Delayed cord clamping in a hospital - WHEN? And vitamin k injection with delayed cord...

[tnrose]

I am currently 37 weeks along.  My OB has been wonderful about allowing me to have a low-intervention pregnancy since I have been seeing him for my primary care (I was originally planning a home birth with a midwife and had to switch to having a hospital birth at 30 weeks due to non-health-related personal circumstances - this OB had seen me a few times for blood testing and ultrasounds, though, when I was receiving my primary prenatal care from the midwife from the first trimester until 30 weeks).

I had decided to allow the eye goop and vitamin k shot at the hospital, but now that I am doing more research on delayed cord clamping/cutting, I'm wondering... if I fight to have the hospital delay clamping/cutting the umbilical cord (they routinely clamp/cut the cord immediately), is there any harm in still allowing the vitamin k shot?  Since the increased blood supply allows an increase in vitamin k as opposed to immediately-clamped-cord babies, can the infant receive too much vitamin k?

I am going to decline an IV while in labor, which the OB is fine with, but warned me that I will probably have to fight the nurses on it.  I am prepared to deal with that.  If I decide to have them wait to clamp/cut the cord, I have a feeling it will be a fight also.  I am planning on talking to the OB about it when I see him on Wednesday, but when he went over the "routine" a few weeks ago, he did say he would cut the cord right after she was birthed, so I'm not sure what he'll have to say about it.

I'm still reading/researching, because at this point I don't know if I should have them wait 1 minute, 3 minutes, after pulsing has stopped, after the placenta is birthed, or when...  I do feel there are benefits of delaying to ANY extent, even just for a minute or two, but I just don't know WHEN I should suggest they cut it... any advice from mamas who've been there/done that? 
 

[greengirl1]

http://www.sciencedaily.com/releases/2007/08/070816193328.htm

[1love4ever]

Well, here are a few good articles that I really recommend.  And unless you have gonorrhea or clamydia the eyedrops are pointless because those are the only things they are meant to prevent.

http://www.childbirthwithlove.com/controversy.html

http://www.proliberty.com/observer/19990710.htm

At its peak, a newborns vitamin K levels will be 9000 times the recommended daily value for vitamin K, so YES the newborn will have WAY too much vitmain K.  There is also an article in Midwifery Today, summer 2011 about vitamin K if you can get ahold of it!  It brings up more points that the article I listed above does not mention, such as that colostrum has a high vitamin K content, and that when the cord is not cut right away that lots more clotting factors are allowed to go into the babies body.

I love this quote from the second article above “...how could God (or nature) have erred so badly as to give all newborn babies only an infinitesimal fraction of their required vitamin K? Surely the human race could not have survived to this point if all newborns were born with this deficiency and none being administered at birth until very recently.”

And I love this quote when it is applied to both the vitamin K issue, and the reason boys are born with foreskins!   "We must assume this is as nature intended, not a mistake of evolution"

[Jaimee]

I'll start with cord clamping recommendations:

Immediate newborn care practices delay thermoregulation and breastfeeding initiation

1. Howard L Sobel¹,
2. Maria Asuncion A Silvestre²,
3. Jacinto Blas V Mantaring III³,
4. Yolanda E Oliveros⁴,
5. Soe Nyunt-U¹

Abstract

Aim:  A deadly nosocomial outbreak in a Philippine hospital drew nationwide attention to neonatal sepsis. Together with specific infection control measures, interventions that protect newborns against infection-related mortality include drying, skin-to-skin contact, delayed cord clamping, breastfeeding initiation and delayed bathing. This evaluation characterized hospital care in the first hours of life with the intent to drive policy change, strategic planning and hospital reform.

Methods:  Trained physicians observed 481 consecutive deliveries in 51 hospitals using a standardized tool to record practices and timing of immediate newborn care procedures.

Results:  Drying, weighing, eye care and vitamin K injections were performed in more than 90% of newborns. Only 9.6% were allowed skin-to-skin contact. Interventions were inappropriately sequenced, e.g. immediate cord clamping (median 12 sec), delayed drying (96.5%) and early bathing (90.0%). While 68.2% were put to the breast, they were separated two minutes later. Unnecessary suctioning was performed in 94.9%. Doctors trained in neonatal resuscitation were 2.5 (1.1–5.7) times more likely to unnecessarily suction vigorous newborns. Two per cent died and 5.7% developed sepsis/pneumonia.

Conclusions:  This minute-by-minute observational assessment revealed that performance and timing of immediate newborn care interventions are below WHO standards and deprive newborns of basic protections against infection and death.

........

Third, delaying cord clamping until cord pulsations stop, typically around one to three minutes, reduces the risk of anaemia (18,19). Furthermore, in preterm infants, delayed cord clamping is associated with fewer transfusions and fewer intraventricular haemorrhages (20).

.....

[Interesting info about breastfeeding initiation...]

This evaluation found that 68.2% were put to the breast, similar to national survey results (3). However, this process was not optimal because the infants’ mouths were pried open, positioned onto the areola and their cheeks were stroked to trigger rooting only 10 min after birth, a time before newborns are ready to breastfeed (14). They were allowed only two minutes of this forced attachment.

The Academy of Breastfeeding Medicine (23) states that, for a healthy newborn, procedures should be delayed to allow early parent–newborn interactions and the first breastfeed. Newborns were typically separated for weighing, examination, eye prophylaxis and injections at only 12 min after delivery. The majority (88%) were reunited with their mothers at 155 min, a time when newborns younger than 24 h are usually asleep. When newborns eventually initiate breastfeeding, the risk for infection-related death is doubled or tripled (21).

Edited by Jaimee - 10/28/11 at 5:23pm

[tnrose]

1love4ever - Thanks for the articles, I will go over them.  As far as the eye prophylaxis, I am aware of what it's intended to prevent, but I haven't seen in my readings that there is any harm in applying it, either, aside from making the baby's eyesight blurry for a little while.  I am not sexually active, have been tested for STDs since the last time I had intercourse, and will not be sexually active for the duration of this pregnancy, so no, there is no point in my infant receiving the erythromycin if all it prevents is gonorrhea or chlamydia.  HOWEVER -  there are a couple of things I am intending to "fight" the hospital on, and the erythromycin is just one more thing I would have to worry about, so I have decided to allow it just to make it easier on me (I am a single mother and will not have a whole lot of support at this birth).  The nurses at this place are horribly pushy, and I will not be in any emotional state to fight with them more than necessary post-partum.  I am picking my battles, with the most important ones taking precedence.

From everything I read, the vitamin k injection is helpful if the infant has had a traumatic birth (long pushing stage, very molded head, etc.), and can prevent internal bleeding... and again, the only consistent downside I found was that the baby would have to endure the pain of an injection, even if there was no real necessity for the supplement.  My main concern is the baby receiving too much vitamin k, as I said in my OP...

Is it possible to receive too much and if so, what is the effect on the infant's system?

--

For what it's worth, this hospital promotes immediate skin-to-skin contact and breastfeeding as soon as possible.  Babies are kept in the room unless requested to be taken to the nursery by the mother (which isn't happening!).  They will perform all newborn care on the mother's abdomen if requested.  So I think the only reason she would be taken out of my arms is when they weigh her and clean her up, and when they do that is up to me.

[AfricanQueen99]

Are you sure you'll need to fight for these things at the hospital?  I only ask because I deliver in hospitals, too, and I'm presented with a checklist (literally, check if you want it, leave blank if you don't) for a number of things - eye ointment, Vit K, Hep B, circumcision - and it's not even a discussion.  I live in a fairly large area and have access to 17 hospitals within a 20 mile radius so they all know women can go anywhere, but they simply don't care when I refuse these things.  The same with IVs and fetal monitoring - they're ok with refusals.

Also, there ARE benefits for Vitamin K, as you noted. 

Good luck with your labor.  I hope it's peaceful for you and your babe.

[tnrose]

AfricanQueen99 - I'm assuming so, since it's routine for them to immediately clamp/cut the cord after birth, and IVs during labor/post-partum are also routine (two things I'm SURE I'm going to fight against).  My experiences so far with the nurses employed here is that they don't tolerate very well having people challenge them - I have had issues with many nurses thus far, and all I've done is decline one internal exam, decline the gestational diabetes screen, and asked for detailed information on why they do the eye prophylaxis/vit k/hep b/etc.  The OB told me the nurses will at minimum want to put a hep-lock on me when I check in, but he said just tell them no until they quit asking.  I have yet to talk to him about the cord (I will this week at my appt) - since he will be present at the time that's normally done, it may be easier to prevent them fighting with me on that.

The state requires the erythromycin and the vitamin k, but you can decline if you sign a waiver.  The 24-hr blood screen is required by the state and is not optional at all.  The Hep B shot is optional, no waiver needed.  I wish they provided a checklist, that would make it so much easier!!

[tnrose]

I'm considering possibly going the oral vitamin k route (weekly administration) after much reading... instead of one huge dose, that would break it down into gradually increasing levels in the baby's system.

This seems to be a pretty good article, and includes a lot of information I've found over and over again in other articles:

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

[cameragirl]

I'm going to ask for cord clamping to be delayed until the cord stops pulsing, and will negotiate from there if I need to. The OB I chose is more welcoming to natural birth, VBAC, and vaginal twin births. Her practice has a standard checklist and the cord clamping isn't on it, but I assume it won't be a big fight.

[LivingSky]

tnrose - We went the oral vitamin K route with our DS. I could not find any harmful side effects to too much vitamin K, so the only thing I objected to was the injection. Oral vitamin K was a good compromise - I too did not want to end up fighting over every procedure.

I did decline the eye goop because studies have shown that the blurry eyesight makes it hard for mom and baby to have good eye contact while baby is nursing the first few days, which can impact bonding.

Cord clamping - we waited about 10 minutes for the cord to stop pulsing. You might need to play that by ear though, because if the cord is too short then leaving it attached for a while can delay how quickly babe can be put to your breast. If you have lots of cord length then that won't be an issue.

Have you investigated finding a birth doula in your area? Most cities have some and a lot of them are willing to work for a reduced rate or for free if money is a concern for you. Then you'd have someone in your corner to fight for you so that you don't have to deal with that stuff during and after labor. Also, a good, short, to the point birth plan given to your nurses and posted in your room could be a big help for you!

[1love4ever]

As far as the eye ointment goes- it is an antibiotic and should be used with just as much caution as any antibiotic, and can and does contribute to antibiotic resistant bacteria just as any other antibiotic does.  As with all interventions there are always risks including allergy.  As far as I am aware, there are waivers you can sign ahead of time to decline the eye drops, vitamin K, etc.  You can and should write letters AHEAD of time to the hospital, and talk with the dr about it, this way they will have all of these things on record and not be pushy.  You are paying them for a service, their job truely is customer service, so they do have to listen to your wishes.  And, you can always threaten to sue the hospital if they ignore your waivers and such :).  Also making a birth plan and bringing it with you that states your wishes.

Here is also another more in depth article that has more stats and such about vitamin K and the dangers of the shot.  http://www.vaclib.org/basic/vitamin-k.htm

[mamaecho]

According to my midwife, you can do both the cord clamping and vitamin k shot. We are most likely circ'ing (please, no flames..) and she said if we are circ'ing we would have to do the vitamin K shot, but knows we are delaying the cord cut and didn't say that it's contradictory.

[1love4ever]

Originally Posted by mamaecho 

According to my midwife, you can do both the cord clamping and vitamin k shot. We are most likely circ'ing (please, no flames..) and she said if we are circ'ing we would have to do the vitamin K shot, but knows we are delaying the cord cut and didn't say that it's contradictory.

And you should wait til day 8 to circ, then k shot is not necessary.  Have you done your research on circ so as to make an informed decision?  Here's an article thats very informative that you should read irregardless of your decision  http://www.psychologytoday.com/blog/moral-landscapes/201109/myths-about-circumcision-you-likely-believe   and a video my midwife gave me  http://www.nocirc.org/   please read and watch