Is this birth plan reasonable

OzMW · Mar 18, 2008

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.

Where I work ALL of this is STANDARD practice for most women unless the baby is flat, aprt fromt he cord stuff. There is no evidence that you can't leave a cord puslating even with active third stage. FIGO/ICM promote that. :redbeathe

OzMW · Mar 18, 2008

Right that proves my point about neonatal jaundice, CEG. There is increased incidences of polycythemia (an increase primarily of RBC) in those newborns with delayed cord clamping. Since most neonatal jaundice is physiologic in nature their systems can't handle the increased breakdown of those extra RBC ang get jaundiced.
.

Eden how did the human race survive before birth attendants started clamping cords because they were concerned that the babe would be polycythemic and jaundiced? We now have a situation where infants are low in iron later in the first year of life solely due to the concern about this rubbish at birth. We have an human intervention which was based on theory, introduced what maybe 30 years ago? And now we have to "prove" why we shouldn't be doing it! The FIGO and the ICM put out a statement on active management last year or the year before; stating that there is NO evidence that early cord clamping is required even with active management; will get back later with the link.:redpinkhe

beckinben, CNM · Mar 19, 2008

Eden how did the human race survive before birth attendants started clamping cords because they were concerned that the babe would be polycythemic and jaundiced? We now have a situation where infants are low in iron later in the first year of life solely due to the concern about this rubbish at birth. We have an human intervention which was based on theory, introduced what maybe 30 years ago? And now we have to "prove" why we shouldn't be doing it! The FIGO and the ICM put out a statement on active management last year or the year before; stating that there is NO evidence that early cord clamping is required even with active management; will get back later with the link.:redpinkhe

I have people request delayed cord clamping quite often. I absolutely support it, but I have had to do quite a bit of education with others about the latest recommendations. So I have these all bookmarked. :)

FIGO/ICM recommendations on active management: http://www.pphprevention.org/files/ICM_FIGO_Joint_Statement.pdf

- Note that cord clamping is to be done "once pulsation stops" in healthy newborns

WHO also recommends delayed cord clamping to reduce infant anemia:

http://www.who.int/making_pregnancy_safer/publications/WHORecommendationsforPPHaemorrhage.pdf

Summary of randomized trial published in Pediatrics:

http://www.medscape.com/viewarticle/530352

Abstract of JAMA review supporting delayed cord clamping:

http://jama.ama-assn.org/cgi/content/abstract/297/11/1241

OzMW · Mar 19, 2008

I have people request delayed cord clamping quite often. I absolutely support it, but I have had to do quite a bit of education with others about the latest recommendations. So I have these all bookmarked. :)
FIGO/ICM recommendations on active management: http://www.pphprevention.org/files/ICM_FIGO_Joint_Statement.pdf
- Note that cord clamping is to be done "once pulsation stops" in healthy newborns
WHO also recommends delayed cord clamping to reduce infant anemia:
http://www.who.int/making_pregnancy_safer/publications/WHORecommendationsforPPHaemorrhage.pdf
Summary of randomized trial published in Pediatrics:
http://www.medscape.com/viewarticle/530352
Abstract of JAMA review supporting delayed cord clamping:
http://jama.ama-assn.org/cgi/content/abstract/297/11/1241

:redbeathe:redbeathe

Thanks you saved me some work:up: Yep I agree with the work it takes to get this through to people. It is such an entrenched practice supported by an obstetric myth! I sometimes reckon clamping the cord has become part of the mechanism of labour!!

Just to add we notice a big difference in those babes who have delayed cord clamping. They are lovely and pink, acrocyanosis is not seen. They often wee a huge amount soon after birth (adequately perfused kidneys?). Judith Mercer touches on some of this in her stuff and the theory is that actually there would be less jaundice and hypoglycemia in these kids coz there organs are perfused as they should be! Its fascinating.

CEG · Mar 19, 2008

CEG, one of the sites I based it on is http://pedbase.org/j/jaundice-neonatal/
http://findarticles.com/p/articles/mi_gGENH/is_all/ai_2699003534.
That's all I have time for now but I will try and look up more. I know what you mean by feeling like you are hijacking a thread:p

Thanks for the links. I just wish I could find an actual quality study. I looked in one of my texts (Maternal, Fetal, and Neonatal Physiology. Blackburn, Susan, 2007) It says "no disadvantage was found for term infants placed in the mother's abdomen with delay of clamping until cessation of pulsations...late cord clamping is associated with increased initial blood volume, which may be important for early transition...late clamping or clamping after cessation of pulsations was associated with a transient polycythemia, peaking at up to 12 hours after birth, with a return to normal ranges by 24 to 36 hours. No adverse affects of this polycythemia were noted." (bolding mine) (p 247) so it seems to me that like many obstetrics policies, this one is not as evidence-based as we would like.

OzMW · Mar 19, 2008

Interesting paper on a new theory of newborn transition, including the importance of an adequate transfuion of blood from the placenta.

J Perinat Neonat Nurs 2002;15(4):56-75

Neonatal Transitional Physiology:

A New Paradigm

Early clamping of the umbilical cord at birth, a practice developed without adequate evidence,

causes neonatal blood volume to vary 25% to 40%. Such a massive change occurs at no other

time in one's life without serious consequences, even death. Early cord clamping may impede

a successful transition and contribute to hypovolemic and hypoxic damage in vulnerable newborns.

The authors present a model for neonatal transition based on and driven by adequate blood

volume rather than by respiratory effort to demonstrate how neonatal transition most likely occurs

at a normal physiologic birth. Key words: capillary erection, cardiopulmonary adaptation,

the first breath, hypovolemia, neonatal blood volume, neonatal transition, nuchal cord, placental

transfusion, polycythemia, postpartum placental respiration, umbilical cord clamping

Judith S. Mercer, CNM, DNSc, FACNM

Rebecca L. Skovgaard, CNM, MS

OzMW · Mar 19, 2008

Thanks for the links. I just wish I could find an actual quality study. I looked in one of my texts (Maternal, Fetal, and Neonatal Physiology. Blackburn, Susan, 2007) It says "no disadvantage was found for term infants placed in the mother's abdomen with delay of clamping until cessation of pulsations...late cord clamping is associated with increased initial blood volume, which may be important for early transition...late clamping or clamping after cessation of pulsations was associated with a transient polycythemia, peaking at up to 12 hours after birth, with a return to normal ranges by 24 to 36 hours. No adverse affects of this polycythemia were noted." (bolding mine) (p 247) so it seems to me that like many obstetrics policies, this one is not as evidence-based as we would like.

CEG the JAMA systematic review should do the trick for you as quoted in a post above. There have been multiple RCTs done on the subject. This paper also summarises the studies done and there results... Polycythemia is transient and not an issue in most newborns. Nor is the supposed increased jaundice.

BMJ 2006;333;954-958

Patrick F van Rheenen and Bernard J Brabin

A practical approach to timing cord clamping in resource poor settings.

CEG · Mar 20, 2008

CEG the JAMA systematic review should do the trick for you as quoted in a post above. There have been multiple RCTs done on the subject. This paper also summarises the studies done and there results... Polycythemia is transient and not an issue in most newborns. Nor is the supposed increased jaundice.
BMJ
2006;333;954-958
Patrick F van Rheenen and Bernard J Brabin
A practical approach to timing cord clamping in resource poor settings.
Thanks. OzMw. I am firmly on the late clamping side! I was hoping to get some info from the "other side" as it's a very prevalent belief here that late cord clamping causes problems. Thanks for the additional info and all the informative posts.