hospital VBAC protocols

[The Morrigan]

This is from RWH Melbourne. Everything covered by studies below is marked **

http://www.rwh.org.au/rwhcpg/maternity.cfm?doc_id=1824

VBAC - Vaginal Birth after Caesarean: Intrapartum Management
On admission
Ongoing management
Note
On admission
**Registrar to be informed on admission to *******y Suite of all women who have a uterine scar. The registrar must make an appropriate management plan.
Anaesthetist and theatre to be notified of any patient for planned VBAC in *******y Suites and in labour.
**IV access with 16G cannula from onset of labour.
Blood to be taken for
Group and Save
Hb


Ongoing management
**ARM to be performed once the cervix is
3cm dilated, &
effaced, &
applied to the presenting part
**Continuous Electronic Fetal Monitoring throughout the labour
**Aim to ******* within 12 hours of onset of active labour
First Stage:
**Vaginal Examination by RMO / Registrar every 4 hrs until 7cm dilated, and 2-hourly thereafter. RMO to notify Registrar of findings at each assessment.
**Progress: anticipate 1 cm dilatation / hour (after achieving 3cm). Discuss progress with obstetric consultant if less.
**Augmentation: not contraindicated, but use MUST be discussed with the consultant prior to commencement of a Syntocinon infusion.
**Epidural may be used as indicated.
Second Stage:
Registrar to be notified when patient assessed / considered to be fully dilated.
Length should not exceed 2 hours: 1 hour to allow for Passive descent, but no more than 1 hour of Active pushing (or 30 minutes if the woman has had a prior vaginal *******y).
The option of any mid-cavity assisted vaginal *******y MUST be discussed with the consultant
No midcavity assisted *******y to be performed without the consultant being present, and then to be performed in the operating theatre.
Third Stage:
**Active Management
Digital examination of the scar is not required

This is the VBAC protocol of Box Hill hospital.

" Vaginal Birth after Caesarean Section

Purpose:
To describe the care required during the vaginal birth of a baby, to a woman who has previously given birth by Caesarean section.

Background:
The best available date on the relative safety of a planned vaginal birth after Caesarean come from observational prospective cohort studies. In these studes, in which the proportion of women who undertook a planned vaginal birth after previous Caesarean varied from 20 to 80%, successful vaginal births occurred in from 67 to 84%, averaging about 80% of women who made the attempt (A guide to effective care in pregnancy and childbirth, Enkin et al, 2000)

Guidelines/Principles:
A planned vaginal birth after a previous Caesarean section should be offered for women who first Caesarean was by lower segment transverse incision and who have no other indication for Caesarean section in the present pregnancy. Scare dehiscence may occur in about 0.5% of cases (1 in 200).

The likelihood of vaginal birth is not significantly altered by the indication for the first Caesarean section, including CPD and failure to pregress, nor by a history of more than one previous Caesarean section. The choice of the woman plays an important role in the decision and her informed choice should be a major deciding factor.

A history of classical, low vertical or unknown incision or hysterotomy carries with it an increased risk of uterine rupture and in most cases in a contraindications to trial of labour.

Oxytocin induction or stimulation and epidural analgesia, may be used for the usual indications. Oxytocin should be discontinued if response to uterine stimulation does not occur properly.

The care of a woman in labour after a previous lower segment Caesarean section should be little different from that of any woman in labour, however careful monitoring of the condition of the woman and fetus is required, as for all pregnancies. There should be increased vigilance of observations in the hour after *******y of the placenta. Internal palpatation of the lower segment should only be performed on the woman if there are signs of abnormal persistent bleeding postpartum.

Procedure:
Antenatal Assessment for VBAC:
Obtain the woman's previous Caesarean documentation for review.
If at another hospital, organise the information to e faxed or mailed to _____.

Document all discussion about associated risks in the woman's history.

The decision for a planned vaginal birth after previous caesarean section should be made in consultation with the woman and the Senior Registrar/Consultant.

In cases where labour commences spontaneously:
An intravenous bung is inserted to allow immediate access in the event of an emergency.

Blood is taken and sent for group and saving of serum and FBE. Cross-match 2 units of blood.

Clear fluids in labour.

Epidural analgesia may be used for usual indications. (refer to Epidural clinical guidelines)

Cessation of uterine contractions and/or foetal heart rate abnormalities and/or vaginal bleeding are ominous signs and should be notified immediately, to the RMO/Registrar and Consultant on-call.

If mid-cavity instrumental birth is required, the Consultant on-call must be notified.

In cases where labour is induced:
Cervical ripening with porstaglandins is probably safe in selected cases but the numbers studied are small. The use of prostoglandins with a scarred uterus is contrary to the manufacturer's recommendations.

If cervix favourable an ARM may be performed inaccordance with the protocol (Refer to ARM protocol).

Syntocinon induction or stimulation may be used with caution for the usual indications. (refer to "Syntocinon Infusion" Clinical Practice Guidelines) and should be discussed with the consultant on-call prior to use."

[The Morrigan]

I've just looked up the Quality of Care annual report and they have the 2003 data.

34% of women who had a previous c-sec chose VBAC - this means that the others chose repeat elective c-sec.
Of the women who chose VBAC, "between 60% and 65%" achieved it. That's a direct quote from the report.

Pretty crap. I actually rang the hospy trying to ask them and you'd think I was asking for something no one has ever heard of LOL. I had to explain what VBAC was to about 5 different people LOL.

[The Morrigan]

Registrar to be informed on admission to ******** Suite of all women who have a uterine scar. The registrar must make an appropriate management plan. How about the woman and her team tell the registrar the plan and he/she sticks to it unless otherwise necessary?
Anaesthetist and theatre to be notified of any patient for planned VBAC in ******** Suites and in labour.
IV access with 16G cannula from onset of labour. How about the woman continues to eat and drink so this is unnecessary? How long would it really take them to stick an IV in your arm in an emergency? And how much will the pain of it being inserted and the the difficulty of using that hand impact on the woman's innate ability to birth her baby?
Blood to be taken for
Group and Save
Hb


Ongoing management
ARM to be performed once the cervix is
3cm dilated, &
effaced, &
applied to the presenting part Rightio so labour will potentially speed up with the woman lying on her back (see below!) and the baby will get jammed into her pelvis as well as potentially stuck with mum's pelvis collapsed around it.
Continuous Electronic Fetal Monitoring throughout the labour Despite the evidence that it doesn't improve outcomes but does lead to caesarean? Isn't this a VBAC plan?
Aim to ******* within 12 hours of onset of active labour Why? Will she explode or turn into a pumpkin after this arbitrary time limit has passed?
First Stage:
Vaginal Examination by RMO / Registrar every 4 hrs until 7cm dilated, and 2-hourly thereafter. RMO to notify Registrar of findings at each assessment. And yet the woman stuck on her back with the drip and the monitor is supposed to be progressing. Now she has strangers sticking their hands ni her vagina and rating her body's capability on their scale that has no basis in reality. They are also exposing her to the high risk of infection in hospitals by this unsanitary and painful practice.
Progress: anticipate 1 cm dilatation / hour (after achieving 3cm). Discuss progress with obstetric consultant if less. Not the damn Friedman Curve again. That was discredited with the flat earth philosophy.
Augmentation: not contraindicated, but use MUST be discussed with the consultant prior to commencement of a Syntocinon infusion. Actually, use of Syntocinon is specifically warned against by the manufacturers of the drug as being likely to cause rupture in women with OR WITHOUT previous surgery.
Epidural may be used as indicated. Despite it too being implicated as a contributing factor to caesareans? How about the woman is allowed to move freely, adopt natural positions, labour in water, receive massage, acupressure or whatever works for her?Second Stage:
Registrar to be notified when patient assessed / considered to be fully dilated.
Length should not exceed 2 hours: 1 hour to allow for Passive descent, but no more than 1 hour of Active pushing (or 30 minutes if the woman has had a prior vaginal ********). So if the baby is fine, you still have a time limit. And how is this woman strapped to the bed without food or drink supposed to push a baby out anyway?
The option of any mid-cavity assisted vaginal ******** MUST be discussed with the consultant How about you discuss it with the woman and her team? And let her labour upright unencumbered by wires and machines.No midcavity assisted ******** to be performed without the consultant being present, and then to be performed in the operating theatre.
Third Stage:
Active Management
Digital examination of the scar is not required Should we be grateful?

[The Morrigan]

Here's another great article about how EFM increases the likelihood of surgery.

Here's a quote.

http://www.gentlebirth.org/archives/vbacjjg.html

Most hospitals require you to have an IV and an external or internal fetal monitor. These inhibit mobility, and make you feel like there's something wrong just by their being there. Obstetricians believe that these monitors provide a more accurate record of the baby's heart rate, thus guaranteeing safer outcomes by providing the opportunity for quicker intervention. The monitors do provide very detailed information, but machines can and do malfunction, showing distress where there is none. A. Prentice and T. Lind surveyed monitoring trials and reported their conclusions in the journal Lancet in 1987. They found that "many mothers will have operative *******ies for "distressed" babies who show no such distress at birth" (Korte and Scaer 111). These researchers also noted that Van den Berg et al. reported that 71-95% of babies diagnosed as distressed during labor show no distress at birth. In other words, the monitor provides a "false positive" up to 95% of the time, and ! ! mothers undergo all the risks of surgery for nothing (111).

In a groundbreaking study done by Dr. Albert Haverkamp to assess the worth of external fetal monitoring, the results of a study group of 483 mothers showed that among those who had an external fetal monitor, the cesarean section rate was 2 1/2 times as high as it was in the group which had auscultation. However, there was no corresponding increase in the rate of problems for the monitored babies (Jones 15-16). These results surprised Haverkamp. Several other studies have verified this outcome. The EFM does not make your baby safer; it simply increases your risk of having surgery, which in turn, greatly increases your risk of injury or death, as described above. Another EFM study even found that the monitor did not improve neurological health outcomes for premature babies (Korte and Scaer 111), who certainly fit the definition of high risk, which is what the monitor was designed for originally!

[The Morrigan]

And excellent info on how epidurals increase the risk of caesarean.

Read the rest of the article. It's very thorough and well evidenced.

http://www.healing-arts.org/mehl-mad...l.htm#cesarian

Overall complications rates for epidural anesthesia
A general estimate of the overall complication rate of epidural anesthesia is 23%.2

1. Effects of epidurals on cesarean rate:

When the dose is too large or when it sinks down into the sacral ("tailbone") region of the body, the perineum and the vagina are anesthetized. Anesthetic is intentionally injected into this area late in labor to deaden all sensation. When it "accidentally" happens earlier in labor, the muscles of the pelvic floor are prematurely relaxed, thereby interfering with the normal flexion and rotation of the baby's head as it passes through the birth canal. This interference can lead to abnormal presentations which are more dangerous for the baby or to what is called "failure to descend," an indication for Cesarean birth.

Thorp, et al3 studied 711 consecutive nulliparous women at term, with cephalic fetal presentations and spontaneous onset of labor. They compared 447 patients who received epidural analgesia in labor with 264 patients who received either narcotics or no analgesia.

The incidence of cesarean section for dystocia was significantly greater (p < 0.005) in the epidural group (10.3%) than in the nonepidural group (3.8%). There remained a significantly increased incidence (p < 0.005) of cesarean section for dystocia in the epidural group after selection bias was corrected and the following confounding variables were controlled by multivariate analysis: maternal age, race, gestational age, cervical dilatation on admission, use of oxytocin, duration of oxytocin use, maximum infusion rate of oxytocin, duration of labor, presence of meconium, and birth weight.

The incidence of cesarean section for fetal distress was similar (p > 0.20) in both groups. There were no clinically significant differences in frequency of low Apgar scores at 5 minutes or cord arterial and venous blood gas parameters between the two groups. They concluded that epidural analgesia in labor increases the incidence of cesarean section for dystocia in nulliparous women.

Frequently the epidural is so effective that it eliminates uterine contractions. The nerves which tell the uterus to contract are all anesthetized. The uterus becomes quiet and must be driven artifically with the hormone oxytocin (Pitocin or Syntocinon).

As the cervix becomes fully dilated and the head descends, the woman (in a normal birth) feels pain and pressure in the lower pelvis and rectum. The last injection of anesthetic during the process of epidural anesthesia occurs after the head has rotated and come down onto the perineum. Higher concentrations of anesthetic are used to assure perineal relaxation. Sometimes the mother is sat upright or at least at a 45 degree angle to be certain that the anesthetic will descend to the sacral nerve roots. When the sacral nerve roots are blocked, the woman looses the urge to push.

After controlling for potentially confounding variables with multiple logistic regression analysis, Adashek, et al4 found that epidural anesthesia was an independent risk factor for cesarean birth among women over age 35 (R = 0.195, p < 0.001).

[The Morrigan]

Here is a few studies demonstrating the Friedman Curve to be pointless and actually dangerous since it means women are forced into using Syntocinon, a drug specifically contraindicated in women with previous uterine surgery.

Am J Obstet Gynecol. 2002 Oct;187(4):824-8.
Reassessing the labour curve in nulliparous women.

Zhang J, Troendle JF, Yancey MK.

Division of Epidemiology, Statistics, and Prevention Research, National Institute of Child Health and Human Development/NIH, Building 6100, Room 7B03, Bethesda, MD 20892, USA. jim_zhang@nih.gov

OBJECTIVES: Our purpose was to examine the pattern of labor progression in nulliparous parturients in contemporary obstetric practice. STUDY DESIGN: We extracted detailed labor data from 1329 nulliparous parturients with a term, singleton, vertex fetus of normal birth weight after spontaneous onset of labor. Cesarean *******ies were excluded. We used a repeated-measures regression with a 10th-order polynomial function to discover the average labor curve under contemporary practice. With use of an interval-censored regression with a log normal distribution, we also computed the expected time interval of the cervix to reach the next centimeter, the expected rate of cervical dilation at each phase of labor, and the duration of labor for fetal descent at various stations. RESULTS: Our average labor curve differs markedly from the Friedman curve. The cervix dilated substantially slower in the active phase. It took approximately 5.5 hours from 4 cm to 10 cm, compared with 2.5 hours under the Friedman curve. We observed no deceleration phase. Before 7 cm, no perceivable change in cervical dilation for more than 2 hour was not uncommon. The 5th percentiles of rate of cervical dilation were all below 1 cm per hour. The 95th percentile of time interval for fetal descent from station +1/3 to +2/3 was 3 hours at the second stage. CONCLUSION: Our results suggest that the pattern of labor progression in contemporary practice differs significantly from the Friedman curve. The diagnostic criteria for protraction and arrest disorders of labor may be too stringent in nulliparous women.

PMID: 12388957 [PubMed - indexed for MEDLINE]

Here’s a comment on the above study.

The Friedman Curve: An Obsolete Approach to Labor Assessment
The Friedman curve, the gold standard for rates of cervical dilation and fetal descent during active labor, was developed almost 50 years ago. To define a modern curve for normal labor, these researchers evaluated data on 1329 nulliparous, full-term women with spontaneous labors and vertex presentations who gave birth to singletons of normal birth weight from 1992 to 1996.
Dilation in the active phase was much slower on the modern curve than on the Friedman curve (mean time from 4 cm to complete dilation, 5.5 vs. 2.5 hours). Among the current study's patients, labor lasting more than 2 hours without apparent change was not uncommon before 7 cm of dilation. Friedman described 3 stages in the active phase: acceleration, maximal slope, and deceleration. No deceleration stage was noted in the contemporary curve.
Comment: The Friedman curve for normal active labor is one of the first pieces of knowledge that most obstetric students acquire. Comparison of Friedman's population with the current study's population shows marked differences: Anesthesia and augmentation are much more common now than in the past, and birth and maternal weights have increased substantially. The authors suggest that in addition to the discrepancies between the 2 groups of parturients, methodologic differences also might explain the differences between the curves. For example, Friedman actually plotted 500 individual curves and then synthesized them into 1 curve, whereas the current researchers used repeated-measures analysis with 10th-order polynomial function.
The authors conclude that the Friedman curve likely represents an ideal, rather than an average, curve. Although this study has limitations (e.g., assessment of cervical dilation is somewhat subjective), practitioners who base their diagnoses of protraction and arrest solely on the Friedman curve might need to reconsider their approach to labor assessment.
— Ann J. Davis, MD
Published in Journal Watch Women's Health February 19, 2003

http://www.breechbabies.com/birth_enemy.htm

Reevaluation of Friedman’s Labor Curve: A Pilot Study
Sandra K. Cesario
Sandra K. Cesario, RNC, PhD, is the director of research and assistant professor in the College of Nursing, Texas Woman’s University–Houston Center.
Address for correspondence: Sandra Cesario, RNC, PhD, College of Nursing, Texas Woman’s University, 1130 John Freeman Blvd., Houston, TX 77030. E-mail: scesario@twu.edu .
Objective: To reevaluate the average length of each phase/stage of labor for multiparous and primiparous women in North America who received no regional anesthesia or oxytocin augmentation or induction, to describe a range of labor lengths associated with good childbirth outcomes, and to determine if there is a consensus among labor and ******** nurse managers responding to the survey regarding the need to revise Friedman’s Labor Curve.
Design: This pilot study used a descriptive and anonymous cross-sectional survey design. Surveys were mailed to 500 maternity care agencies in the United States, Canada, and Mexico with a return rate of 17.8% (n = 89). Each participating agency was asked to submit five patient cases to be included in the analysis.
Sample and Setting: The sample of patient cases (n = 419) was drawn from randomly selected maternity care agencies throughout North America representing all sizes of agencies and geographic locations. The cases submitted for analysis represented women 14 to 44 years of age with varying ethnicities who received no regional anesthesia or oxytocin augmentation or induction. Twenty-three percent of the women in the sample (n = 97) were primigravidas.
Results: The average length of labor for primiparous and multiparous women today is similar to the average length of labor described by Friedman in 1954. However, a wider range of "normal" was found in cases included in the current study. Primiparous women remained in the first stage of labor for up to 26 hours and the second stage of labor up to 8 hours with no adverse effects to mother or infant. Multiparous women remained in the first stage of labor for up to 23 hours and the second stage of labor for up to 4.5 hours with good birth outcomes. In addition, 87.6% of nurse managers responding to the survey believed that Friedman’s Labor Curve should be revised to meet the needs of current patient populations, technological advances, and nursing responsibilities.
Conclusions: This study suggests that the parameters to determine if a labor is progressing satisfactorily may need to be expanded. With the availability of technology to assess maternal and fetal well-being, labor should be allowed to progress past the rigid 2-hour time limit for the second stage of labor artificially imposed on women in some childbirth settings. More emphasis should be placed on the nursing assessment techniques used to reassure the family and health care practitioners that labor is progressing safely and the nursing interventions that may have an impact on the length of each stage of labor.

[The Morrigan]

This is a thorough list of who should and shouldn't receive Syntocinon. I've made the particularly relevant parts obvious to the eye.

http://www.medsafe.govt.nz/Profs/Dat...tocinoninj.htm

Contraindications
Hypersensitivity to the drug
Hypertonic uterine contractions, foetal distress when ******** is not imminent.
Any condition in which, for foetal or maternal reasons, spontaneous labour is unadvisable and/or vaginal ******** is contraindicated: e.g. significant cephalopelvic disproportion, foetal malpresentation; placenta praevia and vasa praevia, placental abruption, cord presentation or prolapse; overdistension or impaired resistance of the uterus to rupture as in multiple pregnancy, polyhydramnios, grand multiparity and in the presence of a uterine scar resulting from major surgery including classical caesarean section.Syntocinon should not be used for prolonged periods in patients with oxytocin-resistant uterine inertia, severe pre-eclamptic toxaemia or severe cardiovascular disorders.
Special Warnings and Special Precautions for Use
The induction of labour by means of oxytocin should be attempted only when strictly indicated for medical reasons rather than for convenience. Administration should only be under hospital conditions and qualified medical supervision. When given for induction and enhancement of labour, Syntocinon must only be administered as an i.v. infusion, and never by s.c., i.m. or i.v. bolus injection. Careful monitoring of foetal heart rate and uterine motility (frequency, strength, and duration of contractions) is essential, so that the dosage may be adjusted to individual response.
When Syntocinon is given for induction or enhancement of labour, particular caution is required in the presence of borderline cephalopelvic disproportion, secondary uterine inertia, mild or moderate degrees of pregnancy-induced hypertension or cardiac disease and in patients above 35 years of age or with a history of lower-uterine-segment caesarean section.In the case of foetal death in utero, and/or in the presence of meconium-stained amniotic fluid, tumultuous labour must be avoided, as it may cause amniotic fluid embolism.
Because oxytocin possesses slight antidiuretic activity, its prolonged i.v. administration at high doses in conjunction with large volumes of fluid, as may be the case in the treatment of inevitable or missed abortion, or in the management of postpartum haemorrhage, may cause water intoxication associated with hyponatraemia. To avoid this rare complication, the following precautions must be observed whenever high doses of oxytocin are administered over a long time: an electrolyte-containing diluent must be used (not dextrose); the volume of infused fluid should be kept low (by infusing oxytocin at a higher concentration than recommended for the induction or enhancement of labour at term); fluid intake by mouth must be restricted; a fluid balance chart should be kept and serum electrolytes should be measured when electrolyte imbalance is suspected.
When Syntocinon is used for prevention or treatment of uterine haemorrhage, rapid i.v. injection should be avoided, as it may cause an acute short-lasting drop in blood pressure.
Interactions with Other Medicaments and Other Forms of Interaction
Prostaglandins may potentiate the uterotonic effect of oxytocin and vice versa; therefore, concomitant administration requires very careful monitoring.
Some inhalation anaesthetics, e.g. cyclopropane or halothane, may enhance the hypotensive effect of oxytocin and reduce its oxytocic action. Their concurrent use with oxytocin has also been reported to cause cardiac rhythm disturbances.
When given during or after caudal block anaesthesia, oxytocin may potentiate the pressor effect of sympathomimetic vasoconstrictor agents.
Adverse Effects
When oxytocin is used by i.v. infusion for the induction or enhancement of labour, its administration at too high doses results in uterine overstimulation which may cause foetal distress, asphyxia and death, or may lead to hypertonicity, tetanic contractions or rupture of the uterus.
Water intoxication associated with maternal and neonatal hyponatraemia has been reported in cases where high doses of oxytocin together with large amounts of electrolyte-free fluid have been administered over a prolonged period of time (see 'Special Warnings and Special Precautions').
Rapid i.v. bolus injection of oxytocin at doses amounting to several IU may result in acute short-lasting hypotension accompanied with flushing and reflex tachycardia.
With either mode of administration, oxytocin may occasionally cause nausea, vomiting or cardiac arrhythmias. In a few cases, skin rashes and anaphylactoid reactions associated with dyspnoea, hypotension or shock have been reported.
Overdose
The symptoms and consequences of overdosage are those mentioned under 'Adverse effects'. In addition, placental abruption and/or amniotic fluid embolism as a result of uterine overstimulation have been reported.
Treatment: When signs or symptoms of overdosage occur during continuous i.v. administration of Syntocinon, the infusion must be discontinued at once and oxygen should be given to the mother. In the event of water intoxication, it is essential to restrict fluid intake, promote diuresis, correct electrolyte imbalance; and control possible convulsions by judicious use of diazepam.


Pitocin.
http://www.kingpharm.com/uploads/pdf...Pitocin_PI.pdf

http://www.childbirth.org/articles/pit.html

[The Morrigan]

Do vaginal exams really help us? Especially if performed hoping to see the discredited Friedman Curve in action?

http://www.radmid.demon.co.uk/Evidence.htm

. Vaginal Examinations
Practice Recommendations
• Many women find vaginal examinations painful and sometimes traumatic (Menage 1996); sensitivity to this issue, privacy and continuity of midwife will make them less so.
• Vaginal examinations measure of the progress of labour imprecisely when performed by different examiners (Clement 1994). Where possible therefore, they should be carried out by the same midwife.
• Examinations should not be routine or prescriptive but carried out only where there is clinical necessity and after discussion with the woman.
• Midwives should give weight to their other skills in determining the progress of labour (McKay and Roberts 1990).
• "Repeated vaginal examinations are an invasive intervention of as yet unproven value" (Enkin 1992).

[The Morrigan]

And now for the myth of managed 3rd stages being better. Better for whom, we should ask. Of course you should read the whole articles to get all the appropriate information.

http://midwiferytoday.com/articles/bristol.asp

The Bristol Third-Stage Trial, conceived and executed by "experts" with no patient input, is very bad news for proponents of gentle, optimal birth. It rationalizes and justifies the alleged safety and efficiency of the horrendous "active management" of third stage. No woman who has experienced or witnessed or read about our careful, gentle management of third stage would agree with the standard "active" management. Good mothering is enhanced and facilitated by inner peace, confidence and bonding to baby, and these are not favoured by thoughtless, hasty obstetrical routines.

http://www.cordclamping.com


http://cordclamping.com/ZICCthe%20PrimeInjury.doc

Immediate Cord Clamping: the Primary Injury

By George Malcolm Morley, MB ChB FACOG (obgmmorley@aol.com)

Immediate clamping of the umbilical cord before the child has breathed (ICC) has been condemned in obstetrical literature for over 200 years. [1] [2] In the 1970s, primate research [A][3][4] using ICC to produce neonatal asphyxia resulted in brain lesions similar to those of human “neonatal asphyxia.” Two extensive review papers on placental transfusion and the time of cord clamping [5,6] both condemned the practice of ICC:

• Linderkamp ‘82 [5]: “… immediate cord clamping can cause hypovolemia, hypotension and anemia …”
• Peltonin ’81 [6]: “Thus [clamping before the first breath] is unphysiological and should be avoided under certain unfavourable circumstances the consequences may be FATAL.”

Peltonen described the effect of ICC on cardiac ventricle filling visualized under fluoroscopy – there was momentary “cardiac arrest.” This effect is seen in [A] when a normal neonate is subjected to ICC: the heart rate (AND CARDIAC OUTPUT) fall immediately by about 50%. The umbilical vein is comparable to the vena cava. Sudden removal of this large venous return to the heart has major effects on tissue perfusion of the neonate, as does sudden removal of a very large volume of placental blood from the general circulation.

However, in the early 1980’s, ICC use increased, as neonatologists demanded ICC for instant neonatal transport to the resuscitation table to correct and prevent neonatal asphyxia. Neonatal deaths decreased markedly; the incidence of cerebral palsy stayed constant. Lives were saved; brains were not saved.

By the early 1990’s, medico-legal advice encouraged obstetricians to send an immediately excised portion of cord for blood analysis [9] to prove that the child was not asphyxiated at birth. By 2000, ICC was standard practice. In August 2003, ACOG quietly revoked publication of Practice Bulletin 138; obstetricians, perinatologists and neonatologists continue to think that ICC is harmless.

[The Morrigan]

Some thoughts on ARM.

http://www.radmid.demon.co.uk/arm.htm