What are the different types of breech birth presentations?

• Complete breech: Here, the buttocks are pointing downward with the legs folded at the knees and feet near the buttocks.
• Frank breech: In this position, the baby’s buttocks are aimed at the birth canal with its legs sticking straight up in front of his or her body and the feet near the head.
• Footling breech: In this position, one or both of the baby’s feet point downward and will deliver before the rest of the body.

What causes a breech presentation?

The causes of breech presentations are not fully understood. However, the data show that breech birth is more common when:

• You have been pregnant before
• In pregnancies of multiples
• When there is a history of premature delivery
• When the uterus has too much or too little amniotic fluid
• When there is an abnormally shaped uterus or a uterus with abnormal growths, such as fibroids
• The placenta covers all or part of the opening of the uterus placenta previa

How is a breech presentation diagnosed?

A few weeks prior to the due date, the health care provider will place her hands on the mother’s lower abdomen to locate the baby’s head, back, and buttocks. If it appears that the baby might be in a breech position, they can use ultrasound or pelvic exam to confirm the position. Special x-rays can also be used to determine the baby’s position and the size of the pelvis to determine if a vaginal delivery of a breech baby can be safely attempted.

Can a breech presentation mean something is wrong?

Even though most breech babies are born healthy, there is a slightly elevated risk for certain problems. Birth defects are slightly more common in breech babies and the defect might be the reason that the baby failed to move into the right position prior to delivery.

Can a breech presentation be changed?

It is preferable to try to turn a breech baby between the 32nd and 37th weeks of pregnancy. The methods of turning a baby will vary and the success rate for each method can also vary. It is best to discuss the options with the health care provider to see which method she recommends.

Medical Techniques

External Cephalic Version (EVC) is a non-surgical technique to move the baby in the uterus. In this procedure, a medication is given to help relax the uterus. There might also be the use of an ultrasound to determine the position of the baby, the location of the placenta and the amount of amniotic fluid in the uterus.

Gentle pushing on the lower abdomen can turn the baby into the head-down position. Throughout the external version the baby’s heartbeat will be closely monitored so that if a problem develops, the health care provider will immediately stop the procedure. ECV usually is done near a delivery room so if a problem occurs, a cesarean delivery can be performed quickly. The external version has a high success rate and can be considered if you have had a previous cesarean delivery.

ECV will not be tried if:

• You are carrying more than one fetus
• There are concerns about the health of the fetus
• You have certain abnormalities of the reproductive system
• The placenta is in the wrong place
• The placenta has come away from the wall of the uterus (placental abruption)

Complications of EVC include:

• Prelabor rupture of membranes
• Changes in the fetus’s heart rate
• Placental abruption
• Preterm labor

Vaginal delivery versus cesarean for breech birth?

Most health care providers do not believe in attempting a vaginal delivery for a breech position. However, some will delay making a final decision until the woman is in labor.
The following conditions are considered necessary in order to attempt a vaginal birth:

• The baby is full-term and in the frank breech presentation
• The baby does not show signs of distress while its heart rate is closely monitored.
• The process of labor is smooth and steady with the cervix widening as the baby descends.
• The health care provider estimates that the baby is not too big or the mother’s pelvis too narrow for the baby to pass safely through the birth canal.
• Anesthesia is available and a cesarean delivery possible on short notice

What are the risks and complications of a vaginal delivery?

In a breech birth, the baby’s head is the last part of its body to emerge making it more difficult to ease it through the birth canal. Sometimes forceps are used to guide the baby’s head out of the birth canal. Another potential problem is cord prolapse.
In this situation the umbilical cord is squeezed as the baby moves toward the birth canal, thus slowing the baby’s supply of oxygen and blood. In a vaginal breech delivery, electronic fetal monitoring will be used to monitor the baby’s heartbeat throughout the course of labor. Cesarean delivery may be an option if signs develop that the baby may be in distress.

When is a cesarean delivery used with a breech presentation?

Most health care providers recommend a cesarean delivery for all babies in a breech position, especially babies that are premature. Since premature babies are small and more fragile, and because the head of a premature baby is relatively larger in proportion to its body, the baby is unlikely to stretch the cervix as much as a full-term baby. This means that there might be less room for the head to emerge.

Want to Know More?

• Creating Your Birth Plan
• Labor & Birth Terms to Know
• Cesarean Birth After Care

Compiled using information from the following sources:

• ACOG: If Your Baby is Breech
• William’s Obstetrics Twenty-Second Ed. Cunningham, F. Gary, et al, Ch. 24.
• Danforth’s Obstetrics and Gynecology Ninth Ed. Scott, James R., et al, Ch. 21.

The post Breech Births appeared first on American Pregnancy Association.

Using Local Anesthesia During Labor

Local anesthesia is injected into a specific area to provide pain relief during labor. Local anesthesia methods include:

Epidurals – medication given through a tube placed in the lower back

pudendal blocks -medication used to relieve pain in the vagina, vulva, and perineum

spinal blocks – medication given as a single shot into the fluid around the spinal cord

It is also given near the end of birth for an episiotomy, to relieve the discomfort of the perineum stretching and also after birth to repair tears and episiotomies.

When used at the end of birth or after birth, medication such as procaine (Novocain), lidocaine (Dalcaine, Dilocaine, L-Caine, Nervocaine, Xylocaine), and tetracaine (Pontocaine) are injected into the skin, muscle, or cervix for the fast, temporary relief of pain in the perineal area.

Though rare, a local anesthesia may be injected into the perineum when the baby’s head position will not allow a pudendal block to be administered.  This will ease the pain of the perineum stretching, but will not relieve the discomfort of contractions during labor.

Are there any risks when using local anesthesia to relieve discomfort in the perineum?

Studies show there are no significant risks, except for rare allergic reactions. Some believe the injection may cause swelling of the perineal tissue and increase the likelihood of tearing if an episiotomy is not done. However, Kegel exercises can significantly strengthen the perineum.

Sources:

American College of Obstetricians and Gynecologists: Medications for Pain Relief During Labor and Delivery

ACOG: Making Sense of Childbirth Pain Relief Options

The post Local Anesthesia appeared first on American Pregnancy Association.

Cesarean birth can be life-saving for the baby and/or the mother, but doctors are concerned cesarean deliveries are overused. Today, approximately 60% of all cesarean births  are for a woman’s first delivery. If you have a medical issue that could complicate labor or delivery, such as maternal high blood pressure or the baby is in a breach position (buttocks or feet first), your doctor will opt for a C-section. In emergency situations when the baby or mother is in distress delivery will be via an “emergency”  C-section. Let’s explore how to avoid a cesarean birth.

How Can I Reduce My Chances of a Cesarean Birth?

ACOG ‘s Safe Prevention of the Primary Cesarean Delivery recommends reducing cesarean deliveries by:

• Allowing prolonged latent (early) phase labor.
• Considering cervical dilation of 6 cm (instead of 4 cm) as the start of active phase labor.
• Allowing more time for labor to progress in the active phase.
• Allowing women to push for at least two hours if they have delivered before, three hours if it’s their first delivery, and even longer in some situations, for example, with an epidural.
• Using techniques to assist with vaginal delivery, which is the preferred method when possible. This may include the use of forceps, for example.
• Encouraging patients to avoid excessive weight gain during pregnancy.

Don’t panic if your delivery ends in a C-section anyway. Sometimes surgery really is the best method to protect you and your baby from complications.

• Find a health care provider and birth setting with low rates of intervention. Be sure to ask you health care provider about their philosophy on cesareans and their cesarean rate (rates vary between 10-50%¹ nationally).
• Become more educated about birth by taking childbirth classes, reading books, and asking lots of questions.
• Create a Flexible Birth Plan

Key topics to discuss with your healthcare provide include:

• How long can you stay home before going to the hospital? For example, she might recommend heading in when contractions are four or five minutes apart, at least a minute long, for at least an hour. Often, the longer you’re in the hospital before the baby is born, the higher your risk of intervention.
• Explore options for coping with pain. If you can, avoid epidural analgesia, at least in early labor. An early epidural limits your movements and your baby’s movements which can lead to the need for an intervention (IV, continuous monitoring, bladder catheter, etc.).
• Avoid continuous electric fetal monitoring during labor. Studies show that EFM can increase the chance of cesarean by up to one-third.
• Ask for recommendations on turning a breech baby, and actively attempt these if necessary.
• Avoid induction if possible.
• Arrange for continuous labor support from a professional, like a midwife or doula. (Studies show that women with continuous labor support are 26% less likely to have a cesarean).

Want to Know More?

• Reasons for a Cesarean
• Creating a Positive experience
• Cesarean Aftercare

Complied using the following sources:

• ACOG: Nation’s Ob-Gyns Take Aim at Preventing Cesareans
• Maternity Center Association. What every pregnant woman needs to know about Cesarean section. New York: MCA, April 2004.
• Facker SB. Stroup DF. Peterson HB. Continuous electronic fetal heart monitoring during labor. In Neilson JP et al., eds.
• Pregnancy and Childbirth Module of the Cochrane Database of Systematic Reviews, updated June 1996.

The post How to Avoid a Cesarean Birth appeared first on American Pregnancy Association.

This allows quick pain relief to the perineum, vulva, and vagina. A pudendal block is usually given in the second stage of labor just before delivery of the baby. It relieves pain around the vagina and rectum as the baby comes down the birth canal. It is also helpful just before an episiotomy.

Lidocaine is usually preferred for a pudendal block because it has a longer duration than chloroprocaine, which usually lasts less than one hour.

Things to know about a pudendal block

A pudendal block may involve one or more of the following risks:

• Large doses of local anesthesia may be needed to experience relief
• Local anesthesia medications enter the bloodstream and cross the placenta
• Some babies have trouble breastfeeding immediately after birth
• Risk of local anesthetic toxicity
• Risk of a hematoma (blood clot)
• Risk of infection

Want to Know More?

Birth Plan

Signs of Labor

Compiled using information from the following sources:
William’s Obstetrics Twenty-Second Ed. Cunningham, F. Gary, et al, Ch. 19.
Danforth’s Obstetrics and Gynecology Ninth Ed. Scott, James R., et al, Ch. 3.
Ransjo-Arvidson A et al. Maternal analgesia during labor disturbs newborn behavior: effects on breastfeeding, temperature, and crying. Birth 28(1):5-12.
The Physician’s Desk Reference (Oradel,NJ: Medical Economics Go., 1996).

The post Pudendal Block appeared first on American Pregnancy Association.

Episiotomy is a procedure in which a small cut is made to widen the opening of the vagina when a woman is giving birth. It may be done to avoid tearing of the skin at the opening of the vagina. It also may be done to help with delivery of the baby. It’s needed when:

• Birth is imminent and the perineum hasn’t had time to stretch slowly
• The baby’s head is too large for the vaginal opening
• The baby is in distress
• The mother needs a forceps or vacuum-assisted delivery
• The baby is in a breech presentation and there is a complication during delivery
• The mother isn’t able to control her pushing

How Is Episiotomy Performed?

If you have already had an epidural, you will probably not need any further anesthetic. If otherwise, it will be necessary to utilize a local anesthetic called a pudendal block in your perineum. The mediolateral cut is angled down, away from the vagina and the perineum, into the muscle. The midline cut is performed by cutting straight down into the perineum, between the vagina and anus.

How Can I Prevent the Need to Have an Episiotomy?

During right before or during the second stage of labor perineal massage can decrease muscular resistance and reduce the likelihood of laceration. Moreover, use of warm compresses on the perineum during pushing can reduce third-degree and fourth-degree lacerations.

• Good nutrition — healthy skin stretches more easily!
• Kegels (exercise for your pelvic floor muscles)
• A slowed second stage of labor where pushing is controlled
• Avoiding lying on your back while pushing

Can Episiotomy Be Harmful?

Episiotomies have the following potential side effects:

• Infection
• Bruising
• Swelling
• Bleeding
• Extended healing time
• Painful scarring that might require a period of abstinence from sexual intercourse
• Future problems with incontinence

What Should I Do if I Have Pain From a Perineal Tear or an Episiotomy?

As you heal from a vaginal delivery, you’ll likely experience a few weeks of swelling and pain in your perineum (the area between your vagina and anus). If you had a perineal tear or episiotomy, the pain may be more severe and the area may take longer to heal. Try these tips to relieve your discomfort:

• Apply an ice pack or cold gel pack to the perineal area for 10 to 20 minutes at a time. This is most effective in the first 24 to 72 hours after birth.
• Apply witch-hazel pads to the perineal area.
• Take ibuprofen.
• If sitting is uncomfortable, sit on a pillow. There also are special cushions that may be helpful.
• Try a sitz bath (sitting in warm, shallow water). Special basins are made for this purpose.
• When you are on the toilet, clean your genitals with warm water from a squeeze bottle.
  This also can help trigger the flow of urine. Pat dry when you’re finished.
• Try breastfeeding while lying on your side. This position may be more comfortable
  because it doesn’t put pressure on your perineum.

What if I Want to Avoid Having an Episiotomy?

Talk with your ob-gyn about episiotomy at one of your prenatal care visits. The American College of Obstetricians and Gynecologists (ACOG) recommends that episiotomy be done only when it is absolutely necessary. This might include situations when the fetus is stressed and needs to be delivered more quickly, or to prevent larger tears that may happen during delivery. Ask your ob-gyn:

• How often he or she does episiotomies
• What type is most often done
• What type of situations call for this procedure

Together you can make a decision about your particular situation.

Want to Know More? Read the Following Articles:

• Creating Your Birth Plan
• Labor & Birth Terms to Know
• Cord Blood Banking – Your Three Choices Explained

Compiled using information from the following sources:
William’s Obstetrics Twenty-Second Ed. Cunningham, F. Gary, et al, Ch. 17.
Danforth’s Obstetrics and Gynecology Ninth Ed. Scott, James R., et al, Ch. 2.
ACOG: What is an episiotomy?

The post Episiotomy: Advantages & Complications appeared first on American Pregnancy Association.

What Is a Retained Placenta?

Labor takes place in three stages:

1. The first stage of labor begins with contractions that indicate that the uterus is preparing to deliver a baby.
2. Once a woman has given birth, the second stage of labor is complete.
3. The final stage of labor takes place when the placenta is expelled from the woman’s womb. This stage usually takes place within 30 minutes of the baby’s birth.

However, if the woman has not expelled the placenta after 30 minutes of delivery, this is considered a retained placenta. If a retained placenta is not treated, the mother is susceptible to both infection and extreme blood loss, which could be life-threatening.

Two Approaches to Delivering the Placenta

If your pregnancy has moved through the labor and birth stages normally, you can choose how to handle the final stage of labor. This process is usually a part of a woman’s birth plan discussion.

There are generally two approaches used when dealing with the placenta, whether a natural approach or a managed approach.

1. A natural approach allows the woman’s body to naturally expel the placenta on its own.
2. Medical personnel assists the managed approach and usually, occurs when a shot is administered to the thigh while the baby is being born to cause the woman to expel her placenta.

Syntometrine, ergometrine, and oxytocin are the drugs used to cause a woman’s body to contract and push out the placenta. If a woman has had complications like high blood pressure or preeclampsia during her pregnancy, Syntocinon is given.

The benefit of opting for a managed final stage of labor is the reduction in bleeding immediately after the baby is born.

Three Types of Retained Placenta

1. Placenta Adherens: occurs when the contractions of the womb are not robust enough to completely expel the placenta. This results in the placenta remaining loosely attached to the wall of the uterus. This is the most common type of retained placenta.
2. Trapped Placenta: is when the placenta successfully detaches from the uterine wall but fails to be expelled from the woman’s body it is considered a trapped placenta. This usually happens as a result of the cervix closing before the placenta has been expelled. The Trapped Placenta is left inside the uterus.
3. Placenta Accreta: is when the placenta attaches to the muscular walls of the uterus instead of the lining of the uterine walls. Delivery becomes more difficult and often results in severe bleeding. Blood transfusions and even a hysterectomy may be required.

What Causes a Retained Placenta?

• Placenta Percreta occurs when the placenta grows all the way through the wall of the womb.
• Uterine Atony occurs when a woman’s contractions stop or are not strong enough to expel the placenta from her womb.
• Adherent Placenta takes place when all or part of the placenta is stuck to the wall of the woman’s womb. In rare situations, this happens because the placenta has become deeply embedded within the womb.
• Placenta Accreta takes place when the placenta has become deeply embedded in the womb, possibly due to a previous cesarean section scar.
• A Trapped Placenta results when the placenta detaches from the uterus but is not delivered. Instead, it becomes trapped behind a closed cervix or a cervix that has partially closed.

A midwife can help prevent a retained placenta on rare occasions by gently pulling on the umbilical cord. However, the cord may break if the placenta hasn’t completely separated from the uterine walls or if the cord is thin. If this happens, delivery of the placenta can take place by using a contraction to push it out.

What Are the Signs and Symptoms of a Retained Placenta?

The most obvious sign of a retained placenta is when the placenta fails to be completely removed from the womb an hour after the baby’s delivery. Other symptoms may include:

• fever
• a foul-smelling discharge from the vaginal area
• large pieces of tissue coming from the placenta
• heavy bleeding
• pain that doesn’t stop

Who Is At Risk for a Retained Placenta?

Certain factors increase the likelihood of a woman experiencing a retained placenta.
They include:

• A pregnancy that occurs in women over the age of 30
• Having a premature delivery that takes place before the 34th week of gestation
• Experiencing an extremely long first and second stage of labor
• Delivering a stillborn baby

How Is a Retained Placenta Treated?

The treatment for a retained placenta is simply the removal of the placenta from the woman’s womb. Different methods to achieve this include:

• A doctor may attempt to remove the placenta manually. However, this does carry some risk of infection.
• Medications that relax the uterus to make it contract can also be used to help expel the placenta from the womb.
• Breastfeeding can be utilized in some situations because the process causes the uterus to contract and may be enough to expel the uterus from the womb.

Sometimes, something as simple as urinating is effective enough to expel the placenta because a full bladder can sometimes get in the way of expelling the placenta from the womb.

Unfortunately, if none of these methods succeed in removing the placenta from the uterus, emergency surgery may be needed as a last resort. This is usually saved as the last approach because of the complications that surgery can create.

What Are the Potential Complications of a Retained Placenta?

The risk of heavy bleeding increases. This condition is referred to as primary postpartum hemorrhage (PPH). When the managed delivery of the placenta takes longer than 30 minutes, heavy bleeding often results.

You do have the option of requesting a general anesthetic, but you incur more risks, especially if you want to breastfeed right after the procedure. Traces of the drug will still be in your system which means the drug would also be in your breastmilk. You also need to make sure that you are alert enough to hold and support your baby for breastfeeding firmly.

However, if you do opt for the anesthetic, the placenta and any other remaining membranes will be manually removed from your womb while your legs rest in stirrups in the lithotomy position. After the procedure, you will be given antibiotics intravenously to avoid the risk of infection. Additional drugs will be given to help your womb to contract afterward.

What Is the Outlook for Women with a Retained Placenta?

A retained placenta can be treated. Timing is everything. The sooner steps are taken to rectify the problem, the better the outcome.

If you fall into a high-risk category for a retained placenta or have experienced one in the past, talk to your doctor before giving birth again. Your doctor will help you prepare for the possibility of complications.

Can I Prevent a Retained Placenta in My Next Pregnancy?

Your chances of having a retained placenta increase after you’ve already had one. But, you can still have a healthy pregnancy that doesn’t produce this type of complication.

If your child is born premature, the risks increase as well. The placenta is supposed to stay in place for 40 weeks. As a result, premature labor may lead to a retained placenta.

Doctors do everything in their power to prevent a retained placenta by taking actions that hasten complete delivery of the placenta after the birth of the baby.

These steps are as follows:

• Medication that encourages contractions in the uterus to help push out the placenta. Oxytocin (Pitocin) is an example of a medication that might be used
• Control Cord Traction (CCT) after the placenta has released
• Stabilizing your uterus by applying CCT through touch manual touch

These are all standard steps that your doctor may perform before you deliver the placenta. After childbirth, your doctor will also recommend massaging your uterus to encourage contractions that stop the bleeding and allow the uterus return to return to a small size.

In the unfortunate event that your cord snaps or your cervix closes too quickly after the oxytocin injection, consider a physiological third stage if you conceive again.

If you allow the placenta to deliver naturally, the cervix will more than likely close at the appropriate time, instead of closing too quickly. Discuss your options with your doctor.

However, keep in mind that the prolonged use of Syntocinon (artificial oxytocin) during labor has contributed to retained placentas.

This concern may develop if your labor is induced or sped up. However, although the potential for having a retained placenta with future pregnancies is prevalent, it’s not a guarantee that you won’t have a healthy pregnancy and delivery.

Want to Know More?

• Labor & Birth Term to Know
• Stages of Childbirth: Stage III

Compiled using information from the following sources:

1. Begley C. 2014. Physiology and care during the third stage of labor. In: Marshall JE, Raynor MD. eds. Myles Textbook for Midwives 16th ed. Edinburgh: Churchill Livingstone, 395-416.

2. BMagann EF, Lutgendorf MA, Keiser SD, et al. 2013. Risk factors for a prolonged third stage of labor and postpartum hemorrhage. South Med J 106(2):131-5.

3. Coviello, E. M., Grantz, K. L., Huang, C. C., Kelly, T. E., & Landy, H. J. (2015, July 28). Risk factors for retained placenta.

4. Mayo Clinic Staff. Placenta: How it works, what’s normal.

https://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-by-week/in-depth/placenta/art-20044425

5. Use of nitroglycerin to deliver a retained placenta.

https://www.cochrane.org/CD007708/PREG_use-nitroglycerin-deliver-retained-placenta

6. Weeks, A. Retained placenta after vaginal birth.

https://www.uptodate.com/contents/retained-placenta-after-vaginal-birth

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What is dilation?

Dilation is when your cervix opens (dilates) and the opening is measured in centimeters. During the first stage of labor, the cervix opens and thins out (effaces) to allow the baby to move into the birth canal. During the second stage of labor, your cervix is fully dilated, your baby is descended down the birth canal and you will be encouraged to push and deliver your baby.

What causes dilation and effacement?

When your baby starts to drop down into your pelvis this puts pressure on your cervix causing it to efface and open up in preparation for labor.

When labor begins, contractions of the descent of the baby will cause your cervix to fully dilate, allowing your baby to enter the birth canal and be delivered. Cervical dilation may happen naturally or be induced.

When do you start dilating?

The timing is different for every woman. As you get closer to your due date, your cervix may start to dilate without you knowing it.  Dilation is a gradual process that, for some can take weeks, even up to a month. Others will dilate and efface overnight.

Phases of Dilation

Here’s what’s going on as you progress through labor and how to visualize the opening of your cervix.

Early Phase: Your cervix dilates 1-3 cm with mild contractions.

• 1 cm dilated = Cheerio
• 2 cm dilated = Grape
• 3 cm dilated = Banana Slice

Active Phase: The cervix expands from 6 to 10 cm and your contractions become more regular and intense.

• 4 cm dilated = Cracker
• 5 cm dilated = Lemon Slice
• 6 cm dilated = Cookie
• 7 cm dilated = Orange Slice
• 8 cm dilated = Halved Apple
• 9 cm dilated = Donut
• 10 cm dilated = Melon

Symptoms of Dilation

Other than a physical exam by your healthcare provider, symptoms you’re beginning to dilate include:

• Losing your mucus plug: During pregnancy, the opening of the cervix is blocked by a thick plug of mucus to prevent bacteria from entering the uterus. During dilation, this plug is loosened. It may come out as one piece or as thick mucus discharge from the vagina. When this occurs, it is an indication that the cervix is beginning to dilate, although not all women will notice this mucus plug being released.
• Having a bloody show: This usually comes along with the mucus plug and may continue throughout labor, making the mucus tinged pink, red, or brown. Fresh, red blood is usually not associated with dilation, but rather with serious complications such as placental abruption (when the placenta detaches partly or entirely from the wall of the uterus) or placenta previa (when the placenta attaches low within the uterus, covering all or part of the cervix).

Sources: 

• American College of Obstetricians and Gynecologists
• Mayo Clinic

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Delayed cord clamping is the prolongation of the time between the delivery of a newborn and the clamping of the umbilical cord. Delayed umbilical cord clamping is usually performed 25 seconds to 5 minutes after giving birth. DCC allows more blood to transfer from the placenta to the baby, sometimes increasing the child’s blood volume by up to a third. The iron in the blood increases the newborn’s iron storage, which is vital for healthy brain development.

More mothers than ever before are inquiring about delayed cord clamping (DCC). This rise correlates with the World Health Organization’s recommendation that the umbilical cord should not be clamped earlier than necessary. Although there is much debate surrounding the optimal time to clamp the umbilical cord, WHO’s findings suggest that late cord clamping (one to three minutes after delivery or longer) is recommended for all births. However, most midwives advise a woman to wait until the cord quits pumping.

These findings also suggest that immediate cord clamping (ICC) isn’t recommended unless the newborn is asphyxiated and needs immediate resuscitation. However, do the benefits of DCC outweigh the associated risks?

Is Delayed Cord Clamping Common?

DCC is typically only used with preterm infants, as babies born before full-term are said to benefit greatly from the extra blood received.

The American Congress of Obstetricians and Gynecologists (ACOG) endorses DCC in preterm infants but believes there isn’t enough evidence at this time to confirm the potential benefits of delayed umbilical cord clamping in full-term babies.
The lack of research in the past has meant that for many years, standard care during the delivery of the placenta has been to clamp the umbilical cord immediately after birth (10 – 30 seconds). ICC has also been the preferred option because it allows for the immediate transfer of the baby to the neonatologist.

However, as suggested by Dr. Heike Rabe, a neonatologist specializing in related research in the UK:

“There is growing evidence from a number of studies that all infants, those born at term and those born early, benefit from receiving extra blood from the placenta at birth.”

What are the Benefits?

Some new studies have found that DCC can have a positive effect on both preterm and full-term babies. These benefits include an increase in placental transfusion, a 60% increase of RBCs and a 30% increase in neonatal blood volume.

Another advantage of DCC is the decreased risk of iron deficiency anemia. By performing DCC, an additional 40 to 50 mg/kg of iron transfers to the newborn, which reduces the risk of the baby suffering from the severe side effects associated with iron deficiency.

Common side effects of iron deficiency at birth include cognitive impairment and central nervous system problems.
Dr. Rabe believes there are other benefits:

“The extra blood at birth helps the baby to cope better with the transition from life in the womb, where everything is provided for them by the placenta and the mother, to the outside world. Their lungs get more blood so that the exchange of oxygen into the blood can take place smoothly.”

Do the Benefits Outweigh the Risks?

There are three areas of concern surrounding DCC. Infants associated with DCC are said to be at a greater risk of polycythemia, hyperbilirubinemia, and respiratory distress. However, significant research does not support the risk of these conditions on babies receiving DCC. Here is a breakdown of the concerns:

Hyperbilirubinemia
Hyperbilirubinemia occurs when bilirubin levels build up too much in the blood. Bilirubin results from a breakdown of red blood cells. In the womb, the placenta takes care of the excess bilirubin, but after birth, the baby’s liver must process the bilirubin on its own. The build-up of bilirubin often causes a yellowish tint to the eyes and skin, called jaundice. This is normal to some extent in newborns and often requires phototherapy to reduce it.

It is hypothesized that DCC babies will have a greater incidence of hyperbilirubinemia due to increased iron stores. Consequently, there are concerns they will need phototherapy for jaundice.

However, other reports have found there is no significant difference in mean serum bilirubin levels between ICC and DCC infants, meaning there is no increased risk of jaundice in DCC babies.

Polycythemia
Polycythemia occurs when there is an excess of red blood cells in circulation. This can cause issues with breathing, circulation, and may lead to hyperbilirubinemia.

Another proposed risk is that when there is excess blood flow to the newborn, the development of blood hyperviscosity (increased thickness) should be a primary concern. It has also been theorized that DCC could put a newborn at increased risk for polycythemia.

However, a Cochrane meta-analysis found that DCC infants are not exposed to an increased risk of developing polycythemia. More research is needed to determine with certainty whether DCC has a hand in newborns developing polycythemia.

Respiratory distress
Respiratory distress occurs when there is not enough of a liquid coating in the lungs (surfactant) after birth to keep the airways and tiny alveoli of the lungs open. This can cause a buildup of damaged cells near the lungs and a buildup of carbon dioxide in the blood. When this happens, babies often need to be placed on a ventilator.

It is suggested that the delayed absorption of lung fluid due to the increase in blood volume may cause transient tachypnea (rapid breathing). A Cochrane review found a similar number of DCC and ICC infants were admitted with respiratory distress, which suggests DCC babies are no more at risk than ICC infants.

If an infant is in respiratory distress during delivery, DCC can delay resuscitation efforts. However, DCC will not be performed in these circumstances, and ICC will be adopted instead.

Are There Any Maternal Risks To Delayed Cord Clamping?

Concerns about delayed cord clamping also surround the mother. It has been implied that DCC may lead to an increase in postpartum hemorrhage.
However, there is no statistical evidence proving that DCC results in an increase in blood loss. There is also no significant difference regarding blood loss greater than 500ml between early and delayed cord clamping.

Should I Add DCC To My Birth Plan?

Ultimately, as you have read, the benefits of delayed cord clamping do outweigh the hypothesized risks. There is no evidence to suggest that full-term infants cannot gain the same benefits from delayed cord clamping as preterm babies.
A final study by The JAMA Network also suggested a couple more minutes attached to the umbilical cord can translate into a small boost in neurodevelopment.

Want to Know More?

• Cord Blood Banking
• Creating Your Birth Plan

Compiled using information from the following sources:

1. ACOG, American College of Obstetricians and Gynecologists. Delayed Umbilical Cord Clamping After Birth.

https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Delayed-Umbilical-Cord-Clamping-After-Birth

2. American College of Nurse-Midwives. Delayed Umbilical Cord Clamping (Position Statement).

https://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000290/Delayed-Umbilical-Cord-Clamping-May-2014.pdf

3. AAP News and Journals Gateway, Delayed Cord Clamping in Very Preterm Infants Reduces the Incidence of Intraventricular Hemorrhage and Late-Onset Sepsis: A Randomized, Controlled Trial.

https://pediatrics.aappublications.org/content/117/4/1235.short

4. PubMed Health, U.S. National Library of Medicine. Early cord clamping versus delayed cord clamping or cord milking for preterm babies.

https://www.ncbi.nlm.nih.gov

5. Kerry M Sims MD FACOG of the University of South Carolina, 2016 Midlands Perinatal Conference. Delayed Cord Clamping

6. Advanced Healthcare Network for NPs and PAs. Delayed Cord Clamping
Do the benefits outweigh the risks?

https://nurse-practitioners-and-physician-assistants.advanceweb.com/Features/Articles/Delayed-Cord-Clamping.aspx

7. NPR.org. Delayed Umbilical Cord Clamping May Benefit Children Years Later.

https://www.npr.org/sections/health-shots/2015/05/26/409697568/delayed-umbilical-cord-clamping-may-benefit-children-years-later

8. Obs Gynae & Midwifery News. Delaying umbilical cord clamping for preterm infants results in better motor development.

8. WHO, World Health Organization. Guidelines for Recommendations
on Newborn Health.

9. The JAMA Network, 2015;169(7):631-638. Effect of Delayed Cord Clamping on Neurodevelopment at 4 Years of Age: A Randomized Clinical Trial.

https://jamanetwork.com/journals/jamapediatrics/fullarticle/2296145

10. Stanford Children’s Health: Pages on Hyperbilirubinemia, Polycythemia, and Respiratory Distress Syndrome.

https://www.stanfordchildrens.org/en/default.page

The post Delayed Cord Clamping appeared first on American Pregnancy Association.

As you prepare yourself for “labor day,” try to learn as much as possible about pain relief options so that you will be better prepared to make decisions during the labor and birth process. Understanding the different types of epidurals, how they are administered, and their benefits and risks will help you in your decision-making during the course of labor and delivery.

What Is an Epidural?

Epidural anesthesia is regional anesthesia that blocks pain in a particular region of the body. The goal of an epidural is to provide analgesia, or pain relief, rather than anesthesia, which leads to a total lack of feeling. Epidurals block the nerve impulses from the lower spinal segments. This results in decreased sensation in the lower half of the body.

Epidural medications fall into a class of drugs called local anesthetics, such as bupivacaine, chloroprocaine, or lidocaine. They are often delivered in combination with opioids or narcotics such as fentanyl and sufentanil in order to decrease the required dose of local anesthetic.

This produces pain relief with minimal effects. These medications may be used in combination with epinephrine, fentanyl, morphine, or clonidine to prolong the epidural’s effect or to stabilize the mother’s blood pressure.

How Is an Epidural Given?

Intravenous (IV) fluids will be started before active labor begins and prior to the procedure of placing the epidural. You can expect to receive 1-2 liters of IV fluids throughout labor and delivery. An anesthesiologist (specialize in administering anesthesia), an obstetrician or nurse anesthetist will administer your epidural.

You will be asked to arch your back and remain still while lying on your left side or sitting up. This position is vital for preventing problems and increasing epidural effectiveness.

1. An antiseptic solution will be used to wipe the waistline area of your mid-back to minimize the chance of infection. A small area on your back will be injected with a local anesthetic to numb it. A needle is then inserted into the numbed area surrounding the spinal cord in the lower back.
2. After that, a small tube or catheter is threaded through the needle into the epidural space. The needle is then carefully removed, leaving the catheter in place to provide medication either through periodic injections or by continuous infusion. The catheter is taped to the back to prevent it from slipping out.
3. You’ll start to notice the numbing effect about 10 to 20 minutes after the first dose of medication, though the nerves in your uterus will begin to go numb within a few minutes. You’ll receive continuous doses of medication through the catheter for the rest of your labor.

Different Types of Epidurals

There are two basic epidurals in use today. Hospitals and anesthesiologists will differ on the dosages and combinations of medication. You should ask your care providers at the hospital about their practices in this regard.

Regular Epidural

After the catheter is in place, a combination of narcotics and anesthesia is administered either by a pump or by periodic injections into the epidural space. A narcotic such as fentanyl or morphine is given to replace some of the higher doses of anesthetic, like bupivacaine, chloroprocaine, or lidocaine.

This helps reduce some of the adverse effects of the anesthesia. You will want to ask about your hospital’s policies about staying in bed and eating.

Combined Spinal-Epidural (CSE) or “Walking Epidural”

A spinal block is sometimes used in combination with an epidural during labor to provide immediate pain relief. A spinal block, like an epidural, involves an injection in the lower back. While you sit or lie on your side in bed, a small amount of medication is injected into the spinal fluid to numb the lower half of the body. It brings good relief from pain and starts working quickly, but it lasts only an hour or two and is usually given only once during labor. The epidural provides continued pain relief after the spinal block wears off.

What Are the Benefits of Epidural Anesthesia?

• An epidural provides a route for very effective pain relief that can be used throughout your labor.
• The anesthesiologist can control the effects by adjusting the type, amount, and strength of the medication. This is important because as your labor progresses and your baby moves down into your birth canal, the dose you’ve been getting might no longer be adequate, or you might suddenly have pain in a different area.
• The medication only affects a specific area, so you’ll be awake and alert during labor and birth. And because you’re pain-free, you can rest (or even sleep!) as your cervix dilates and conserve your energy for when it comes time to push.
• Unlike with systemic narcotics, only a tiny amount of medication reaches your baby.
• Once the epidural is in place, it can be used to provide anesthesia if you need a c-section or if you’re having your tubes tied after delivery.

What Are the Risks of Epidural Anesthesia?

• You have to stay still for 10 to 15 minutes while the epidural is put in, and then wait up to 20 minutes before the medication takes full effect.
• Epidurals may cause your blood pressure to suddenly drop. For this reason, your blood pressure will be routinely checked to help ensure adequate blood flow to your baby. If there is a sudden drop in blood pressure, you may need to be treated with IV fluids, medications, and oxygen.
• You may experience a severe headache caused by leakage of spinal fluid. Less than 1% of women experience this side effect. If symptoms persist, a procedure called a “blood patch”, which is an injection of your blood into the epidural space can be performed to relieve a headache.
• After your epidural is placed, you will need to alternate sides while lying in bed and have continuous monitoring for changes in fetal heart rate. Lying in one position can sometimes cause labor to slow down or stop.
• You might experience the following side effects: shivering, a ringing of the ears, backache, soreness where the needle is inserted, nausea, or difficulty urinating.
• You might find that your epidural makes pushing more difficult and additional medications or interventions may be needed, such as forceps or cesarean. Talk to your doctor when creating your birth plan about what interventions they generally use in such cases.
• For a few hours after the birth, the lower half of your body may feel numb. Numbness will require you to walk with assistance.
  In rare instances, permanent nerve damage may result in the area where the catheter was inserted.
• Though research is somewhat ambiguous, most studies suggest that some babies will have trouble “latching on” causing breastfeeding difficulties. Other studies suggest that a baby might experience respiratory depression, fetal malpositioning, and an increase in fetal heart rate variability, thus increasing the need for forceps, vacuum, cesarean deliveries, and episiotomies.

How Long Does an Epidural Last?

Once the catheter is in place, the anaesthetist can set up an epidural pump. The pump feeds the epidural solution into the catheter continuously, providing pain relief for as long as needed.

The type, amount and strength of the anaesthetic can be adjusted, as necessary. You might also be given the option of having control of the medication pump. This is called patient controlled analgesia. The amount of painkiller is still regulated, so you can’t accidentally overdose.

You can have the dose lowered for second stage pushing, but it takes some time for the pain relief and numbness to wear off, so if this is important to you, discuss it with your care provider early on.

Common Questions About Epidurals

Does the Placement of Epidural Anesthesia Hurt?

The answer depends on who you ask. Some women describe an epidural placement as creating a bit of discomfort in the area where the back was numbed, and a feeling of pressure as the small tube or catheter was placed.

When Will My Epidural Be Placed?

Typically epidurals are placed when the cervix is dilated to 4-5 centimeters and you are in true active labor.

Can an Epidural Slow Labor or Lead to a Cesarean Delivery (C-Section)?

There is no credible evidence that it does either. When a woman needs a C-section, other factors usually are at play, including the size or position of the baby or slow progression of labor due to other issues. With an epidural, you might be able to feel contractions — they just won’t hurt — and you’ll be able to push effectively. There is some evidence that epidurals can speed the first stage of labor by allowing the mother to relax.

How Can an Epidural Affect My Baby?

As previously stated, research on the effects of epidurals on newborns is somewhat ambiguous, and many factors can affect the health of a newborn. How much of an effect these medications will have is difficult to predetermine and can vary based on dosage, the length of labor, and the characteristics of each individual baby.

Since dosages and medications can vary, concrete information from research is currently unavailable. One possible side effect of an epidural with some babies is a struggle with “latching on” in breastfeeding. Another is that while in-utero, a baby might also become lethargic and have trouble getting into position for delivery.

These medications have also been known to cause respiratory depression and decreased fetal heart rate in newborns. Though the medication might not harm these babies, they may have subtle effects on the newborn.

How Will I Feel After the Placement of an Epidural?

The nerves of the uterus should begin to numb within a few minutes after the initial dose. You will probably feel the entire numbing effect after 10-20 minutes. As the anesthetic dose begins to wear off, more doses will be given–usually every one to two hours.

Depending on the type of epidural and dosage administered, you can be confined to your bed and not allowed to get up and move around.

If labor continues for more than a few hours you will probably need urinary catheterization, because your abdomen will be numb, making urinating difficult. After your baby is born, the catheter is removed and the effects of the anesthesia will usually disappear within one or two hours.

Some women report experiencing an uncomfortable burning sensation around the birth canal as the medication wears off.

Will I Be Able to Push?

You might not be able to tell that you are having a contraction because of your epidural anesthesia. If you can not feel your contractions, then pushing may be difficult to control. For this reason, your baby might need additional help coming down the birth canal. This is usually done by the use of forceps.

Does an Epidural Always Work?

For the most part, epidurals are effective in relieving pain during labor. Some women complain of being able to feel pain, or they feel that the drug worked better on one side of the body.

When Can an Epidural NOT Be Used?

An epidural may not be an option to relieve pain during labor if any of the following apply:

• You use blood thinners
• Have low platelet counts
• Are hemorrhaging or in shock
• Have an infection on or in your back
• Have a blood infection
• If you are not at least 4 cm dilated
• Epidural space cannot be located by the physician
• If labor is moving too fast and there is not enough time to administer the d

Questions to Ask Your Healthcare Providers Now and at the Time of Delivery in the Hospital:

• What combination and dosage of drugs will be used?
• How could the medications affect my baby?
• Will I be able to get up and walk around?
• What liquids and solid foods will I be able to consume?

Want to Know More? Read the Following Articles:

• Nitrous Oxide During Labor
• Stages of Labor: Stage 1
• Inducing Labor
• Cord Blood Banking: Your Three Choices Explained

Compiled using information from the following sources:

1. American Academy of Family Physicians

https://www.aafp.org

2. William’s Obstetrics Twenty-Second Ed. Cunningham, F. Gary, et al, Ch. 19.

3. Mayo Clinic Guide To A Healthy Pregnancy Harms Roger W., M.D., et al, Part 2.

The post Epidural – Everything You Should Know About It appeared first on American Pregnancy Association.

Types of Natural Childbirth Techniques

Lamaze

Dr. Ferdinand Lamaze developed this method beginning in Russia using “Psychoprofilaxis.”  This method utilizes distraction during contractions to decrease the perception of pain and reduce discomfort. In Lamaze class, you and your partner will learn controlled deep breathing, massage, concentration and how to maintain control during labor.
For more information and to find a class near you: www.lamaze.org

Water Delivery

Giving birth in a warm tub of water can help a woman relax. The buoyancy also helps alleviate discomfort and pressure. Some believe that water helps the baby enter the world with less light, sound, and dramatic change.

Water delivery is not recommended for women with high-risk pregnancies and in every case, preparation should be made for delivery to occur out of the water if complications arise.

The Alexander Technique

In learning how to deal with his own vocal problem, F. M. Alexander (1869-1955) developed a technique for sitting, standing and moving with safety, efficiency, and ease. Anyone, including a pregnant woman, can learn to release muscular tension to increase breathing capacity and restore the body’s original poise and proper posture.

As your body begins to experience lower back pain, balance and digestive problems, and shortness of breath, simple modifications in your movement can help alleviate these symptoms. When the time for delivery arrives, you will be able to breathe better, calm yourself, focus during the birth, help open the cervix during dilation and prepare for effective pushing as the baby comes.
For more information: www.alexandertechnique.com

The Bradley Method

Developed by Dr. Robert Bradley in the late 1940s, this method helps women deliver naturally, with few or no drugs. Courses emphasize excellent nutrition and exercise, relaxation techniques to manage pain, and the effective involvement of the husband or partner as a coach.

You will also learn how to tune in to your body and the positions which will ease labor pains and prepare you for the stages of labor. You will learn how to avoid having a cesarean section, how to breastfeed, and how to discuss your birthing plans with your doctor.
For more information:  American Academy of Husband-Coached Childbirth 1-800-423-2397

Hypnosis

In the 1940s, Dr. Grantly Dick-Read pioneered the use of hypnosis during labor to bring a woman into a state of total relaxation where her body’s muscles can function according to the way they are designed. Women using this method report feeling lost in a daydream, relaxed, calm, aware and in control.
For more information: www.hypnobirthing.com

Want to Know More?

• Creating Your Birth Plan
• Stages of Labor
• Cord Blood Banking – Your Three Choices Explained

The post Natural Childbirth Techniques appeared first on American Pregnancy Association.