An interesting article From Journal of Midwifery& Women's Health
<http://www.medscape.com/viewpublication/870_index>
Evidence-Based Practices for the Fetal to Newborn Transition
Judith S. Mercer, CNM, DNSc; Debra A. Erickson-Owens, CNM, MS, ; Barbara
Graves, CNM, MN, MPH; Mary Mumford Haley, CNM, MS Author Information
Abstract Posted 06/22/2007
Many common care practices during labor, birth, and the immediate postpartum
period impact the fetal to neonatal transition, including medication used
during labor, suctioning protocols, strategies to prevent heat loss,
umbilical cord clamping, and use of 100% oxygen for resuscitation. Many of
the care practices used to assess and manage a newborn immediately after
birth have not proven efficacious. No definitive outcomes have been obtained
from studies on maternal analgesia effects on the newborn. Although
immediate cord clamping is common practice, recent evidence from large
randomized, controlled trials suggests that delayed cord clamping may
protect the infant against anemia. Skin-to-skin care of the newborn after
birth is recommended as the mainstay of newborn thermoregulation and care.
Routine suctioning of infants at birth was not been found to be beneficial.
Neither amnioinfusion, suctioning of meconium-stained babies after the birth
of the head, nor intubation and suctioning of vigorous infants prevents
meconium aspiration syndrome. The use of 100% oxygen at birth to resuscitate
a newborn causes increased oxidative stress and does not appear to offer
benefits over room air. This review of evidence on newborn care practices
reveals that more often than not, less intervention is better. The
recommendations support a gentle, physiologic birth and family-centered care
of the newborn.
Introduction
The transition from fetus to newborn is a normal physiologic and
developmental process -- one that has occurred since the beginning of the
human race. Many hospital routines that are used to assess and manage
newborns immediately after birth developed because of convenience,
expediency, or habit, and have never been validated. Some practices are so
ingrained that older traditional practices, such as providing skin-to-skin
care or delaying cord clamping, must be considered "experimental" in current
studies.[1] However, recent research is beginning to identify some older
practices that should not have been abandoned and some current practices
that should be stopped. In order to achieve a gentle, physiologic birth and
family-centered care of the newborn, practices that might interfere with
maternal and newborn bonding need to be closely scrutinized. This article
examines the evidence about practices related to the newborn transition,
including the effects of various drugs used labor, umbilical cord clamping,
thermoregulation, suctioning, and resuscitation of the newborn
More: An interesting article From Journal of Midwifery (cont'd)
<http://www.medscape.com/viewpublication/870_index>
> Van Rheenen and Brabin[31] conducted a systematic review of two
> randomized controlled trials[34,36] that compared immediate versus
> delayed cord clamping in term infants to determine the effect on
> anemia status after 2 months of age. Their secondary objective was to
> assess the incidence of polycythemia and/or jaundice during the first
> week of life in infants who experienced delayed cord clamping. The
> authors found that delayed cord clamping, especially in anemic
> mothers, increased hemoglobin status and reduced the risk of anemia at
> 2 to 3 months of age (RR, 0.32; 95% CI, 0.02-0.52). Although infants
> with delayed clamping had higher hematocrit levels, no reports of
> symptomatic polycythemia or jaundice were found. The authors stated
> that delaying clamping may be especially beneficial in developing
countries where anemia rates are high.
>
> The current literature refutes the idea that delayed cord clamping
> causes symptomatic polycythemia and indicates that immediate clamping
> of the cord may often lead to anemia of infancy.
> Clamping the Nuchal Cord Before Delivery of the Shoulders
> In addition to anemia, possible neurologic harm from clamping a nuchal
> cord before birth has been identified.[37] A recent integrated review
> of the literature on nuchal cord management found reports showing
> increased risks to the newborn when the cord was clamped before the
> shoulders are delivered.[38] Leaving the cord intact and using the
> somersault maneuver is recommended especially if shoulder dystocia is
> suspected. During the somersault maneuver, the infant's head is kept
> near the perineum as the body
> delivers so that little traction is exerted on the cord (Figure
> 1).[38] Resuscitation at the perineum allows the infant to regain the
> blood trapped in the placenta and can be accomplished using all the
> proper tenets of neonatal resuscitation.
<http://images.medscape.com/images/558/124/art-jmwh558124.fig1.gif>
Somersault maneuver. The somersault maneuver involves holding the
infant's head flexed and guiding it upward or sideways toward the
pubic bone or thigh, so the baby does a "somersault," ending with the
infant's feet toward the mother's knees and the head still at the perineum.
1, Once the nuchal cord is discovered, the anterior and posterior shoulders
are slowly delivered under control without manipulating the cord. 2, As
> the shoulders are delivered, the head is flexed so that the face of
> the baby is pushed toward the maternal thigh. 3, The baby's head is
> kept next to the perineum while the body is delivered and
> "somersaults" out. 4, The umbilical cord is then unwrapped, and the
> usual management ensues.
> Cord Blood Harvesting
> Increasing blood volume by delayed clamping should result in the
> infant receiving a greater allotment of hematopoietic stem cells and
> red blood cells. Hematopoietic stem cells are pluripotent, meaning
> that they can develop into many different cell types.[39] Evidence
> suggests that hematopoietic stem cells may migrate to and help repair
> damaged tissue during inflammation and can differentiate into such
> cells as glia, oligodendrocytes, and cardiomyocytes as needed.[40] In
> a rat model of cerebral palsy, half the damaged rats were given human
> umbilical stem cells within 24 hours of the injury. The infusion of
> cord blood appeared to prevent development of the rodent version of
> cerebral palsy, which was clearly evident in the damaged rats who did
> not get human cord blood.[41] Yet cord blood harvesting companies
advertise cord blood as "medical waste"
> and encourage parents to collect it at birth. Although cord clamping
> time is not prescribed in the instructions for cord blood harvesting, the
suggestion
> is that the earlier the cord is clamped, the larger the harvest will be.
> This practice of cord blood harvesting is not supported by the
> American Academy of Pediatrics unless there is a clear medical need
> within the family.[42] Parents need to be fully informed by providers
> during pregnancy in order to make sound decisions about storing cord
blood.
>
> In summary, the current literature supports a lack of harm for full
> term infants when cord clamping is delayed up to 10 minutes with the
> newborn placed on the maternal abdomen or held below the level of the
> perineum. In addition, the evidence is strong that delayed cord
> clamping offers full-term
> infants protection from anemia. Based on the current evidence, the
> recommendation is to delay cord clamping to prevent anemia of infancy.
Also,we recommend that clinicians not cut a nuchal cord before delivery of
> the shoulders, but instead, use the somersault maneuver to deliver the
child and
> resuscitate at the perineum as necessary.
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