Is this birth plan reasonable

[wulfbourne]

Hi, my only experience is in med-surg nursing, so I was wondering if I could run a possible birth plan by you guys and get professional opinions on it. I kept it short and sweet because I know you guys don't have a lot of time to read an essay:) Also, do most hospitals put the erythromycin ointment in the babies eyes right away? I don't want to go as far as to refuse it, even though I know I'm std neg, but I did want to wait until after I had a chance to do my first feeding before it was applied. Anyway, here is what I have so far...

I would like to have the baby placed on my stomach/chest immediately after delivery.

I would prefer that the umbilical cord stop pulsating before it is cut.

I would like to hold the baby while I deliver the placenta and any tissue repairs are made.

I would like to hold the baby for fifteen minutes before he/she is weighed and measured. I would also prefer the evaluation of the baby be done with the baby on my abdomen.

I plan to breastfeed the baby and would like to begin nursing shortly after birth.

I do not wish to have any bottles given to my baby. If supplements are needed I would prefer syringe or finger feeding.

While I would like minimal interventions, the health of my baby (first) and I (second) are the priorities. Thank you for being here and helping us achieve these goals.

[MalgaBSN]

public release date: 16-aug-2007

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[color=#2c56ac]bmj-british medical journal

umbilical cord clamping should be delayed, says expert

editorial: umbilical cord clamping after birth

clamping and cutting of the umbilical cord should be delayed for three minutes after birth, particularly for pre-term infants, suggests a senior doctor in this week's bmj.

early clamping and cutting of the umbilical cord is widely practised as part of the management of labour, but recent studies suggest that it may be harmful to the baby. the rate of early cord clamping varies widely in europe, from 17% of units in denmark to 90% in france.

so dr andrew weeks, a senior lecturer in obstetrics at the university of liverpool, looked at the evidence behind cord clamping.

for the mother, trials show that early cord clamping has no ill effects, he writes. but what about the baby"

at birth, he says, the umbilical cord sends oxygen-rich blood to the lungs until breathing establishes. so as long as the cord is unclamped, the average transfusion to the newborn is equivalent to 21% of the neonate's final blood volume and three quarters of the transfusion occurs in the first minute after birth.

for babies born at term, the main effect of this large autotransfusion is to increase their iron status. this may be lifesaving in areas where anaemia is endemic.

in the developed world, however, there have been concerns that it could increase the risk of polycythaemia and hyperbilirubinaemia (abnormally high levels of red blood cells and bile pigments in the bloodstream, often leading to jaundice). but trials show this is not the case.

for pre-term babies the beneficial effects of delayed clamping may be greater, he says. although the studies are smaller, delayed clamping is consistently associated with reductions in anaemia, bleeding in the brain (intraventricular haemorrhage), and the need for transfusion.

so how should we approach cord clamping in practice, he asks"

in normal deliveries, delaying cord clamping for three minutes with the baby on the mother's abdomen should not be too difficult.

the situation is a little more complex for babies born by caesarean section or for those who need support soon after birth. nevertheless, it is these babies who may benefit most from a delay in cord clamping. for them, a policy of 'wait a minute' would be pragmatic, he says.

there is now considerable evidence that early cord clamping does not benefit mothers or babies and may even be harmful, he writes. both the world health organisation and the international federation of gynecology and obstetrics (figo) have dropped the practice from their guidelines.

it is time for others to follow their lead and find practical ways of incorporating delayed cord clamping into delivery routines, he concludes.

i looked into the who recommendations a little further and they came up with the average of 3 minutes as about when the cord stops pulsing. in my practice i have seen various lengths for the cord to stop pulsating.

[CMCRN]

The AAP recomends erythromycin and Vitamin K be given within the first 6 hours after birth. There is no advantage to giving them in the first few minutes except convience for the hospital personell in getting the baby "done". I agree with Malaga

[RainDreamer, BSN, RN]

I think everything you're asking for sounds totally reasonable.

The only thing that I kind of shudder against is the syringe feed. If it were my baby, I would rather give a bottle, only if it were absolutely necessary, than to risk aspiration or a bad head from hypoglycemia. Maybe that's the NICU nurse in me talking, I don't know ..... but that's the only part of the birth plan that made me think twice. Everything else sounds great and I wish you the best!

[kythe, LPN]

I think everything you're asking for sounds totally reasonable.

The only thing that I kind of shudder against is the syringe feed. If it were my baby, I would rather give a bottle, only if it were absolutely necessary, than to risk aspiration or a bad head from hypoglycemia. Maybe that's the NICU nurse in me talking, I don't know ..... but that's the only part of the birth plan that made me think twice. Everything else sounds great and I wish you the best!

Really? La Leche League recommends syringe feeding if nursing is not possible. Bottle feeding leads to nipple confusion since the baby sucks differently from the bottle vs breast. I haven't heard that normal full-term newborns have an aspiration risk. I syringe-fed my son at birth when he had trouble latching on, and that was at the advice of a Lactation Consultant.

I've noticed several posters here referring to giving something else for hypoglycemia, but I'm not sure why. Breastmilk is the best source of everything a baby needs, including sugar. As long as the mother is capable of producing milk, there shouldn't be a need for any foreign substances.

[MalgaBSN]

Really? La Leche League recommends syringe feeding if nursing is not possible. Bottle feeding leads to nipple confusion since the baby sucks differently from the bottle vs breast. I haven't heard that normal full-term newborns have an aspiration risk. I syringe-fed my son at birth when he had trouble latching on, and that was at the advice of a Lactation Consultant.

I've noticed several posters here referring to giving something else for hypoglycemia, but I'm not sure why. Breastmilk is the best source of everything a baby needs, including sugar. As long as the mother is capable of producing milk, there shouldn't be a need for any foreign substances.

Exactly.

[justme1972]

If it were me, I would want my baby assessed before anything else. Those first few moments are so critical after birth.

As a mother, I fully appreciate the need for you wanting to bond (b/c I never had that opportunity myself due to the critical nature of my twins), but your baby's health should come first.

The bottle issue, I also understand, as I wanted to breast feed my babies and never got a chance b/c my milk dried up from the stress before they could be breast fed...however, just be sure you don't refuse the obvious. I personally believe nipple confusion is 100% myth as I have known way too many mothers that have done both (bottle/nipple) successfully...babies will eat from whatever source if they are hungry enough.

I too, would shudder at the thought of syringe feeding...a 1% risk of aspiration is too much of a risk for me.

[justme1972]

I had read, probably by someone here, that even if I don't have STD's the erythromycin ointment was still a good idea due to just the general level of germs in the hospital. Does anyone have any information about this? If I was having a home birth I would refuse it, but I'm worried about hospital germs. Also, I don't want to put anyone in a bad position as far as disobeying hospital policy.

Sorry for the double post.

As a wife who just found out a few months ago that my husband was having an affair (and I am a very, very sharp individual, I suspected nothing, and would have staked my life on his fidelity), there is no way I would refuse the ointment b/c it's just a simple thing to make sure their eyesight is intact...bottom line, you never, ever know what another person is doing 24 hours a day.

The vitamin K is the same issue...1% chance of bleeding is 1% too great for me.

[Spidey's mom, ADN, BSN, RN]

Sorry for the double post.

As a wife who just found out a few months ago that my husband was having an affair (and I am a very, very sharp individual, I suspected nothing, and would have staked my life on his fidelity), there is no way I would refuse the ointment b/c it's just a simple thing to make sure their eyesight is intact...bottom line, you never, ever know what another person is doing 24 hours a day.

The vitamin K is the same issue...1% chance of bleeding is 1% too great for me.

I agree - the ointment is no big deal. Neither is the Vit K.

(I'm sorry about your husband - truly).

steph

[eden]

Your plan does not sound unreasonable to me. We do all of this rountinly here including the thorough assessment on mom's chest, if so desired. The only thing we don't like to do is not cutting the cord until it stops pulsating. The reason is there are studies that showed delayed clamping causes an increase in jaundice.

[RainDreamer, BSN, RN]

Why does LLL recommend syringe feeding over bottle feeding? If you give a bottle of EBM or formula for hypoglycemia, are they really going to get nipple confused? I'm just curious as to why the syringe feeds are recommended.

And I have seen babies in the unit for aspiration due to syringe feeds.

[Elvish, BSN, DNP, RN, NP]

I have not ever seen a true case of nipple confusion. There is as much of a difference between a breast & a syringe as there is between a breast & a bottle. So many patients breast and bottle feed and it works fine.

That said, I do encourage breastfeeding before anything else, and have seen many many times over that having baby nurse for a good 20-30min will bring a blood sugar up in a normal newborn.

There are times, however, if blood sugar is *really* low (

[CEG]

your plan does not sound unreasonable to me. we do all of this rountinly here including the thorough assessment on mom's chest, if so desired. the only thing we don't like to do is not cutting the cord until it stops pulsating. the reason is there are studies that showed delayed clamping causes an increase in jaundice.

actually this is not true. there are many benefits to delayed cord clamping. there are few benefits to early cord clamping. active management of the third stage is the only evidence for early cord clamping and studies have not isolated whether the early cord clamping is of any benefit.

from jama- march 2007:

late vs early clamping of the umbilical cord in full-term neonates: systematic review and meta-analysis of controlled trials.

hutton ek, hassan es.

"late cord clamping was delayed for at least 2 minutes (n = 1001 newborns), while early clamping in most trials (n = 911 newborns) was performed immediately after birth. benefits over ages 2 to 6 months associated with late cord clamping include improved hematologic status measured as hematocrit (weighted mean difference [wmd], 3.70%; 95% confidence interval [ci], 2.00%-5.40%); iron status as measured by ferritin concentration (wmd, 17.89; 95% ci, 16.58-19.21) and stored iron (wmd, 19.90; 95% ci, 7.67-32.13); and a clinically important reduction in the risk of anemia (relative risk (rr), 0.53; 95% ci, 0.40-0.70). neonates with late clamping were at increased risk of experiencing asymptomatic polycythemia (7 studies [403 neonates]: rr, 3.82; 95% ci, 1.11-13.21; 2 high-quality studies only [281 infants]: rr, 3.91; 95% ci, 1.00-15.36). conclusions: delaying clamping of the umbilical cord in full-term neonates for a minimum of 2 minutes following birth is beneficial to the newborn, extending into infancy. although there was an increase in polycythemia among infants in whom cord clamping was delayed, this condition appeared to be benign"

also:

midwifery womens health. 2001 nov-dec;46(6):402-14. links

current best evidence: a review of the literature on umbilical cord clamping.

mercer js.

nurse-midwifery program, university of rhode island college of nursing, kingston 02881-2021, usa.

"immediate clamping of the umbilical cord can reduce the red blood cells an infant receives at birth by more than 50%, resulting in potential short-term and long-term neonatal problems. cord clamping studies from 1980 to 2001 were reviewed. five hundred thirty-one term infants in the nine identified randomized and nonrandomized studies experienced late clamping, ranging from 3 minutes to cessation of pulsations, without symptoms of polycythemia or significant hyperbilirubinemia. higher red blood cell flow to vital organs in the first week was noted, and term infants had less anemia at 2 months and increased duration of early breastfeeding. in seven randomized trials of preterm infants, benefits associated with delayed clamping in these infants included higher hematocrit and hemoglobin levels, blood pressure, and blood volume, with better cardiopulmonary adaptation and fewer days of oxygen and ventilation and fewer transfusions needed. for both term and preterm infants, few, if any, risks were associated with delayed cord clamping. longitudinal studies of infants with immediate and delayed cord clamping are needed."