Charlotte Kenyon, Senior Lecturer and Midwife, University of Huddersfield
The Hungarian obstetrician and midwife Agnes Gereb said that you can measure the freedom of a country by its freedom to birth. Within the UK we are fortunate that despite the budgetary and staffing constraints currently being experienced across the National Health Service, there are still a range of care choices available for expectant women and their families. The wonders of modern medicine mean that we are in the position to be able to meet the needs of an increasingly complex population. Moreover we are able to save the lives of mothers and babies who in might otherwise have died. Pregnancy and birth for the majority of women remains low risk and obstetric intervention is not needed, but the advancement of medicine is a double edged sword; with the massive achievements of modern medicine there is a potential risk of over medicalising the care of those who remain low risk. I would like to suggest that in developed countries, where there is freedom to choose our agenda, we should focus on the premise that the health of a nation can be measured by its health around birth.
It is only in recent times that there has been growing awareness of the need for analytical scrutiny of the evidence to support clinical practice. Prior to this many clinical interventions became embedded through custom and practice rather than robust research and review. With custom and practice there is a risk that we cause more harm than good through our actions. One such example can is the practice of managing the third stage of labour; in this stage the placenta and amniotic membranes are birthed. During an undisturbed, physiological third stage of labour, the umbilical cord will continue to pulsate for several minutes with the transfer of placental blood is known as placental transfusion. For a number of years it has been common practice to clamp and cut the cord, and administer a synthetic oxytocic drug to the woman in order to reduce the risk of post partum haemorrhage. Many newly qualified midwives may not have observed, yet alone undertaken a physiological third stage by the time that they qualify. The famous French obstetrician Michel Odent has written extensively about the potential harm, including a possible link to autism, caused by widespread use of synthetic oxytocin. Whilst there is still much research be undertaken in this area, until recently the impact of concurrent early severance of the umbilical cord on the neonate has received scant attention. At the risk of sounding crass, these babies are our future and the impact on them of our actions at birth have the potential for significant long term consequences, not just for individual them self but for society as a whole.
The effect of early clamping of the cord on neonatal circulation is a 20-35% reduction in blood volume. Notwithstanding the negative effects of a sudden drop in circulating volume on the fetal brain and internal organs, this loss of blood volume deprives the neonate of a significant amount of iron, enough iron to meet the needs of a newborn for around 3 months. This is further magnified in pre-term neonates. The continuing flow of blood from the placenta to the neonate assists the complex transition from fetal circulation in the uterus to neonatal circulation in extra-uterine life. Early cord clamping therefore has a detrimental effect on this transition. Even a brief delay in clamping the cord will be advantageous to cardio respiratory transition and stabilisation of blood volume, pressure and circulation. Many individuals believe that reduction in blood volume and associated nutrients alone in this critical period of neonatal development has the potential to contribute to a number of medical disorders in later life including cardiovascular disease, late onset diabetes mellitus and mental wellbeing. Fortunately, the scrutiny of evidence mentioned earlier has enabled us to advance our understanding of the impact of our actions on the neonate and to begin to address them. The Royal College of Obstetricians, Royal College of Midwives, International Federation of Gynaecologists and International Confederation of Midwives, World Health Organisation to name just a few are now recommend a delay in clamping the cord which is more in line with the physiological processes. However, we must still continue to ensure that we analyse and evaluate the care we provide and the consequences of our clinical actions. Only through doing so can we seek to ensure that our actions are supportive of optimum health not just for individuals but for society as a whole.