An Update on Delayed Cord Clamping, and Thoughts on Internet Expertise
Two years ago, I penned a post entitled “Delayed Cord Clamping Should be Standard Practice in Obstetrics”, which was read by many. Later I gave a grand rounds on the topic, which was viewed by many. In doing so, I contributed to a growing movement towards delaying cord clamping after the birth of preterm and term neonates. This was all well and good. But something else happened as well.
In the eyes of many, I became an “Expert in Delayed Cord Clamping”, worth quoting to others, and even name dropped as some sort of trump card – “Well, Dr Fogelson says….” So let me set the record straight. I am not an expert in delayed cord clamping, if such a person even exists. I am certainly not an activist for the idea, not am I sure that such activism could be justified in the literature.
What I am is this:
1. An educated person with access to the literature and training in interpretation of medical research.
2. A physician with intellectual expertise in maternal health, and first hand experience in its practice
3. A person with a platform where his opinion would be heard.
and
4. A person who chose to express said opinion on that platform.
And that’s it. Does that make me an expert? I say no. Nonetheless, it seems that anyone that chooses to speak in a public forum will be given great respect as an expert in whatever they choose to speak about, if only because they took the effort to open their mouth and be heard. It is this instant “respect to the one who takes the trouble to speak” that makes public speaking so powerful. But let’s not go overboard. I encourage anyone who has read what I have written to investigate the literature, consider the non-data driven logical and physiologic arguments, and then decide for themselves. If you do this, you will be as great and expert as I.
So with that in mind, consider what’s new in the field.
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Since the 2009 article, several randomized trials have been published, as well as review articles on the topic.
Andersson et al recently published work that demonstrated improved iron stores, lower prevalence of iron deficiency anemia in delayed clamped infants, without evidence of any adverse effects. This data was interesting in that it was produced in a population with a lower prevalence of maternal iron deficiency than the population studied by Chaparro et al in Mexico.
Oh et al recently published data for a randomized groups of 33 very low birth weight infants ( < 1500 grams), which showed higher hematocrits in the delayed clamped infants. They found non significant trends towards improved morbidity rates. Mercer et al demonstrated improved morbidity rates with a sample size of slightly more than double the number of infants studied by Oh, suggesting that Oh may have lacked adequate power to find a difference between groups. It is also possible that Mercer’s data represented an alpha error and overstated the actual benefit of delayed clamping, and that Oh’s data is more representative of reality.
De Paco et al looked at cord gasses from infants of delayed versus immediate clamping, and found minimal differences between the groups.
A JAMA meta-analysis concluded that delayed clamping at term had both short and long term neonatal benefits without apparent downside risk.
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So how are we to interpret this and previous work? Firstly, you get to decide for yourself, as I am just one person. Some people with similar backgrounds to myself see it differently. But the following is how I would interpret it.
Delayed cord clamping is more akin to the natural process of birth that we have evolved towards, and to the birth process shared by all land mammals. Immediate cord clamping clearly reduces the amount of blood in the infant in terms of volume, blood cells, and iron content. In my mind, this action removes blood from the infant that the infant was “destined” to receive absent the intervention of immediate cord clamping.
That said, human beings born at term clearly thrive no matter what is done. One only needs to deliver a few hundred infants, clamp their cords immediately after birth, and watch them go home apparently healthy to know this. However, when we measure outcomes at a population level, delayed cord clamping appears to benefit infants. These benefits appear to be clear for iron stores. In preterm neonates, there appears to be a benefit in terms of intraventricular hemorrhage and perhaps sepsis, but we must remain conscious that these data are based on small sample sizes, and are therefore at risk for being the product of statistical error.
Most important in my mind, however, is that there is no real data to suggest that delayed cord clamping is at all harmful to an infant. For that reason, the combination of the underlying physiologic and rational argument with the available data is compelling enough to me to support a policy of routine delayed cord clamping for term and preterm neonates.
But let’s not get ahead of ourselves with this data. Some are supporting delaying cord clamping in an infant that is born distressed in clear need of resuscitation. To me this seems foolish. An infant that is bradycardic from hypoxia is going to have a hard time circulating through its cord. It needs oxygen, and the way to deliver that is through its lungs. If we can devise a way to do this while leaving the cord intact, so much the better, but lacking this lets just be pleased that we have wonderful pediatric staff who can deliver expert care to these infants, and let issues of the cord fall away. Let’s not also hang on the theoretical possibility of placental ECMO, or continued neonatal gas exchange through the cord after delivery. This idea clearly has some physiologic merit, but we have no data whatsoever that would support delaying resuscitation of a infant in jeopardy under the belief that it will self-resuscitate through the cord. Sadly, some have quoted me in support of such a policy, so let me make it clear that I cannot support the idea outside of a research protocol. We are so good at resuscitating infants with proper airway management and ventilation. Let’s not impede our ability to use our strength in pursuit of naturalism. Infants in distress deserve better.
So let’s support delayed clamping and do it whenever feasible. It makes senses and there is data to support it. But holding it up as the one critical moment of an infants birth is more religion that science. And for crying out loud, an infant that is born near lifeless needs to breathe a lot more than it needs an intact umbilical cord. We must remember that if that baby is lifeless, the cord wasn’t doing a very good job up to that point. We’d better give it a break and take over.
Academic OB/GYN 
I’ve assisted a few homebirth midwives (both DEMs who later became CNMs to be able to practice legally) and they resuscitate with the baby on the cord. It’s definitely doable, but you have to bring the equipment to the baby, rather than the baby to the equipment. The midwives I’ve worked with use a portable resuscitation surface–usually a rigid board with a heating pad on top, wrapped in some sort of towel. They also carry portable O2 tanks, so they can bring the equipment wherever it’s needed.
Resuscitating and leaving the cord intact doesn’t have to be an either-or proposition, but it does mean relearning how to resuscitate without the baby on a separate resuscitation cart (often several feet away from the mother).
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Needed it
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How about newborn in distress gets the best of both? http://www.lwh.me.uk/Library/news_centre/Life_Saving_Trolley_Basics_Case_Study.pdf . Surely you have heard of the BASICS Trolley being implemented in UK which allows for complete evaluation and resuscitation of newborn without severing the umbilical cord.
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I think the idea of simultaneous placental transfusion with transpulmonary resucitation is a great idea, but is impractical in any delivery room I have ever seen. I have heard of the BASICs cart (trolley), but have never seen one, making it a theoretical idea for me at this point.
While I strongly support delayed cord clamping, I have occasionally heard of women being so adamant about it that they are resisting efforts to provide resuscitation to an infant in need. It concerns me that information I have presented may have been a part of promoting that idea, which I certainly cannot support.
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I believe to do neonatal resuscitation with the intact cord appear to be a rather contemporary approach.
Possibly, it is like the simplified version of the EXIT procedure, where we fix the lung while the cord keep the baby well.
Theoretically, intact cord continues to increase the oxygen-carrying haemoglobins while the neonatal resuscitation loads the haemoglobins with oxygen in the lungs.
However, is there any conclusive or ongoing trial showing evidence of this practice?
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I appreciate your podcast and reviews of the literature because those of us not affiliated with a university do not have access to the literature beyond what is available through Pub Med. As you know, it is not possible to achieve a balanced view of the literature just reading the journals to which one can afford to subscribe. I see this as a significant barrier to the promotion and implementation of evidenced based practice. I think that this lack of access also contributes to seeing those who speak out as experts. You invite us all to become “experts” but with limited access to the literature, it is simply not possible. BTW, I have resuscitated newborns with the cord attached. Believe me, since I was a NICU nurse before I was a CNM, I am a devotee of NRP and timely PPV!
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It would be great if all the peer reviewed journals were open-access, but I’m not sure how that would work. The reason magazines can be distributed far below cost of production (or even free) is that they depend on wide circulation to drive up their advertising rates. Peer reviewed journals have minimal advertising compared to any commercial publication, and rely on high subscription fees for financial support. Its a bit of a catch-22.
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Nrp & Ppv ?
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Beethoven’s music was on the radio yesterday in celebration of his birthday. Hearing an elegy for a baroness patron who died in childbirth reminded me that that would have been my fate if I had given birth back in the 19th century.
My first son suffered severe head trauma (cephalhematoma) at birth. His developmental delays were evident from the beginning. I did survive to have three more sons. My second son’s birth was even more traumatic (a face presentation). for years I believed he was stillborn, brought back to life after many tense minutes of resuscitation. At 8 pounds 14 ounces he looked fine within a day or two. He had no developmental delays and was precocious in learning to speak. Sadly at age 3 he was diagnosed as having autism. His speech was clear but consisted only of phrase fragments (echolalia).
Who am I, to suggest birth injury as cause of his autism?
1. I returned to school to study biochemistry and neuroscience, and am well-trained in interpretation of medical research, which I have followed for more than 4 decades now.
2. I chose family over pursuing a career in research, and am viewed as just a mother.
3. I have no platform from which to express an opinion that could be taken seriously.
4. However, I will keep trying to point out that ischemic injury at birth affects the brain in a very clear-cut pattern of damage that could interfere with normal language development, and I only hope someday this will be recognized:
In 1959 Ranck and Windle published their surprise finding of subcortical damage caused by “asphyxia” at birth, with most prominent ischemic lesions in nuclei of the auditory pathway. See Ranck JB, Windle WF. Brain damage in the monkey, Macaca mulatta, by asphyxia neonatorum. Exp Neurol. 1959 Jun;1(2):130-54.
In 1962 Kety published results of his work on blood-flow in the brain with the surprise finding that nuclei of the brainstem auditory pathway have higher blood flow than any other area of the brain, which explains their greater vulnerability to ischemic impairment. See Kety SS. Regional neurochemistry and its application to brain function. Bull N Y Acad Med. 1962 Dec;38:799-812. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1804882/?tool=pubmed.
In 1969 Faro and Windle published their finding that brain maturation does not follow a normal course in monkeys subjected to “asphyxia” at birth. See Faro MD, Windle WF. Transneuronal degeneration in brains of monkeys asphyxiated at birth. Exp Neurol. 1969 May;24(1):38-53.
In 1940 William Windle stated, “. . . the rather common practice of promptly clamping the cord at birth should be condemned. Of course this will make it impossible to salvage placental blood for ‘blood banks.’ However, the collection of usable quantities of placental blood robs the newborn infant of blood which belongs to him and which he retrieves under natural conditions.” See Windle WF. Round table discussion on anemias of infancy (from the proceedings of the tenth annual meeting of the American Academy of Pediatrics Nov18-20, 1940) Journal of Pediatrics 1941 Apr; 18(4):538-547.
You point out that “human beings born at term clearly thrive no matter what is done. One only needs to deliver a few hundred infants, clamp their cords immediately after birth, and watch them go home apparently healthy to know this.”
My stillborn son was resuscitated, came home apparently healthy, and appeared to develop normally for about 3 years. However, abnormalities of the auditory system in victims of autism have recently been reported. See Kulesza RJ Jr, et al. Malformation of the human superior olive in autistic spectrum disorders. Brain Res. 2011 Jan 7;1367:360-71.
Clearly most infants suffer no harm from clamping the cord immediately at birth. However, the developmental course of these infants should be followed into the school years, and into their teens. Schizophrenic decline becomes apparent sometimes as late as a person’s 30s, and includes auditory system dysfunction.
I wish my son could have been resuscitated without clamping the cord. I realize now that he was not stillborn, and at 8 pounds 14 ounces had been well nourished and oxygenated from the placenta. Allowing placental blood-flow to continue during ventilation of his lungs would have been healthier, but I realize that in earlier generations we might both have died in childbirth.
Thank you, Dr Fogelson, for continuing to advocate delayed clamping of the cord at birth. I do hope Drs. Weeks’ and Hutchon’s BASICS trolley can soon come into routine use for depressed babies.
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Thank you for your comment. I think there are some interesting theories that can be made between immediate cord clamping, loss of iron stores, effects of iron on neuronal development, and subsequent neurological disease. At this point they are just A->B->C->D ideas, with no idea how E-Z come into play. There may be an actual connection, or there may not. Many autistic children have no history of childbirth hypoxia, and many infants with childbirth hypoxic events do not develop autism. Its an interesting idea though.
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Help I need to try to get my hands on some info on this topic in SPANISH to present to the Drs in the Dominican republic where we bring students and help with deliveries a few times a yr.any leads ?? Thanks Much Lisa Aman LM dancingmidwife@gmail.com
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As an avid reader of cord clamping ‘information’ – literature, articles, blogs and birth stories – I have seen your contributions to social media widely distributed and discussed. However, I have to disagree that (m)any advocates of delayed cord clamping believe this is all compromised infants require. I take your word for it that you have been quoted in this way, however like the posters above me, the discussion and advocacy I’ve come across is concerned with preserving the anatomy of birth so that placental transfusion is still possible – nothing to do with delaying or withholding resuscitation.
I recently wrote to Dr. David Odd (UK) to discuss his work (re: resuscitation at birth and cognition at 8 years of age: a cohort study) and in his reply he stated: “At present we don’t know if early cord clamping is good OR bad for compromised infants at birth: but I am aware of research being planned in this area so we may have an answer in a few years”. Sounds promising.
The implementation of the B.A.S.I.Cs trolley in the UK may be able to begin generating data but it would also be good to have longer term studies that track outcomes.
All the best,
Kate
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Kate – I completely agree. Advocates (like me) are not proposing the idea… but some people are hearing that message anyway. I think that resucitation with the cord intact is the ideal situation, and like you would like to see that be made easier to do.
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If the cord is pulsing in a compromised infant, it is my understanding that is an indication that the blood is flowing from the placenta to the baby. And even in the absence of a pulsing cord, the flow from placenta to baby is passive, which means if you hold the baby on an equal level or lower than the placenta, the placental blood will drain into the baby. That’s the baby’s blood in the placenta, and especially compromised infants should have all of their oxygenated blood.
Regardless of whether you think the cord has done a great job or not if a baby is born flat, the reality is that the reason that baby grew and lived long enough to be born is because the placenta and the cord did a good enough job.
Another reason to leave the cord intact, besides oxygen and blood stores from the placenta, is that the cord attached to the placenta (which is usually still inside the mother) makes it impossible to remove the baby from the mother, at least not very far. See Dr. Nils Bergman’s work at http://www.skintoskincontact.com for an explanation as to why it is especially important for compromised babies to stay with their mothers: in a nutshell, the mother is the baby’s safe place, and when the baby is removed from the mother’s presence, the baby goes into despair-distress mode, which negatively affects heart rate and oxygenation.
Midwife Thinking’s blog has a post on the topic of resuscitating with the cord intact: http://midwifethinking.com/2010/08/26/the-placenta-essential-resuscitation-equipment/
Also, see this website for photos and description of a baby being resuscitated in mother’s arms: http://www.homebirth.net.au/2008/04/resuscitation-of-newborn.html
It can be done.
Let’s start to assume, as the first rule of medicine requires, that any intervention is harmful until proven safe (First, do no harm). Including the intervention of cutting the cord so you can resuscitate a baby. Use the cord and the placenta, don’t sever them. How long would it take to retrain any one medical professional in resuscitating a baby on a board on their lap or with the baby in the mother’s arms? Strictly technically speaking, I don’t think it would take very long. Skills are the same. It’s the attitudes that need to change.
Cutting the cord at any time should be assumed harmful until proven safe. The physiological process is that the placenta & cord separates from the baby when the cord dries. Let’s put the onus on the INTERVENTION to prove itself, not the other way around.
Mothers of Change is doing a series on cord clamping right now: http://www.mothersofchange.com
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That was a really interesting point. Many people confuse the term expert, with educated. However, you have experience which adds to your educated reliability! I would definitely call you a great source of reliable information!
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It is ancient Indian practice to try to revive a still born by heating up the placenta and massaging it. Apparantly, it does help revive some infants.
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Does anyone have an experience with delayed cord clamping and privately banking cord blood? My wife and I are expecting our first child in just a few weeks. We first learned about the benefits of delayed cord clamping in a child birth class we recently took. I never heard of the idea until then. Weeks before this class we had already signed up with a private cord blood banking company. After doing a lot of research and watching Dr. Fogelson’s Grand Rounds lecture we have become more and more interested in delaying the clamping of the umbilical cord when our child is born but are conflicted because we don’t think we will be able to bank anything either. I can’t find any information on anyone who was able to do both. Our private banking company said we could but run the risk of not collecting enough to bank. My wife and I are in the mind set now that we are going to do what we think is right for our baby and if we can bank something as well then fine but we are having a hard time justifying taking away from our child for something we hope we never have to use (and may not even be able to use). So does anyone have any experience/evidence of being able to do both?
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Apparently banked cord blood is a bit of a fallacy, in terms of thinking that your baby’s blood will be useful for your child if your child should get sick. I am on a maternity care discussion group list, and while I can’t copy and paste verbatim what a doctor said on the subject (as that would be plagiarism), she said that a Pediatric Oncologist did grand rounds at their hospital and she learned that children with blood cancers cannot use their own banked cord blood to help their illness, as it contains the same genetic information and is therefore risky. They do use cord blood, but they get it from a cord blood bank.
You may also find this article helpful. http://www.scienceandsensibility.org/?p=2359
Basically, banked cord blood is usable in about 1 of 3000 cases (that’s considered fairly low, as it’s 0.03 % chance) and cord blood collection is only recommended as a possible consideration for families with an already identified first-degree relative with an illness where cord blood could be useful.
Sounds like you are on your way to an informed decision! So happy to hear that you are looking at delayed cord clamping. You may be interested to read these posts on the subject as well (from the bottom up)
http://www.mothersofchange.com/search/label/delayed%20cord%20clamping
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While some argument can be made for public cord banking, private cord blood banking is something that is hard to support at any evidence based level. It is predominantly a bet on a science fiction future where we can use these cells, which at this point is still speculative. Given the benefit of delayed clamping, I’d rather see the blood go into the baby.
I was at a talk yesterday about public banking which was really interesting. One thing that was quite fascinating was some new data on cord blood amplification, which would allow a small sample of cord blood stem cells to be amplified ex vivo after being thawed, dramatically increasing the population of stem cells available for transplantation. If this becomes more mainstream, one might be able to significantly delay cord clamping for the newborn’s benefit, then bank what remains in the placenta. While this smaller amount would typically not be enough for a good stem cell transplant, with amplification it could be.
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As a CNM in a birth center,We have delayed cord clamping as long as 10 mins and still able to collect adequate cord blood for storage. I have yet to have a cord blood collection not sufficient for the cord blood bank.
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The question is not whether or not the sample can be banked, it is whether or not that sample is actually very useful for tranfusion. A private bank is happy to take any sample you give them. They make money on it. A public bank prefers bigger samples, but will take smaller ones up to a certain limit. Particularly small samples may for research rather than for banking for potential transfusion. In the end, transfusion success is highly dependent on the volume of the cord blood sample. The volume that transfuses to the infant with delayed clamping is ultimately in inverse relationship to the volume of a banked cord blood sample.
There are some things on the horizon, however, that may make this moot. One is that many hematologists are moving towards using multiple cord blood units for transfusion into the same recipient, mitigating the effect of small sample. The other is work in cord blood amplification, which increases the amount of stem cells prior to transfusion.
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We do understand that private banking is a risk in that you very well may never be able to use the cells should someone in the family need them. If someone were inclined to do both how long should clamping be delayed in order for the baby to benefit?
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I really don’t think it makes a great deal of sense to do both, outside of the possibility that a small sample could be amplified in the future. Delaying clamping reduces the residual blood in the placenta, and the effectiveness of a cord blood transfusions is very tied to blood volume.
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The article in Science and Sensibility (I posted the link in an earlier post) has ideas for delaying cord clamping and cord blood collection.
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I donated my daughter’s cord blood to a public bank AND delayed cord cutting– in fact the banking instructions specify a delay is fine- I know others who try to chime in from time to time and mention that this is a possibility- and most of us started off with everyone telling us it couldn’t be done. I just made a phone call to the company I used and also looked at the instructions that came with my kit – it did NOT indicate immediate clamping was necessary- instructions specified that it had to be done before the placenta was delivered which takes some time (I cannot remember the instructions for csection births)
If you have a specific medical reason for banking you might want to allow your care provider to minimize or avoid the delay .Like Dr Fogelson mentioned, there could be a chance you would not get enough blood volume- but from talking to midwives and others it seemed that there was enough blood for the collection in most cases. So yes, in these rare cases I can see a family choosing to avoid the risk and cut the cord immediately for banking. Luckily, most of us are not in this difficult position and we should be guided toward public banking options for the hope that many many many more people would find help through a National registry.
Call your cord blood representative- ask questions- tell your care provider your wishes and show them the instructions that back you up BEFORE your birth, look into public donation. If you have a genetic reason for banking, check to see if you can use the public system and still keep your donation earmarked for your family (this I had read was available in a few specific cases). Private storage may not be what your family needs.
Paying for cord blood banking seems to be preying on parents insecurities- in most cases.
This may be controversial for those that believe the delay needs to be 15 min or hours long…. there may be times when you don’t get the proper sample, and drs may believe they can’t get a sample … but explore the choices that are available before discounting the possibilities.
Jessica
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It can be done, and the banking companies officially have no position….. but in the end you aren’t donating a particularly useful unit of blood. The efficacy of a transfused unit is highly dependent on the volume of that unit. A 150 cc donation is a very useful cord blood unit. A 90 cc donation is far less so.
This is somewhat mitigated by new tranfusion practices of infusing multiple units simultaneously.
I agree with your point about public cord blood banking. It makes a great deal more sense than private banking.
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Does anyone know if pitocin administered right after birth (possibly to speed up the third stage of labor) has any affect on the oxygen supply to the newborn if the cord was not clamped upto 10 minutes after birth?
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As the baby is getting oxygen via the lungs at this point, it should not affect oxygen delivery unless it interferes with breathing.
However, as noted below, we do not have any reliable data on the effect of oxytocics (syntocinon, ergometrine) given for PPH prevention on the baby, as the original data on active third stage included early cord clamping.
Need more studies in view of this recommended change of practice.
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Also wish to find out if drugs used in a managed third stage or induction prevent delayed cord clamping..
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We don’t really have any data on this.
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Judith Mercer is quoted as saying:
“The concern that delayed cord clamping may lead to overtransfusing the infant after administering a uterotonic the third stage of labor is unsupported. Yao and colleagues (Yao, Hirvensalo et al. 1968) demonstrated that the infant recieves a maximum of 90 mL/kg (normal physiologic volume) within the first few minutes after a uterotonic is administered, no matter how long the cord clamping is delayed. They used a very strong IV uterotonic no longer in use today.”
From CURRENT BEST EVIDENCE: A REVIEW OF THE LITERATURE ON UMBILICAL CORD CLAMPING
(Mercer, 2001)
The use of oxytocic drugs has been shown to speed up placental transfusion (67) to the infant…
(67) Yao AC, Lind J. Blood flow in the umbilical vessels during the third stage of labor. Biol Neonate 1974;25:186–93.
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Greetings from New Zealand, where a large proportion of the birthing population is delivered by Registered Midwives, in homes, in hospitals, wherever the birthing event is occurring. My question is around active management of the third stage and delayed cord clamping, do you have an a opinion about the administration of a tocolytic prior to the clamping of the umbilical cord?
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There is yet more to be learned about the disadvantages of immediate cord clamping and why blood banking taking the blood from the cord, should be banned. Since stem cells exist in placentas, techniques should be perfected to harves that, not rob babies of stem cells and red blood cells that they need.
I’ve addressed some of these situations in this blog:
http://www.beyondconformity.co.nz/_blog/Hilary's_Desk/post/Why_Immediate_cord_clamping_must_cease/
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A lot of what you are written I agree with, particuarly that cord blood banking supporters seem to entirely ignore the potential benefit of autotranfusion of blood back into the fetus. That said, I hope you and your readers realize that most of the connection you claim between immediate cord clamping and autism is highly speculative, and at this point completely unproven. Science is about making a hypothesis, designing an experiment to test that hypothesis, and then answering the question. Your article makes a lot of conclusions without data to support, which is more empiricism than science.
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I agree , but I think you implied in the youtube clips, that you once thought the opinions of parents who wanted the cord NOT to be clamped was also empiricism. Didn’t you assume that immediate cord cutting must have had some good scientific basis behind it? Have you ever sat back and really looked at how much medical practice is also empiricism? I’ve spent decades studying medical literature, and been amused at how much medical practice was and still is, empirical in nature, yet is talked about it as if it’s fact. How many drugs are prescribed for children, which have never been tested in children? How many drugs prescribed to women have gone through proper trials in women? Many of them were done on men, and then prescribed to women – a big no-no in my opinion.
I don’t view cord cutting as a major cause of autism even if Professor G Morley does. I was stating what he says, and provided embedded articles by him, where he states his view. My views on that are much more controversial, but that’s not the topic of conversation here. What I presented in the blog was other people’s opinions, including yours, which I think parents need to consider.
Perhaps it’s time I did a blog on the massive extent of “empiricism” in medical practice which is silently passed off as fact, and which parents agree to, simply because they assume that the doctor is practicing scientific fact.
Just as parents once assumped that immediate cord clamping was fact and was done because science had shown that to be good.
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Thanks for the comment. I agree that there is a huge amount of empiricism in medical ‘knowledge’. I had a professor once tell me “half of what we “know” is actually wrong. Over your career your job is to figure out which half”
I think, though, that a good biological scientist makes hypotheses based on knowledge of human physiology, and thus hopefully has ideas that are plausible. I find that a lot of the pseudoscientific experts have a tendency to make arguments that to me are utterly unplausible, in that not only are they unproven, but there is no real physiologic basis to believe that they would be. When I am told a piece of ‘knowledge’ by another person who would claim to be an ‘expert’, I have to run it through my basic ‘bullsh*t’ filter, and ask myself ‘based on what I know about how the body actually works, is that idea plausible?”. If the answer is yes and the source is someone I consider to be intelligent and reasonable reliable, they I will tend to believe that this has a good chance of being a correct piece of information. It it does not seem plausible, or the claim seems very extraordinary, then I am going to need a lot more evidence to believe.
For example, if a surgeon tells me that it is best to operate on someone that has been shot in the belly, I would think that this is non-extraordinary claim and probably believe it, even though we probably lack any real systematic data to prove this point.
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I can see your point. First let me restate this: I really liked what you said on the youtube clips. You have plainly decided to look outside of one box and probably even more as well, and I very much like that.
Here is the problem for most parents who have normal medical model doctors. (I don’t think you are “normal” though.)
How accurate is the bullshit detector, of the person who is their doctor?
As the long standing Precursors study has shown over the decades, not only is a medical student, and subsequently those doctor’s own health determined by their attitudes, … the decision making and aggressiveness of their practice is determined by their personality flaws, response to challenge… AND whether or not those doctors get cancer, acute disease or commit suicide has everything to do with how they “think” – not the medicine they practice, or even the gene theories so often touted.
So how much should parents – who don’t know their doctors in this day and age -, trust the bullshit detector of a professional as opposed to their own? Where is the balance?
The place of an educated parent is far more difficult than the medical profession realises, because the doctor who is normal, tends to protect their butt, not that of the parent.
A parent is an expert in their child. Sometimes, being ordinary and having commonsense, is an adaptive advantage, even if in the process parents are considered pseudoscientific laity –which medical school did you – this lay person, go to — though that’s never stated bluntly, but it’s often implied. (BTKT)
Here is are two simple examples from my days as a mother. and this still happens today, as my telephone line proves.
1) The parent whose child suddenly gets a mild fever (38.2 C) and instantly the nurses and doctors are wanting to administer acetaminophen because, “We’ve got to get this temperature down” – which has been the mantra for the last I don’t know how many years.
What happens if the parent believes that a temperature has a function which is designed to give the child an adaptive advantage, and if you use a chemical which downregulates the immune system, you give the bacteria the adaptive advantage? What happens if that parents says NO? For the last 30+ years, there has been a huge amount of medical information which shows that chemically reducing a temperature during an infection is dangerous for the child, yet even today, you dare to show that information to a doctor in hospital, and chances are you’ll get your head bitten off.
2) Secondary to this fever, for no good reason, you are suddenly told that this sore throat “must be” strep, so heavy duty antibiotics are imperative right now, because you don’t want your child to get rheumatic fever and have heart problems for the rest of their life.
The parent might reply, “So, um are you going to do a swab, and even if you do, given that ALL of us carry strep at some point, and only a few get rheumatic fever, what is it in a throat swab, that distinguishes a transient carrier, from an active infection, from the likelihood of subsequent rheumatic fever?”
When the mother points out that the medical literature has clearly shown that rheumatic fever has a lot to do with the micro and macronutrient health of the person (which is why most people don’t get it) and their child doesn’t fall into that socio-economic or poverty of knowledge group, they are suddenly dumped into the category of a luddite who has no appreciation for the wonders of modern medicine, and who would rather their child got seriously sick.
The medical professional can then be faced with a choice. Do they tell the parents all the facts (including that their worry meter got the better of them), then let the parent set the boundaries and make a properly informed choice, or do they move in on the basis of “failure to comply” because their authority, “right to prescribe” and professional pride was challenged?
Is any decision to move against the parent made if the “power” base of the professional is more threatened than their ability to admit that the parent might have a legitimate point which they neglected to consider in their rush to do something?
This also applies in obstetrics as well. Having done labour support, I’ve seen many a New Zealand obstetrician move in, because their personal worry meter is being challenged, rather than the fact that there is a real need to do something. I’ve also seen the opposite – when it was plainly obvious to me, that the mother was in real trouble, and the obstetrician was oblivious. It’s very hard for a labour support person to say, “Um do you think you should re-evaluate doing nothing?” It’s even harder to say, “That pudendal block is totally unnecessary….”
The problem here isn’t just that a huge amount practiced in medicine is empirical, but also that it is subjective, and dependant on the hearing ability and personality of the professional involved, not gold standard anything. It might even be dependant on whether or not the medical profession just wants to go home now.
In the meantime, none of us, myself included, can say that our bullshit detector has no defects.
Looking back over the last 30 years it has been interesting to see that my bullshit detector was more accurate than any doctor we have been involved with. Worse, the times when I’ve capitulated to the doctors because I was too big a wimp to push back, have been the times when my kids have paid the price. On two occasions, even when the doctor concerned were big enough to come and say I was right, and they wished they hadn’t done that, it hasn’t been easy for me to forgive myself for not standing up, in line with my bullshit detector.
So what I really look forward to, and hope to see some day, is when all doctors, not just forward thinkers like you, put more trust in parents’ bullshit detectors, and really listen to what it is that parents think, say, take it seriously, and make sure that their patients have a much greater part in the partnership, and in the end say.
The problem is that doing that, takes time.
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Is there any research update on DDC, especially regarding compromised newborns? I am especially looking for any research to support DDC for a newborn that will be born with a heart defect, specifically Holmes Heart. Along with the benefit of keeping her blood supply, is there research about how that full blood volume (as it is allowed to equalize, resulting in the pulse finally ceasing) and pressure benefits cardiac function?
As a homebirth midwife that does not clamp and cut the cord until pulsing ceases, I observe this process with great fascination. The pulse often doesn’t cease completely until the placenta is delivered. It becomes less palpable by distance from the umbilicus. Often the pulse can still be palpable nearer the umbilicus, while the remainder of the cord has had no pulse for several minutes. What exactly is going on in there? What is the sequential physiological process in play between the baby’s heart and attachment/detachment of the placenta? Waterbirths also clearly affect the timing of this process.
Also, while I agree that a severely compromised baby is most in need of resuscitation, if the cord is NOT flat and bradycardic but still pulsing well, then clamping would not be the more beneficial next step. Facilitating NRP guildelines with an intact cord would be optimal. A newborn in need of resuscitation (PPV) often does have a well-pulsing cord. “Stripping” the cord, giving a bolus of blood to the baby, also needs more research.
Also, suction efforts that illicit a vagal response, suppressing respiratory efforts is also a factor. (I believe I have observed this in hospital resuscitations many times, even though NRP updated guidelines no longer require it, even in the presence of mec-stained AF, if the baby is already making some respiratory effort.)
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What about the Monochorionics, Identical
twins & HOMs that share Placentation?
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Your post is a timely cotutibnrion to the debate
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