[Editor's note: This is Part Two of Jackie Levine's essay on The New World of the Newborn in which she explores the frequent dichotomy between up-to-date evidence and common obstetrical practice. To read Part One of this post, go here.]
In the third class of each of my Lamaze education series, I start to disseminate studies about what happens during the first moments in the life of the new baby and the new mother. One of the articles I give out is a copy of a blog post I read in 2009: Dr. Nick Fogelson’s essay on his blog site, the Academic OBGYN. It gives the mothers in my classes a real hard look at obstetric philosophy, politics and practice. It helps them to have a really good look at what docs say to each other and rarely to their patients, and supports parents’ abilities to make informed decisions about acceptance or refusal of care…to demand best-evidence practices for themselves and their babies.
I had really mixed feelings about the article. Fogelson exhorts his colleagues to change the practice of immediate cord clamping and presents a wealth of evidence, yet stays away from a real condemnation of the current practice with language that has a veiled politeness, but he declares that he’s doing due diligence by “blogging” about it. The title of his blog post is “Delayed Cord Clamping Should Be Standard Practice in Obstetrics.” That seems really unequivocal to me…a title that calls out for a total change of the current practice of immediate clamping and cutting of the umbilical cord. In my last post on this subject, I quoted extensively from his article and some of his words are chilling. To recap just two items from his post: “We ought to give the tykes a few minutes to soak up what blood they can from the placenta before we cut ‘em off,” and, “I wonder at times why delayed cord clamping has not become standard already; why by and large we have not heeded the literature. It is sad to say that I believe it is because the champions of this practice have not been doctors but midwives and sometimes we are influenced by prejudice.” (My emphases.)
Nowhere in Dr. Fogelson’s post does he say, “Let’s stop now! All of us! Stop now! Let’s stop harming babies, let’s change the textbooks, let’s put out new practice bulletins immediately!” In his defense, since the writing of that blog post, Dr. Fogelson has delivered a couple of Grand Rounds lectures on the subject, and he continues to be an advocate for DCC, (delayed cord clamping) but his original words seem to make obeisance to the establishment, to ask politely for them to heed best-evidence care.
Dr. G.M. Morley, a Fellow of the American College of Obstetrics and Gynecology says on his website:
The normal healthy newborn with millions of years of experience in its genetic code, clamps its own cord, usually between two to four minutes of birth. After natural closure, the doctor’s cord clamp may be safely applied.”
This advice, when followed, surely cannot harm any doc if he/she heeds it, but can help many newborns.
In an article posted in 2010 by Expert Reviews Ltd., on changing practices in episiotomy, the authors ask in bold subhead: Why Don’t Physicians Follow Clinical Practice Guidelines?1 They answer: The challenges of obtaining high-quality data to direct evidence-based care have been greater in obstetrics than in many other medical disciplines” and “since obstetrics generally has lagged behind other disciplines in its efforts to have standardized, outcomes-based practices, there may be greater cultural barriers among obstetricians to changing practices based on new data.”
More from the same study:
In 1998, a questionnaire mailed to family physicians and obstetricians found that only 40% felt that evidence-based medicine was “very applicable to obstetric practice. Concerning comments from this survey included, ‘obstetrics requires manual dexterity more than science’…’evidence-based medicine ignores clinical experience,’ and that following guidelines could result in ‘erosion of physician autonomy.’”
These views were described as obstacles to the adoption of evidence-based practices, and the authors recommended emphasis of critical analysis of the literature as part of medical education. The following year, Cabana and colleagues published a review of reasons that physicians fail to change their practices in the face of new evidence or published clinical guidelines. They found multiple types of barriers to practice change, including lack of awareness or familiarity with current recommendations, lack of agreement with the recommendations, lack of self-efficacy to make practice changes, inertia and external barriers to practice change. Of those physicians who did not agree with the practice recommendations, a variety of reasons were cited. Some physicians felt the evidence did not support the guidelines, some felt the recommendations were like a ‘cookbook’ or reduced physician autonomy, or did not apply to their patient population. Finally, some physicians had a ‘lack of outcome expectancy,’ or did not believe that making the recommended practice changes would improve clinical outcomes.”
These reasons are not acceptable, they smack of nonsense, and yet they guide practice. It makes me ask, when I read the words that evidence-based practice is not “very applicable to obstetric practice,” why is practicing good medicine on a birthing mother different from practicing good medicine on anyone else? And why will using good science “erode physician autonomy”?
John Maynard Keynes famously said “When the facts change, I change my mind. What do you do (sir)?” What should docs do? Seems simple, doesn’t it? Change practices to reflect best evidence. Do it now. No mother will object, I’m certain. But no one yet has offered an effective way to change these attitudes or overcome the barriers that negate best-evidence care
A study that came out this year entitled, “Scientific Evidence Underlying the American College of Obstetricians and Gynecologists’ Practice Bulletins”2 the conclusion of which was stated in its abstract, proudly announced: “One third of the recommendations put forth by the College in its practice bulletins are based on good and consistent scientific evidence.” How about the other 70%? I cannot imagine another medical discipline that would succeed when only a third of its practices were evidence-based.
The fastest part of birth should probably be slowed considerably. Out comes baby, whoosh, and a mad rush of procedures begin. These first moments are when the fetus becomes a baby, and a huge amount of respect should be paid to the process by which the newborn acclimates to life outside the womb. The immediate, routine, aggressive suctioning of the newborn would likely disturb and irritate the sensitive tissues of even the adult nose and mouth. We have all seen the distressing images of the relentless blue bulb attacks on those delicate newborn passages. How can we imagine what the newborn perceives the world to be like if those actions are the first he experiences? In a World Health Organization Handbook3 written for health care providers, the section entitled Care of the Newborn at Birth says:
Most babies do not need any resuscitation at birth. Mouth suction, face mask oxygen, and vigorous stimulation in order to provoke a first gasp or cry are all pointless rituals that lack any clinical justification.
“Even in a baby born covered in meconium there is no evidence that carefully cleaning of the nose and mouth reduces the risk of meconium being drawn down into the lung.”
In at least one hospital in Vancouver BC, the latest neonatal resuscitation program has been updated to reflect a resuscitation manual which recommends that babies are not routinely suctioned at delivery. As a result of their changes in procedure, they no longer have suction available to the obstetrician at the foot of the bed and on the rescusitaire. As always, practices differ from place-to-place and we can only hope for this best-evidence care to spread like a blessing from birth venue to birth venue.
The practice of an immediate bath in the nursery is also anathema to the newborn’s efforts to adjust and stabilize itself in the first hours of life. The bath, given far away from the mother’s warm body, can be harmful and dangerous, and is usually for the convenience of the nursery staff. The WHO talks about preventing heat loss with this caveat:
“Babies very easily get cold immediately after birth, and using water or oil to clean the skin within four hours of birth before body temperature has stabilised can make the baby dangerously hypothermic (a problem that may well be missed if a low reading thermometer is not used). Nothing is a more effective source of warmth than the mother’s own body as long as the baby is first gently dried to minimize evaporative heat loss and mother and baby are then both protected from draught.”4
There’s a fine video out there about thermal protection of the newborn that should be shown to every caregiver of the motherbaby.
I must reiterate: the studies on delayed cord clamping (DCC) are unequivocal; they all say that it is best for the baby, and that it causes no harm, but that immediate clamping is harmful. Penny Simkin has also done a wonderful video illustrating the reasons for DCC that every educator, doula and mother-to-be should see. Mothers must be aware that their babies need the stores of iron, the stem cells, the hormones, the sheer volume of the blood pulsing out of the placenta.
Mothers-to-be should be strongly encouraged to discuss procedures on their newborns at the moment of birth with their caregivers from the position of informed consent/ refusal. We must encourage them to ask about the benefits and harms accruing to those procedures and demand that their newborns be treated with best-evidence care, and if they know what that care should be, they will be better able to demand it for their newborns. I remember writing about a study in which ACOG recommended “partnering with patients to improve safety.”5 In my experience, most parents-to-be will gladly welcome information that invites them to share in the responsibility for the safety of their babies by demanding best-evidence care from their health care providers.
Posted by: Jackie Levine, LCCE, FACCE, CD(DONA) CLC
1-Changes in Episiotomy Practice: Evidence-based Medicine in Action, Justin R Lappen; Dana R Gossett Posted: 05/12/2010; Expert Rev of Obstet Gynecol. 2010;5(3):301-309. © 2010 Expert Reviews Ltd.
2Obstetrics & Gynecology: September 2011 – Volume 118 – Issue 3 – p 505–512 doi: 10.1097/AOG.0b013e3182267f4373- Integrated Management of Pregnancy and Childbirth. Managing Newborn Problems: a guide for doctors nurses and midwives. WHO 2003 ISBN 92 4 154622 0 ESS-EMCH SECTION 11 Neonatal Emergencies Last updated 27/4/2009 215
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5-ACOG Recommends Partnering With Patients to Improve Safety, Obstet Gynecol. 2011;117:1247-1249