These are Handouts from some of our presentations at various midwifery conferences.

These "Handouts" are notes intended to supplement the presentations. They are  a synopsis of a seminar and should not be taken out of context of the lectures. References and citations are credited to their authors and/or public access  locations.

 

 PRESENTATIONS

 

The Newborn Baby's First Moments of Life; Transitions After Birth 

(Pennsylvania/Oregon; Copenhagen; Russia; Germany;France)


Prolonged Labor (Oregon/Pennsylvania; Denmark; Russia;Germany; Australia;Belgium)


Care during the Prenatal Period 

(Eugene, Pennsylvania, California)


Blood loss and Hemorrage

(Eugene, OR; Anne Arbor,MI; Phoenix, AZ; Seattle WA; Denmark; Moscow, Russian Federation; Australia; Germany; Belgium)


more handouts are available at our older site midwiferyeducation.com    handouts page http://midwiferyeducation.tripod.com/id4.html


________________________________________________________________________________________________


The Newborn's First Moments

(© gail hart, gist of midwifery)

 Transition after birth

 The baby in utero sends almost half his blood supply through the placenta; most of it bypasses the lungs and kidneys (because the placenta is handling the jobs of oxygenation and blood-cleansing). When the umbilical cord is clamped, the circulation redirects a much greater portion of blood to the lungs and kidneys. The baby is born with lungs filled with fluids, but within minutes after birth the fluid is pushed into the circulatory system and the lungs are nearly clear. This process isn’t instantaneous: it requires some time for the baby to fully adapt.

 

NORMAL TRANSITIONS

(from Benson’s Handbook of Obstetrics)

For about thirty minutes the infant is active and alert, heart rate is rapid, and there may be nasal flaring, mild grunting and retracting, ausculatory rales, irregular respiratory movements, and mucus present in the mouth. Body temperature falls. During the subsequent one-half to two hours, the infant falls asleep, has decreased respiratory rates and bowel sounds are present. Then the neonate arouses,.. .. with labile heart rate and swift color changes due to vasomotor instability and a period of hemoconcentration at about six hours of age that contributes to his plethoric appearance.” 

This is all NORMAL behavior. Even a normal baby has some slight periods of ‘instability’. These periods of mild symptoms demonstrate the gradual adjustments which occur over those first few hours. Misunderstanding of the NORMAL adjustment leads some caregivers to overly stimulate and roughly handle the baby. Most babies are better off if there is minimal handling or stimulation in the first minute or two. 

 

THE IMPORTANCE OF DELAYED CORD CLAMPING

In the US, most babies have their cords clamped immediately at birth, but the World Health Organization and other global experts currently recommends that delayed cord clamping should be practiced in EVERY birth!  This point should be negotiated with the caregiver well before labor begins. The doula may have to remind the doctor or midwife that the mother of the baby has requested the cord be left intact for at least three minutes.



WORLD HEALTH ORGANIZATION REPRODUCTIVE HEALTH (http://www.who.int/reproductive- ealth/publications/MSM_98_4/MSM_98_4_chapter4.en.html) <quote>  The timing of cord clamping may have effects on both mother and infant.    Early cord clamping should be avoided in rhesus negative women as it increases the risk of feto-maternal transfusion. However, allowing free bleeding from the placental end of the cord reduces this risk.[i] Delayed cord clamping results in a shift of blood from the placenta to the infant. The volume transfused varies between 20% and 50% of neonatal blood volume, depending on when the cord is clamped and at what level the baby is held prior to clamping. [ii] There have been concerns that the increase in the newborn's blood volume and red blood cell volume that is associated with delayed cord clamping could result in overload of the heart and respiratory difficulties. These effects have not, however, been demonstrated. Placental transfusion associated with delayed cord clamping provides additional iron to the infant's reserves and may reduce the frequency of iron-deficiency anaemia later in infancy. [iii]  Early cord clamping reduces the extent of placental transfusion to the baby and results in significantly lower haematocrit and haemoglobin levels in newborns. [v] <end>

  

THE IMPORTANCE OF GENTLENESS

 The just-born baby needs to be handled gently to help him adapt to extra-uterine life. Some believe that rough handling “shocks” babies and may cause them to cry before their lungs have cleared. This may result in un-even filling and may contribute to respiratory distress. It’s also possible the newborn may be sensitive to emotional or psychological damage from the sudden shock of birth. It’s so easy for us to make birth gentler for the baby, and it seems a humane thing to do so. A doula can really help to make these first moments special for the family.

 After the baby emerges, he should be guided into his mother’s arms and observed. He should not be touched, rubbed, or stimulated – but simply held gently by his mother. Ideally, the room should be darkened, and everyone should be silent or speak very quietly, so that the newborn hears only his family’s voices.

 A dry towel or absorbent blanket can be gently placed over mother and baby to wick away moisture (rubbing is not needed to dry the baby. The baby doesn’t generally even need to be dried if he is kept skin-to-skin. The mother’s abdomen is warm and will keep the baby from becoming chilled).

 A normal baby will clear his lungs and begin to breathe within about  30 seconds, and may cry within the first minute. Some babies never cry even though they are breathing well. This is normal for them!

 If the cord is kept intact, the transition to full lung breathing may occur without danger even as long as a minute or two. The baby should have normal flexion, normal color, and normal heart rate during this time and will probably be breathing slowly until he takes his first deep breath. The normal bluish/dusky birth color will rapidly change to pink – starting at the chest – although hands and feet may stay dusky for several hours or days.

If the baby is born limp or pale, or has any signs of asphyxia, then it needs to be suctioned and stimulated to breathe, and it may even need resuscitation. But the NORMAL baby benefits from a gentle transition without the added stimulation of touch or movement  such as rubbing, jiggling, suctioning. Suctioning is no longer recommended except for babies needing resuscitation, but is a deeply ingrained routine in many hospitals. If parents don’t want their baby suctioned, they need to negotiate this point with their caregivers before labor

 WARMTH

The baby will naturally cool from the intra-uterine temperature. Many modern US nurseries attempt to keep babies close to intra-uterine temperatures and actually over warm them. Overheating increases oxygen consumption and increases blood fragility. The natural physiologic cooling results in lower oxygen demand and may lower the risk of intra-cranial bleeds (deliberate cooling is a new method being used for premature babies. These babies are intentionally cooled to as low as 94 degrees without harm! The cooling seems to lower their risk of damage from asphyxia, and of Intraventricular hemorrhage).

 

The normal newborn will stabilize his temperature to his surroundings. We can easily heat them above physiologic normal by over-dressing them or wrapping them in blankets and hats.

The baby who is kept skin-to-skin will be at physiologic normal temperature (not too hot, nor too cold), will regulate his breathing faster, and will have higher blood sugars than the baby who is wrapped and placed in a warmer. Hats and clothing form a physical barrier between the mother and baby. The best ‘warmer” is the mother! The mother’s arms are the best place for the baby to transition to life outside the womb!

  



[ii] . Yao AC, Lind J. Effect of gravity on placental transfusion. Lancet, 1969, ii:505-8.

Yao AC, Lind J. Placental transfusion. Am J Dis Child, 1974, 127:128-141.

 . Peltonen T. Placental transfusion advantage and disadvantage. Eur J Pediatr, 1981, 137:141-146.

 . Linderkamp O. Placental transfusion: determinants and effects. Clin Perinatol, 1982, 9:559-593

[iv] World Health Organization, Aids Prevention: Guidelines for MCH/FP programme managers, II. Aids and maternal child health. Geneva, WHO, 1990 (document WHO/MCH/GPA/90.2).

Midwife Updates Homepage