future complications that increase after cesarean surgery.  It’s a well-documented fact that a cesarean can adversely affect a woman’s health for the rest of her life and can lead to catastrophic complications in future births.  That’s one reason why, 40 years ago, doctors did everything in their power to prevent that first cesarean from being done.

What if there was a tried method of reducing the cesarean rate within hospitals?  What if it involved some truly innovative thinking?  What if it had a proven track record and had resulted in a significant drop in the rate of surgeries for first-time mothers?  What if it saved money, recovery time for the patient, and better health for the babies?  Would you think that method would be adopted all over North America right away?  Yes, that would be a reasonable assumption.  Unfortunately, this project was undertaken at B.C. Women’s Hospital, it was a success, and it was dropped once the project was complete with a resulting re-increase of the cesarean rate.  No reason for discontinuing the project has ever been given but i will speculate at the end of this post.

A cesarean is major abdominal surgery

A cesarean is major abdominal surgery


The results were published: Grzybowski S, Harris S, Buchinski B, Pope S, Swenerton J, Peter E, et al. First Births Project manual: a continuous quality improvement project. Vol 1. Vancouver: British Columbia’s Women’s Hospital and Health Centre; 1998.

It was the first phase of a Continuous Quality Improvement project with the aim of “Lowering the Caesarean Section Rate“. Start date was January of 1996. The target objective was to lower the caesarean section rate by 25% for nulliparous women, while maintaining maternal and infant outcomes, within 6 months of implementing solutions. 

Staff from all departments of the hospital were brought together in a brainstorming session to share hypotheses on what was causing the high rate of cesareans.  Many of the ideas thrown out were not under the control of the hospital but, in the end, four practices were identified as possibly contributing to the high rate of surgical births.

1. Women were being admitted to hospital too early (before reaching 4 cms dilation, active labour).

2. fetal surveillance by electronic fetal monitoring (continuous electronic fetal monitoring has been proven to increase the cesarean rate with no improvement to the health of the baby)

3. too early use of epidurals (women who get an epidural before 8 cms dilation are at increased risk of surgery)

4. inappropriate induction (inducing birth before 41 weeks gestational age with no medical indication).

Teams of nurses were assigned to do an audit of hospital records to see if these hypothetical practices were, in fact, as widespread as some of the staff thought.  The audit confirmed that these 4 areas were ones that needed attention.  Task forces were created in each area to use the best evidence and existing guidelines, as well as solutions from other hospitals to improve care at BC Women’s Hospital. Guidelines and other strategies in all four target areas were implemented in the spring of 1997.
 

WHAT HAPPENED?
 
According to published results from the hospital:
After six periods, BC Women’s had admitted and delivered 1369 nulliparous women (first time mothers) with singleton, cephalic, term presentations. The Cesarean section
rate was reduced by 21% compared to the 12 periods prior to implementation. The number of epidurals initiated at 3 3 cms was 64% lower, continuous fetal monitoring was used 14% less, the induction rate had dropped 22% and admission at less than 3 cms cervical dilation had dropped 21%. All changes were statistically significant. Newborn outcomes were unchanged post implementation.”

WHAT’S HAPPENING TODAY (2009)?

It’s back to business as usual at this hospital.  Women are induced, monitored, epidural’ed, and admitted early.  The cesarean rate is 30% and the head of obstetrics is concerned but has no action plan.  Why on earth would this be?  I assert that it is because it is an “up at dawn” battle with the physicians to change their ways.  The gossip that I hear from nurses is that the doctors did everything they could to undermine this project.  For example, a doctor would examine his patient and state “She’s 8 cms dilated, get the anaesthetist.”  Then, later, when the woman had her epidural, someone else would examine the same woman and find her to be only 6 cms.  The doctor would smile and shrug his shoulders, “whoops”.  The same thing happened around the issue of monitoring, induction and admitting. . . trickery to subvert the project and return to their old ways of doing things.

It’s a low tech, novel, innovative approach that had excellent results.  I’d love to see it copied everywhere in North America but it’s a bit like dieting. . . everyone knows how to lose weight (eat less, exercise more) but only a few get into action.  We DO know how to lower the cesarean rate, committed action is needed.

Cesareans are seriously harming women.

So many women who have had complications from cesarean surgery think that they are the only one.  They often suffer in silence thinking that the medical profession, by and large, is doing a good job.  If midwives were running the obstetric show in North America and were having this rate of serious complications that could be traced right back to the practitioner, there would be hell to pay.  The cesarean surgery rate has to come down.  The cost to families is too great to continue on this path of destruction.  Gloria

From Reuters Health Information

 

 

Rates of Severe Obstetric Complications Increased Over Last Decade

 

 NEW YORK (Reuters Health) Jan 23/09 – The prevalence of obstetric complications resulting in severe maternal morbidity — particularly pulmonary embolism and need for blood transfusions — increased significantly in the US between 1998 and 2005, investigators report in the February issue of Obstetrics and Gynecology. During the same period, rates of cesarean delivery rose from 21.1% to 31.1%, Dr. Susan F. Meikle, at the National Institutes of Health in Bethesda, Maryland, and co-authors note. The proportion of delivery hospitalizations involving older women and women on Medicaid/Medicare also increased with time, as did deliveries characterized by multiple births, hypertension, and diabetes. However, they point out, “comprehensive population-based information on severe obstetric complications remains very limited.” 

To examine trends in severe labor and delivery complications, the authors used data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project for more than 32 million delivery discharge records. The proportion of deliveries with at least one severe obstetric complication increased from 0.64% in 1998-1999 to 0.81% in 2004-2005, the report indicates. 

There was a 52% increase in pulmonary embolism and a 92% increase in blood transfusions. Rates of renal failure, respiratory distress syndrome, shock, and mechanical ventilation increased by about 20%. By contrast, rates of severe complications of anesthesia declined, and there were no significant changes in heart failure, puerperal cerebrovascular disorders, pulmonary edema, deep venous thrombosis, disseminated intravascular coagulation, and sepsis. 

Adjustment for cesarean delivery explained almost all the increases in estimated risk of renal failure, respiratory distress, and ventilation, although the authors note that their results “do not demonstrate causality.” Dr. Meikle’s team points out that the UK has established a surveillance system for rare obstetric complications. Development of a similar system in the US “may improve the ascertainment, monitoring, and classification of these complications and potentially identify modifiable risk factors.” 

Obstet Gynecol 2009;113:293-299. Reuters Health Information © 2009  

 

Doctors beginning to realize that induction is a big mistake

The wall is beginning to crack.  More and more evidence is piling up that all the inductions in the past 20 years for bogus reasons (like oligohydramnios, pregnancy of 41 weeks and gestational diabetes) have harmed women and babies.  Of course, the obstetricians would never apologize for this bloodbath.  Here’s the latest “study of the studies”–keep in mind that even the biggest, most carefully done studies are suspect in their methodology but, at least this one firmly denounces a number of the favourite reasons for inducing.  Gloria

_______________________________________________________________

Indications for induction of labour: a best-evidence review

  E Mozurkewich, J Chilimigras, E Koepke, K Keeton, VJ King, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA Department of Family Medicine, Oregon Health and Science University, Portland, OR, USA Correspondence: Dr E Mozurkewich, F4835, PO Box 0264, Mott Hospital, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0264, USA.

Email mozurk@umich.edu

 Accepted 2 November 2008. Published Online 4 February 2009.

 Background:  Rates of labour induction are increasing.

 Objectives: To review the evidence supporting indications for induction.

 Search strategy: We listed indications for labour induction and then reviewed the evidence. We searched MEDLINE and the Cochrane Library between 1980 and April 2008 using several terms and combinations, including induction of labour, premature rupture of membranes, post-term pregnancy, preterm prelabour rupture of membranes (PROM), multiple gestation, suspected macrosomia, diabetes, gestational diabetes mellitus, cardiac disease, fetal anomalies, systemic lupus erythematosis, oligohydramnios, alloimmunization, rhesus disease, intrahepatic cholestasis of pregnancy (IHCP), and intrauterine growth restriction (IUGR). We performed a review of the literature supporting each indication.

Selection criteria: We identified 1387 abstracts and reviewed 418 full text articles. We preferentially included high-quality systematic reviews or large randomised trials. Where no such studies existed, we included the best evidence available from smaller randomised trials and observational studies.

Main results: We included 34 full text articles. For each indication, we assigned levels of evidence and grades of recommendation based upon the GRADE system. Recommendations for induction of labour for post-term gestation, PROM at term, and premature rupture of membranes near term with pulmonary maturity are supported by the evidence. Induction for IUGR before term reduces intrauterine fetal death, but increases caesarean deliveries and neonatal deaths.

Evidence is insufficient to support induction for women with insulin-requiring diabetes, twin gestation, fetal macrosomia, oligohydramnios, cholestasis of pregnancy, maternal cardiac disease and fetal gastroschisis.

Authors’ conclusions: Research is needed to determine risks and benefits of induction for many commonly advocated clinical indications.

Keywords: Best evidence, indications, induction.

Please cite this paper as: Mozurkewich E, Chilimigras J, Koepke E, Keeton K, King V. Indications for induction of labour: a best-evidence review. BJOG 2009;116:626-636

 

 http://www.ncbi.nlm.nih.gov/pubmed/19191776

Rose’s birth

Dear Rose,  you’re a grownup young woman now but you’ve asked me to tell you your birth story so here goes.

Your mom phoned me a few weeks before her due date to see if I would help her give birth to you at Surrey Memorial Hospital.  She explained that your older brother had been born by cesarean and she had been planning to have you that way, too.  Her doctor had encouraged her to have a vaginal birth but she originally said “NO.”  I think your Dad was a big influence on that.  He never came around to thinking natural birth was a good idea.  As far as he was concerned everyone should have a cesarean–much neater and tidier in his view.  Of course, no one listened to him.

When your Mom made the request of me to be her birth assistant, she had begun to realize that giving birth vaginally might be better for her health and much easier as far as recovery.  My response to her request was “No, I won’t go to that hospital with you.”  She asked “why not? isn’t that what you do?”  I explained to her that I had never seen or heard of a nice birth at that hospital and that it would hurt me too much to watch her go through their treatment of her.  She asked “What would you suggest I do then?”

I said “Well, I’d like to sidle up to this more obliquely, but we don’t have any time. . . I’d like you to have a home birth.”  Your Mom was astounded.  She had only just started to bend her head around a vaginal birth, she had never known anyone who had a homebirth, and this idea came out of left field.  She said “You would NEVER talk me into that!”  I told her that I’d like to try and that I would give her 3 hours of sales pitch for free if she would let me give it a whirl.  She laughed and said okay and the rest is history.

We met, we talked, we laughed, we watched birth videos, I told her stories and, by the end of our time, she was enrolled in homebirth.

It was a long birth.  Your Mom dilated slowly but steadily.  Your Dad made himself scarce with his motorcycle buddies out back through most of it.  Your Mom was always strong and brave except when your Dad would come in the room so it’s probably good that he wasn’t into it at all.  We had to drag him in the bathroom (where your Mom had decided to give birth), when you were actually emerging and, even then, he pulled his shirt up over his face and just peeked his eyes out.  The minute he could see you were breathing, he rushed out again!

One of my students, Joanne, was with us through the whole birth.  It was the first birth that she ever attended.  I said to her “Joanne are you ready to catch your first baby?” and Joanne gamely nodded “yes”.  So, your lovely momma pushed you out very gently while in an all 4’s position on the bathroom floor.  Joanne received you in such a tender, gentle way and you went right onto your Mom’s skin.  We helped her to turn over and sit leaning back on pillows against the bathtub for a while. Bathroom

Your Mom held you close the whole time. The placenta was born and your cord was cut after it had completely stopped pulsing and the placenta was out.  You were a very sweet, pink little doll.  Your mom was completely captivated and I guess your Dad really liked you a lot because he kept giving us cash after that.  🙂 

When it was time to tuck you and your Mom in bed, we noticed that your Mom was walking towards the bed completely hunched over.  We had to tell her “You haven’t had a cesarean, you can stand up straight to walk.”  She looked so surprised and, yes, she straightened up and stopped protecting her guts.  The next day, I came out and you were nursing like a champ.  I asked your Mom to do some sit-ups and leg raises and she looked at me like I was insane.  Again, I had to say “You haven’t had major abdominal surgery this time, you can lift your legs.”  She was skeptical but did it just fine.  The day after that, when I came she was up, dressed and making spaghetti sauce in the kitchen.  I thought “Whoops, we shouldn’t have told her how strong she is!”  The day after that, I came to do a blood test on your heel and your Mom had taken you and gone to the gym!  She felt so good and she never complained about anything because nothing feels bad after you’ve known what a cesarean feels like.

Your Mom joined my Midwifery Study Group and helped many people to have nice births.  She is such a fun person to work with and I’m so happy that I got to see her give birth powerfully.  Thanks for getting your little head down and cooperating so that I looked good at your birth, honey.

I love you, Gloria