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Tuesday, March 1, 2011

INFOSHEET: A BABY’S TRANSITION FROM THE WOMB TO THE OUTSIDE WORLD

Please read through this INFOSHEET, and post any comments about the statements made, the evidence to support those statements, and the usefulness of the information.



A BABY’S TRANSITION FROM THE WOMB TO THE OUTSIDE WORLD

Consider the impact on the baby’s transition ...

Drugs to relieve pain in labour
Consider the impact of opioids such as Pethidine by injection, and epidural and spinal-epidural anaesthetics.

Clamping of the Umbilical Cord
Consider the increased volume of blood, and reduced risk of anaemia, to the baby when we delay the clamping of the cord.
The cord may be around the baby’s neck at birth, and some attendants will clamp and cut the cord before the baby’s shoulders are born. Consider alternatives.
Consider the impact on the baby when cord blood is collected for stem cell harvesting.

Skin to skin placement at birth
Consider the newborn baby’s ability to stay warm when kept naked against mother’s skin immediately after birth. This practice is important in temperature regulation of the newborn, as well as bonding and initiation of breastfeeding soon after birth.

Suction of the newborn at birth
Consider the impact on the baby of suction in the mouth, nose, trachea and stomach. Note that there is no evidence that a vigorous, mature infant is helped by suction, even if there is meconium in the amniotic fluid.

Resuscitation of the baby using Oxygen 
Current research questions the value of using Oxygen, rather than room air, during resuscitation of the baby who is not able to breathe independently immediately after birth.

Breastfeeding 
Consider the importance to the baby of unlimited access to the mother’s breast as she or he learns to breastfeed, and consider the amazing protective and nutritional properties of breast milk.
There is a strong body of evidence in favour of protecting, promoting and supporting the natural processes in birth, and the baby’s transition to life outside the womb.

Discussion
Birth is a time of enormous change for a baby. The transition from life inside the mother’s womb, to life in this world, requires many important natural or physiological changes to take place. The baby’s lungs need to expand and take in the air, providing oxygen and taking away carbon dioxide. The baby’s heart needs to redirect the blood so that the circulation to the placenta is shut down, and the blood is directed to the lungs. The baby needs to maintain normal body temperature. The baby needs to obtain food. These functions, and many more had, in the womb, been managed naturally via the placenta and the mother’s body.

The vital changes take place naturally at birth when mother and baby are well. Over time many interventions into the birthing process have been adopted by midwives and other birth attendants. Some interventions in certain situations are life-saving, while others are not based on evidence for improved outcomes for mother or baby. Practices that are common in maternity settings today, that may have an impact on the baby’s transition to life outside the womb, include:
  • the use of medicines (drugs and natural substances) in labour
  • mechanical suction of the baby’s airways
  • early clamping of the umbilical cord
  • separation of mother and baby
  • strategies to keep baby warm, and
  • methods of resuscitation of a baby who is not breathing at birth.

In this INFOSHEET we draw attention to various practices. We encourage parents who are seeking maternity care that supports and promotes the natural processes and wellness to discuss these and any other issues that are important to you with your primary caregiver. You can seek to ensure that the midwife or other professional who is attending you in labour understands your wishes for the care of your baby during the transition from the womb to the outside world.

This INFOSHEET is based largely on a published paper, ‘Evidence-Based Practices for the Fetal to Newborn Transition’ (Mercer et al 2007), which provides a review of the relevant literature.

Natural birth is a mother’s own resource
Pregnancy, birth and breastfeeding are natural biological processes. Most women and babies are well during this time, and will be able to proceed through spontaneous unmedicated labour, and give birth to a healthy baby who breastfeeds and thrives naturally. In fact, unless there is a valid reason to interfere, the natural biological processes are the safest for both mother and baby.
There are many aspects of birthing which are un-knowable, and your birth plan should allow for and support your informed decision making at all times. Women who know and trust their midwife or doctor may be more confident in making decisions than those who do not know their primary carer.

Reference: Judith S Mercer and others, 2007. Evidence-Based Practices for the Fetal to Newborn Transition. J Midwifery Womens Health 2007:52(3)262-272

ps. A question has been asked about delayed cord clamping and the possibility of jaundice in the baby.

Evidence from research has been summarised in the Cochrane Reviews http://www2.cochrane.org/reviews/en/ab004074.html

Effect of timing of umbilical cord clamping at birth of term infants on mother and baby outcomes (McDonald and Middleton 2008)

At the time of birth, the infant is still attached to the mother via the umbilical cord, which is part of the placenta. The infant is usually separated from the placenta by clamping the cord. The timing of this clamping is one part of the third stage of labour (the time from birth until delivery of the placenta) which can vary according to clinical policy and practice. Early cord clamping is believed to lead to a reduced risk of bleeding after birth (postpartum haemorrhage). This review of 11 trials showed no significant difference in postpartum haemorrhage rates when early and late cord clamping were compared. For neonatal outcomes it is important to weigh the growing evidence that delayed cord clamping confers improved iron status in infants up to six months after birth, with a possible additional risk of jaundice that requires phototherapy.

6 comments:

Joy Johnston said...

This comments hae been received by email, sent in by a midwifery student in Victoria:

From M:
Just wanted to make a note regarding the parts on the page about suctioning. To me (if I was a woman reading this with limited knowledge of the birth suite environment) it reads as if suctioning is a routine part of birthing. I know previously mec[onium] liqour babies were suctioned on the peri[neum], but I have not seen this practice and have been told, both at uni and work, that it is outdated. In addition, I'm as yet to see any suctioning of babies unless their 1 minute APGAR is low, or prior to minute if medically necessary. Also, at Southern health all babies are resused in air, not oxygen.

Joy Johnston said...

Another email comment from a midwifery student in Victoria:

From J
I have found that it depends on who is receiving the baby. Some paeds (old school ones!) will routinely suction babies post birth (mostly ceasarean babies though), but haven't seen any peri suctioning.
I have also found we use air first to resus[citate] and then O2 if air not working.

Joy Johnston said...

M and J, this is exactly the sort of discussion that we need to hear in reviewing the INFOSHEET. Thankyou!

I think J is quite right in identifying the 'old school' paediatricians as continuing out of date practices. Old school midwives and old school obstetricians and GPs too.

I hope we receive comments from maternity professionals and consumers from other parts of the country, and overseas. I have found that the tertiary hospitals in Melbourne are front runners with applying certain evidence to practice in a systematic way (slowly, and selectively imho), while the doctors at smaller public hospitals and private hospitals are much less likely to change their practices.

Change is very slow, and when I and other midwives have visited resource-poor countries we have been astonished that old practices that we thought had been gone for yonks were still being done - all in the name of good medical practice. I visited remote parts of China in the late 90s, and it was like stepping back 30 years here - the woman had no familiar person near her, she laboured in bed, staff all wore operating theatre garb for the birth, separation of mother and baby, ...

I feel that midwifery students are likely to see practices with fresh eyes, have contemporary professional knowledge, and hopefully they will have the courage to think critically about what they see.

Joy Johnston said...

Comment from midwife Rob:
I would like to see the heading change to A BABY’S TRANSITION FROM THE MOTHERS WOMB INTO HER ARMS and some suggestions for you to take or leave as you feel appropriate. Keep up the good work the women of Australia need the skills of the Midwives who practice Midwifery.

Clamping of the Umbilical Cord
Consider the physiological and chemical changes that need to take place to form a retro-placental clot to reduce the risk of postpartum bleeding. Hasty removal or cutting or separating the baby from the placenta early until at least the cord has stopped pulsating and diminished in size increases the risk of incomplete clotting factors and therefore increased abnormal bleeding.

Skin to skin placement at birth
Consider the arousal of survival skills when the baby is gently and quietly on the mother from birth. Smell, taste, touch, hearing, seeing and movement toward and location of the breast and nipple of mother-baby initiated breastfeeding.

Suction of the newborn at birth
Consider laryngeal stridor caused by incorrect and over vigorous suction.

Joy Johnston said...

Thankyou Julie for this comment:

Some actions are of enormous positive impact, and some scientifically demonstrated to be negative...

I wonder if sub categories would be more clear, along the lines of...

Positive..no suction unless indicated, delayed cord clamping in context (no oxytocics or need to separate baby), SKIN TO SKIN, BREASTFEEDING

Negative...opioids, epidural, separation of baby from mother

Unnecessary/not evidence based....suction, early cord clamping, O2

Also, short term and long term impacts, if pointed out, may be positive motivators, if they could be stated simply eg. long term positive impact of any of the positives...if you can find suitable references .
I think the infosheet is a bit wishy washy...there is clear evidence on these variables, and women need to know the consequences of their choices....that is no more than informed choice.

I always love a flow chart/circles! This info could lend itself quite well to a flow chart!

Joy Johnston said...

And thanks to midwifery student R for this response:

"I'm just doing a bit of research to double check a few things because I don't want to say something then look like a dumb student if it's wrong."

Please don’t (anyone) feel that your questions will be dumb – it’s really important that we know how the information is received by those who aren’t totally absorbed in the culture.