Questions about pitocin and umbilical cords?

[HokieGirl]

Hi,

I had dinner with some friends last night - all somehow involved in the medical field (1 nurse and 2 health policy researchers like myself, one of whom just gave birth 3 weeks ago.)

They know my bias against hospital birth (although I'm not pregnant and have never given birth). We were talking about squatting and the woman said she couldn't squat because she was hooked up to the pitocin drip and they wouldn't let her move around. I got rather passionate and said something along the lines of, but you probably didn't need the pitocin and if they had let you move around that would have sped up the labor naturally.

Anyway - so 2 questions came up.....

They said if the water breaks naturally that you have to deliver within 24 hours or else the risk of infection increases. Ok. I know that, but 1) how much does it increase, 2) doesn't moving and walking around help move labor along? 3) what other things could you do to move labor along other than pitocin and some of the herbs?

2nd set of questions - we were talking about the Electronic Fetal Monitoring. All I have read (and I'll admit I should probably try harder to find some positive support for EFM to balance out my knowledge), says that EFM doesn't really do much. And the nurse pipes in with "But I know one woman who's babies' cord got wrapped around her neck and the EFM alerted them and the nurse was able to manually push the child back up until the woman could be cut open and the child delivered by c-section." So the questions here are 1) how often does that happen? I had heard something along the lines of only 2% of deliveries? 2) wouldn't that kind of thing be captured just as well by a nurse doing manual heartbeat checks with a stethoscope? 3) what could have been done besides the c-section, either in advance or once it was found out?

Thanks for all your help. I'm at the point where I want to be able to start giving exact research/stats/etc. and I can never seem to remember it in the heat of the moment.

Kristi

[Defenestrator]

I will try to remember the all of your questions and answer them -- if I miss one I will write another post.

Studies show that continuous fetal monitoring and intermittant monitoring in low-risk women have virtually identical birth outcomes, except that the women who have continuous monitoring have more c-sections.

Most hospitals and homebirth midwives have a protocol which calls for intermittent monitoring every 30-60 minutes, increasing the frequency during pushing. The practitioner will take a measurement during a contraction and can detect any decelerations of the baby's heartbeat that happens. Some causes for decelerations include cord compression, head compression, and maternal exhaustion. Some decelerations are considered normal. There is a substance in the cord which helps it resist compression called Wharton's jelly. A large percentage of babies (1 in 5, I think) have their cords wrapped around their necks, which is considered a variation upon normal and can usually be dealt with easily at the baby's birth. If the baby has a cord presenting in a place where it is squished by the contractions (like over a shoulder), it is possible for the cord to be compressed during contractions in a way that can stress the baby, but usually a position change will resolve this.

What is a real, scary (but rare) complication is cord prolapse, where the cord falls ahead of the baby's head and gets between the head and cervix/vagina. There is indeed no treatment for cord prolapse that I am aware of except for cesarean. In a home or hospital birth, when a cord prolapse happens, the treatment is to get the mom in the knee-chest position, have the practitioner put pressure on the baby's head to keep it off of the cord, and get to the OR as soon as possible.

But, confusing a true cord prolapse with a cord over the shoulder or wrapped around the neck is a mistake.

Hope this doesn't make things more confusing.

[pamamidwife]

Yes, to what Defenestrator so clearly stated.

Then, in regards to water breaking, the biggest risk with infection is the constant insertion of fingers up inside the vagina after the water has broken. Sterile gloves or no, it increases the risk of infection.

Also, sometimes water will break because of a bacterial infection, in which case you will see signs of infection start rather slowly during labor (increased heart rate with baby, mom may have an increased pulse, etc.).

With broken membranes, the safest place to be is in your own home. The bacteria present in your home is bacteria that not only is your body familiar with, but it is accilimated to. The hospital has bacteria that would not be present in your house - and some very scary bacteria (like antibiotic resistant super bugs!) that you would NOT want in your home. (You cannot mop floors with the same mop over and over, using the same water for different rooms and not increase the risk of spreading infection, etc...hospital floors are very, very icky places to be! Don't ever go barefoot on the floor or sit/lie on the floor!)

A great book that discusses things just like this is Henci Goer's The Thinking Woman's Guide to a Better Birth. It is an amazing book, full of evidence-based information.

[mamallama]

Thanks for all your help. I'm at the point where I want to be able to start giving exact research/stats/etc. and I can never seem to remember it in the heat of the moment.

Here are two excellent & reputable (albeit technical) online resources:

http://www.cochrane.org/cochrane/revabstr/g010index.htm

http://www.maternitywise.org/guide/

Another good resource is Henci Goer's book, A Thinking Woman's Guide to a Better Birth. She also has a version of the book geared toward healthcare professionals. The title is Obstetrical Myths vs. Research Realities.

In additon, I wanted to add that while I don't have specific numbers in mind for rates of infection 24hrs after rupture of membranes, I will say that liklihood is small, providing the mother has no vaginal exams until active labor is well under way. Some careproviders will "allow" a woman to go more than 24hrs if she agrees to iv antibiotics.

[Defenestrator]

Oh, about the water breaking --

Things that could be done to stimulate contractions --

nipple stimulation, heat packs on the fundus, walking, squatting/sitting on the toilet during contractions to bring the baby down, upright positions, etc.

Sometimes it does take more than 24 hours for labor to start on its own when the water has broken. I guess you have a few choices when that happens.

Augment with drug/non-drug methods of stimulating contractions.

Do nothing/rest and give antibiotics.

Do nothing/rest and don't give antibiotics.

I think that probably if the wait and see method is employed, the mom/baby should be monitored for signs of infection and the plan changed if it shows up.

Mom's potential for exhaustion should be taken into account. I had a mom for whom I doulaed a week ago who got 30 hours into her labor after PROM with only weak contractions, was 1cm, decided to get pit and an epidural at that point, and was 1.5 cm 8 hours later. In her case it might have been better to intervene to either speed up contracitons/increase intensity or to get her some rest in early labor so that she wasn't so tired.

hope this helps!

[JesseMomme]

[JesseMomme]

*

[JesseMomme]

*

[JesseMomme]

*

[JesseMomme]

*****

[JesseMomme]

[

[JesseMomme]

*

[JesseMomme]

*

[JesseMomme]

shew last one! sorry about that!

[HokieGirl]

Thanks for the info all you wonderful, knowledgeable women.

[applejuice]

Dear HokieGirl:

Re: "Cord around the neck"

If the cord is wrapped around the baby's neck as it is in 75% of all births, that is a natural protection against cord prolapse with a normal length cord.

I always laugh at all of the things OB teams get nervous about when nature got it right a long time ago.

Who the heck do they think they are?

RE: The EFM

That is exactly correct that the inventor of the EFM developed it for the high risk mothers and regrets that its use has been extended to everybody. As a matter of fact everytime the EFM was introduced into an institiuion, the c/s rate shot up and then went down after everbody on the maternity ward learned how to interpret the squiggles and lines that the readings from the EFM made.

I am sure glad I was not a c/s statistic during anyone's job training period.

RE: What can you do to stimulate labor?

One of the first things that often happens when a women arrives at the hospital in active labor is labor slows or stalls. Look at any mother cat in labor and move her, and her labor will stall or stop also.

We are mammals. We need to learn from animals and how they labor.

Try poking and prodding that mother cat also, and see how far you get.

Walking, squatting, nipple stimulation, loving your partner, drinking water, eating all work to speed up your labor.

[Defenestrator]

Hey --

I did find the statistic I was looking for about how many babies have cords wrapped around their necks. About 20% of babies have a single loop. A much, much smaller amount have multiple loops.

I have to think that Applejuice was just throwing out a round number. I certainly haven't seen 3 out of 4 babies in my experience at births with nuchal cords. Even so, I have also not ever been to a birth where a cord wrapped around a baby's neck was not an easily managed thing.

[applejuice]

That was my point - that the cord around the neck is an easily managed obstacle.


75%- that is from own my personal experience.

And there is nothing like experience.

[MaWhit]

Re: Questions about pitocin and umbilical cords?

Originally posted by HokieGirl
They said if the water breaks naturally that you have to deliver within 24 hours or else the risk of infection increases.

If the waters break either naturally or artificially, there is an increased risk of infection after 72 hours, and most good midwives won't transfer unless labor doesn't start within 24 hours. Starting labor within 24 hours and delivering within 24 hours are two very different things. Staying home, avoiding vaginal exams, and avoiding sex dramatically decrease chance of infection.

Everyone has answered the moving labor along question...

1) how often does that happen? I had heard something along the lines of only 2% of deliveries?

One out of five babies is born with a nuchal cord (cord around neck). This is not a life-threatening condition. The placenta provides oxygen to the baby until the cord is cut, so the cord beig wrapped around the neck of a baby is no more harmful than it being wrapped around a leg. It is not cause for C-section, but rather an excuse.

And about cord prolapse...If my water breaks before delivery is imminent (never happened to me), I will check to see what is presenting (butt, head, face, placenta, cord) and will transfer if necessary (placenta, cord). Prolapsed cord happens in about 1/400 births, usually when water breaks early in labor (naturally or, more often, artificially.) If prolapsed cord is discovered only when birth is imminent (pushing), I will push baby and cord out, as this has been shown to be the safest course of action when this far along. Avoiding artificial rupture of membranes, back-laying pushing, and other interventions can reduce risks of prolapse significantly. And left alone, mothers can instinctively position themselves in the best way to birth a mal-positioned baby/cord without even knowing there is a problem. (e.g., deep squat for fast birth with prolapse, standing squat for breech, hands and knees for posterior or shoulder dystocia, etc)

Good questions.

[annakiss]

what other things could you do to move labor along other than pitocin and some of the herbs?

The Amish like to go on a buggy ride.