Sunday, March 2, 2014

A closer look at delayed cord clamping

I have found it to be pretty standard for most of my clients to request delayed cord clamping as part of the birth wish list. Delayed cord clamping means different things to different people. What is delayed cord clamping? If the standard practice is to clamp the cord and cut it immediately after birth, any amount of delay is delayed cord clamping. What is it that the parents are really asking for? Is any delay beneficial? Would the longer the better be the best philosophy? Is there a point where there becomes a loss of benefit and an increase in risk? Does the position of the newborn in relation to the position of the placenta affect the results? I do not aim to answer these questions for you but rather have collected some resources to help you decide for yourself.

Let us first look at the Society of Obstetricians and Gynecologists Clinical Practice Guidelines on the Active management of the third stage of labour.
"Timing of cord clamping
Clamping of the umbilical cord is a necessary part of the third stage of labour. Its timing varies widely throughout the world, early clamping being the predominant practice in Western countries.32 Physiological studies have shown that 25% to 60% of the fetal–placental circulation is found in the placental circulation.33,34 Early cord clamping in term newborns results in a decrease of 20 to 40 mL/kg of blood, which is equivalent to 30 to 35 mg of iron. A delay in clamping, causing increased neonatal blood volume, may lead to complications such as respiratory distress, neonatal jaundice, and polycythemia. 
Prendiville and colleagues’ meta-analysis espousing the benefit of AMTSL8 included studies that applied early cord clamping, controlled traction, and uterotonics before delivery of the placenta. In these studies, early cord clamping was included as part of controlled traction and was not independently studied to demonstrate a benefit. 
A 2004 Cochrane Review by Rabe et al.35 and a prospective study by Ibrahim et al.36 demonstrated that delaying cord clamping by 30 to 120 seconds resulted in less need for transfusion because of anemia (RR 2.01; 95% CI 1.24 to 3.27) and less intraventricular hemorrhage (RR 1.74; 95% CI 1.08 to 2.81) in nonresuscitated premature infants (< 37 weeks’ gestation). 
A systematic review and meta-analysis comparing cord clamping done early (less than 1 minute after delivery of the infant) and late (at least 2 minutes after delivery) showed that late clamping conferred physiological benefit to the newborn that extended up to 6 months into infancy.37 Advantages included prevention of anemia over the first 3 months of life and enhanced iron stores (weighted mean difference 19.90; 95% CI 7.67 to 32.13) and ferritin concentration (weighted mean difference 17.89; 95% CI 16.58 to 19.21) for up to 6 months. There was no increase in respiratory distress, defined as tachypnea or grunting. Neonates were at increased risk of asymptomatic polycythemia (RR 3.82; 95% CI 1.11 to 13.21). There was no significant difference between the early and late groups in bilirubin levels and proportions of infants receiving phototherapy. 
A 2008 Cochrane review included 11 RCTs that compared the effect on maternal and neonatal outcomes of cord clamping done early (up to 60 seconds after delivery) and late (beyond 60 seconds after delivery).38 The results showed no difference in the incidence of PPH but an increased incidence of neonatal jaundice requiring phototherapy, higher newborn hemoglobin levels up to 6 months of age, and higher ferritin levels at 6 months of age after late clamping. Recommendations
9. Whenever possible, delaying cord clamping by at least 60 seconds is preferred to clamping earlier in premature newborns (< 37 weeks’ gestation) since there is less intraventricular hemorrhage and less need for transfusion in those with late clamping. (I-A)
10. For term newborns, the possible increased risk of neonatal jaundice requiring phototherapy must be weighed against the physiological benefit of greater hemoglobin and iron levels up to 6 months of age conferred by delayed cord clamping."

The SOGC guidelines tell us that delaying cord clamping can increase the risk of respiratory distress, neonatal jaundice, and polycythemia (excess blood cells). One study defines delayed cord clamping as 30 to 120 seconds. The benefit described is less need for transfusion due to anemia.

Avoiding a transfusion for anemia is obviously desireable but is that the standard for which we wish to reach? I looked at the 2004 Cochrane Review referenced in the SOGC guidelines for more information and was interested to find that it suggested that more studies need to be done on the outcomes of infants left attached to the placenta without cord clamping, with a delay of 20 minutes or more and letting the umbilical cord close itself off physiologically.
"There are no reported complications of delivering preterm infants in this manner, and researchers should have no difficulty in obtaining ethical informed consent for a very large control cohort with which to compare Kinmond's method. Gravity, uterine contraction, and a time delay of 20 minutes or more may be required to provide the preterm infant with a blood volume optimal for it's survival."

Next we have Dr. Alan Greene from TICC TOCC. You can watch his Ted Talk on delayed cord clamping below.


In this video he describes the benefits of delayed cord clamping. He pleads with us to wait 90 seconds or more, until the cord stops pulsating on it's own before clamping and cutting. I really love the language he uses. Optimal cord clamping, clamping that is not delayed, it's optimal, because anything less would be early cord clamping.

There has been some suggestion that delayed cord clamping can increase the risk of newborn jaundice due to the liver having to break down excess red blood cells. I find conflicting information regarding this risk. Some studies have found a relationship while others have found no increased risk.

The randomized control trial “Effect of delayed versus early umbilical cord clamping on neonatal
outcomes and iron status at 4 months" found no increased risk for jaundice, polycythemia or postnatal respiratory problems with cord clamping of 2 - 3 minutes when compared to those with early cord clamping.

The review "Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes" did find a small additional risk of jaundice in the infants with delayed cord clamping.
"Jaundice requiring phototherapy
This outcome was reported in seven trials with data for 2324 infants. Significantly fewer infants in the early cord clamping group required phototherapy for jaundice than in the late cord clamping group (RR 0.62 95% CI 0.41 to 0.96, with a LCER of < 5%, I2 5%). This equates to 2.74% of infants in the early clamping group and 4.36% in the late clamping group, a risk difference of < 2% (95% CI -0.03 to 0.00) ( Analysis 1.14). In a subgroup analysis, there were no clear differences in outcomes according to use and timing of uterotonic drugs.
Clinical jaundice
The number of infants with clinical jaundice was reported in six trials with 2098 infants. The difference between early and late cord clamping for clinical jaundice did not reach statistical significance (RR 0.84 95% CI 0.66 to 1.07) ( Analysis 1.15).
Polycythaemia
No difference between the early and late cord clamping groups was detected for polycythaemia in five trials reporting this outcome (RR 0.39 95% CI 0.12 to 1.27; 1025 infants) ( Analysis 1.16)."
It would seem the jury is out on the position of risk of jaundice with delayed cord clamping. We have to take into consideration the definition of delayed cord clamping. All of the reviews I have looked at discuss delayed cord clamping of 1-3 minutes.

Another video series on delayed cord clamping, this time from Dr. Nicholas S. Fogelson. I appreciate this discussion because this doctor addresses the question "what would nature do?". Click the link to watch the series of videos.

Gloria Lemay, famous Canadian traditional birth attendant discusses extended delayed cord clamping and leaving the cord intact here.

Just as with any other decision regarding the birth of your baby, do your research using these and other resources, but most importantly be clear about what you are requesting. Delayed cord clamping means something completely different from one mother to the next and from one care provider to another. How long of a "delay" are you requesting? At least 1 minute? Until the cord stops pulsating?

Links:

SOGC Clinical Practice Guidelines
Active management of the third stage of labour: prevention and treatment of postpartum hemorrhage (Replaces #88 (April 2000))

Dr. Alan Greene TICC TOCC

Ola Andersson et al. “Effect of delayed versus early umbilical cord clamping on neonatal 
outcomes and iron status at 4 months: a randomised controlled trial. British Medical 
Journal 2011;343:d7157 doi.

Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes

The World Health Organization - Effect of timing of cord clampingof term infants on maternal and neonatal outcomes

Tuesday, February 11, 2014

Congenital Heart Defect Week - Baby Ronnie's story

Guest blogger: Momma Ammanda

February is Heart month....this week is Congenital Heart Defect week. Why do I know this? My youngest daughter was born with a severe congenital heart defect in June 2013. It all started when I went for a routine ultra sound at 20 weeks and the technician wasn't able to visualize the heart well, so the OB suggested we go to Kingston to have a fetal echo done..."just for good measure...no real concern" he said....well 4 hours later and an in depth conversation with a paediatric cardiologist told us that they suspected that there was a concern with the baby's heart; we needed to follow up and have an another fetal echo completed at Sick Kids before any diagnosis could be given. Until then I didn't know that 1 of every 100 babies born has some degree of congenital heart defect; some are minor, while others are severe. Veronica's happens to be one of the more severe types; she has transposition of the great vessels(TGA-the main arteries in the heart that supply the body with oxygenated blood are backwards making it impossible for oxygenated blood to get to the body) with a ventricle septal defect (VSD-a small whole in the bottom of her heart) and a restrictive right ventricle(the bottom right side of her heart is small and only functions at about half capacity). We received confirmation only 4 short weeks before she was born that she could not be born at home, she would need medical intervention immediately after birth, and most devastating our new sweet baby girl would need open heart surgery within the first few days of life in order to survive. There were no other options or no alternatives...it was very simple we followed the plan outlined by the staff at Mount Sinai and Sick Kids or our baby would perish.

Of course, when we got home and had a concrete diagnosis, we turned to google to help educate ourselves. We soon found out and had to face the reality that CHD are the top cause of infant deaths in North America. I spent time trying to figure out how and why it happened to us? Most CHD don't have any contributing factors....it's luck of the draw...and this time we were the lucky ones. It was scary to find out that heart defects kill more children each year than all children's cancers combined but we had to focus on the positive and we were eager to learn that Sick Kids has the #1 paediatric cardiac unit in the country, and that they perform around 600 cardiac surgeries a year and about 56 of the arterial switch operations annually; the specific one that the baby required. Now, I know 56 doesn't sound like many but when you put it into the perspective of it being a little more than 1 per week...that sounds a lot more reasonable.

I was induced at exactly 38 weeks at Mount Sinai in Toronto. The plan was to have the baby at Mount Sinai and "stabilize" her and then transfer to Sick Kids across the street. My husband and I were incredibly fortunate to have Leigh Anne and Michelle both come to Toronto with us. Having them there and their support made things a little bit better, and me a whole lot stronger! After a relatively uneventful labour, our beautiful girl was born...and after a quick kiss and a picture or two she was whisked away to the NICU. Once, the NICU staff at Mount Sinai felt that Veronica was stable we were able to see her one more time for a few minutes then she was transferred to the Cardiac Intensive Care Unit at Sick Kids. Leigh Anne and I stayed at Mount Sinai to try and rest; Hubby and Michelle went to Sick Kids with the baby to ensure everything was ok.

This is where our journey really begins...a short time later Leigh Anne got a phone call from Michelle. Veronica was not doing well and they were going to take her in for her first surgery at not quite 4 hours old. From what I can recall, I was up and out of bed, getting dressed, determined to get to Sick Kids before Leigh Anne was off the phone. It was an intense morning, anxiously waiting to hear how the procedure went and was she ok? Finally, after what seemed like agonizing minutes and hours, we were told that Veronica was doing well and that we could see her. We all breathed a sigh of relief, and Michelle and Leigh Anne left us at Sick Kids and travelled home.

I wish this was the point that I could say everything went well but unfortunately, I can't. Veronica had a very difficult course both pre and post heart surgery, this includes 4 general surgeries, 1 open heart surgery, 2 cardiac arrests, 9 chest tube insertions, being ventilated for 11.5 weeks, more x-rays, heart echo's, ultrasounds, pokes, pricks than I could ever try to count. We were at Sick Kids for a total of 16 weeks. 16 weeks of my family being separated, only seeing my other kids on the weekends, and most of those days and weeks hoping and praying that today would be the day that everything turned around for Veronica and it got just a little bit easier for her. I never would have imagined that my sweet baby could exhibit such amazing strength, tolerance, and perseverance....it is a lesson I will remember for a lifetime and beyond. I could easily give a detailed encounter of each and every of the 109 days we were admitted to the hospital, but that would be a whole week of blog posts.

We were finally discharged the end of September 2013, NG tube still in place for all feeds (Veronica had a major oral aversion and couldn't have anything placed in her mouth without gagging and vomiting), needing to be fed for 1 hour every 3 hours around the clock, 9 medications to be taken multiple times a day, and one scared and ecstatic Momma and Papa. Ronnie is now 8 months old and we have now been home for 19 weeks; she had made some HUGE progresses in her physical development and some smaller gains with oral feeding. We are down to 6 medications and still have the NG tube with a tiny amount of supplementation each day by spoon. Every day is all about progress..we ignore any negatives and celebrate all small positives.

Veronica's heart is not "fixed" and she will still require one more open heart surgery within the next year or so. Her congenital heart disease will continue to effect her for all of her days, it's not something that will go away; we will always have to be diligent to monitor for any signs of congestive heart failure, or irregular heart rhythms. I am thankful to the radiologist that set the wheels in motion when they captured that something wasn't right in my ultrasound. I am thankful for the progress that has been made to help people with CHD, and I hope that they can further advance the research so that one day not just Veronica, but all children will be able to be healed and carry on like an average child, and more than anything I hope that fewer families have to find out that their child is 1 in 100.






Tuesday, December 10, 2013

Refilling our cups



Like most women, I am a nurturer, a giver. I grew up the eldest sibling so as birth order would predict this mini mother grew up to choose a career of nurturing others. It is so fulfilling for me because it is so natural. I meet and care for all kinds of women and sometimes it is necessary for me to discuss with them the importance of not over giving, of saying no sometimes, of prioritizing self care. Many women find it uncomfortable to receive, difficult to say no or don't take care of themselves, the way they take care of others.

I've worked on all of the above for myself over the many years I've been taking care of others holistically. There is always room for growth. I've reached another growth spurt. 

Just like I encourage all of my birthing mamas to listen to their bodies, I'm listening to mine. Fatigue, forgetfulness and irritability is my body's way of telling me that I've lost the balance. I know I'm not alone so I'm going to share my self care plan with you because 1. I like to keep it real. I think most of you have come to know that I try to always be very transparent and 2. Because I think there are a lot of you reading this who might recognize yourself in this post who might feel inspired to start 2014 off with a full cup so that you can be the best giver you can be too.

1. Slow down. Take some time off or decrease your work load.

I have a part-time week this week and a very part-time week next week. It's been really hard to ask clients to wait until January because its my first instinct to do whatever I can to support them. I squeeze people in here and there normally. Everyone will get much better quality care in the new year because of the work I am doing now. 

It's okay for you to say no or not right now too. If you don't take care of yourself, who will? You have to put the oxygen mask on yourself so that you can help the people around you. 

2. Book or schedule in some bodywork or other nurturing activities.

Ofcourse I'm receiving weekly reflexology sessions. You might plan massage, Reiki, pedicures or other therapy sessions for yourself. These kinds of treatments are grounding, energizing, deeply relaxing and help your body to release stress.

3. Eat good food. 

You know how when you're working so hard and then you book a vacation and you end up ill for the entire trip? It's important that you nourish your body with really good foods as soon as you become aware that you've been overdoing it. I'm using the juicer more now and making delicious vegetable soups, I've added some healthy supplements to my diet and lots of healthy fats for mood, brain and endocrine system balance. 

4. Yoga.

Yoga is my medicine. Yoga is grounding, it allows you to massage your internal organs, it relieves tension and stress, but the greatest benefit is the peace it brings to your mind. I suggest yoga daily or every other day so I like using DVDs to get my yoga in before breakfast for the best day possible. Other exercise is important too. Pick something fun and consider having enjoyable company to do it with. Exercising with a friend will help you to keep your commitment.

Don't feel guilty if you've lost the balance and need to refill your cup. Like the quote in the above image says, it's essential. Not refilling your cup not only makes you a stressed out cranky person but it usually leads to disease. Listen to your emotional state first so your body won't need to speak to you later.

What else do you do to refill your cup? Do you schedule in regular breaks to prevent you from getting to the point where your cup is already empty? 

To my clients who are patiently waiting for bookings, thank you so much for your understanding. I hope my commitment to my wellness and keeping the balance confirms that I practice what I preach and I look forward to helping you all refill your cups too! <3


Friday, December 6, 2013

Food Friday - Fertility favourites

There are a number of foods that I often encourage my fertility clients to enjoy in plenty while trying to conceive. I have listed some of my favourites below.


"Seed-full" fruits and vegetables - In an age of seedless fruits and vegetables, opt for the natural variety instead. If fertility is something that you are striving for, don't eat infertile foods like seedless cucumbers and seedless grapes. Buy the seeded variety and eat the seeds too. Pomegranates are especially good choices.


Seeds - For the same reasons as above, seeds are full of vital life force energy, they're bursting with the potential of new life and they are a good source of healthy fats too. Opt for raw instead of roasted. Sesame seeds, pumpkin seeds (also known as pepitas), chia seeds and any others that tempt you. Flax seeds can be very beneficial for some women (and men) who are trying to conceive but not for all. Flax seeds contain a gentle phytoestrogen which can block harmful xenoestrogens from the environment, but may provide too much estrogen for some women who already have an excess.


Beans, legumes and lentils - Once again, if you can sprout it, it's a fertile food. These are also a great source of soluble fibre to help remove excess recycled hormones via the digestive tract. Opt for the dried variety and avoid cans. Canned foods are void of qi or vital life force (you could not sprout a canned bean) and the lining in cans contains chemicals that disrupt the endocrine system.


Grounding vegetables - If it grows down in the earth, it has energetic grounding properties which will improve the energy flow to your reproductive organs. Carrots, potatoes, sweet potatoes, yams, garlic, ginger, onions, beets, turnips and more. Each has it's own series of other health benefits too.


Healthy fats - Fat has been given a bad rap but it is making a revival. Your body needs fat for many functions including hormone production and ovulation. Omega 3's increase blood flow to the uterus and EFAs (essential fatty acids) support the follicle to open releasing the egg and nourish your developing embryo. Fish, flaxseeds, and flaxseed oil, walnuts, eggs and chicken are some good sources of healthy fats. 


Water - We all know we need to drink more water. This one is just too important not to include. You wouldn't plant a seed, neglect to water it and expect it to grow. New life needs a plenty of good quality water. Avoid buying bottled water because the plastic is disruptive to your hormones. If you can find a source of chlorine free water (do you have a friend with a good quality well?) or consider a Santevia water filter that energizes and alkalizes your drinking water. 


Monday, December 2, 2013

But even drug addicts get pregnant

I do a lot of work with my fertility clients to help support balanced hormones, I offer diet change suggestions, supplements for fertility, stress reduction therapies and more. Some of my clients work really, really hard to attain optimal fertility. It can be very frustrating for most because they know that very unhealthy people with very unhealthy lifestyle choices get pregnant, sometimes with ease.

How maddening for the woman who has been trying for months or even years to get pregnant to see babies born to unhealthy mothers who have abused their bodies in the worst ways. I think this frustration is certainly warranted. It hardly seems fair.

However, I caution anyone reading this not to let this be an excuse not to strive for optimal health. Think of your body as your nest. You want to create the best nest possible for your future baby. Every healthy lifestyle change you make not only benefits you over the short term and long term, but it helps you to create the best possible environment for your baby. You are going to grow a human afterall, and not just any human, this is your baby! The healthier you become now, the healthier your pregnancy is sure to be. The finer tuned your engine, the better you'll be able to handle the extra stresses that pregnancy can inflict and you're setting yourself up for a better birth as well.

We will never fully understand the ways of the world. We are each here on separate journey's, calling in different experiences. It certainly isn't always fair. Don't compare yourself to anyone else and do whatever you can do to be empowered, healthy and happy. Nutrition, exercise, quality sleep and relaxation are like having good soil, clean water, sunshine and fertilizer. A weed may grow in the cracks of the pavement, but a little effort creating the best environment is the wisest way.

This goes for both parents. If there is a habit or lifestyle change that could be made, do it. Your baby deserves it.

Friday, November 29, 2013

Foody Friday - Delicious Fertility Soup

I cannot get enough of this homemade soup. You might actually all it a stew. My homemade soups often turn into stews because I like to add a lot of stuff to them. This soup has many health benefits but it also occurred to me that it is a great recipe for most of my fertility clients. I say most because I do have some clients that would do best to avoid any extra 'heat' in their system. If you are the type that has night sweats or is generally more warm then the average person, if you have scanty cervical fluid or seminal fluid, this recipe isn't ideal for you. For everyone else, enjoy!


Suggested ingredients (quantities are approximate):

6 cups homemade chicken or vegetable stock (don't use store bought unless you can be sure it is MSG free!)
2 or 3 bay leaves
Real Salt (this is a brand)
1 cup of brown lentils
2 Tbs coconut or olive oil
1 Tbs minced ginger
1 small onion chopped
2 cloves of garlic minced
2 carrots peeled and sliced
1/3 head of cauliflower chopped
1 broccoli floret chopped
1 Tbs curry spice (or to taste)

If possible, soak your brown lentils in water over night or until they sprout slightly. Rinse well.
Bring broth, bay leaves, Real Salt and brown lentils to a simmer covered.

While the lentils and broth are simmering add oil, ginger and onions to a frying pan and saute until onions are softened. Add ginger, carrots, broccoli and cauliflower to the pan. Saute until vegetables soften slightly. Add curry spice and combine well. (I probably add more than 1 Tbs to be honest, but add to your taste). Add sauteed vegetables to broth and continue to simmer on low for 30 mins.


What I love about this recipe?
It's alkalizing. This is a great combination of alkalizing ingredients to raise your pH level which will help your body to balance and heal. Health and fertility thrive in an alkaline body.

It's energizing. Look at the life energy in these brown lentils! Nothing says fertility like a sprouting lentil.


It's an excellent immune booster. This soup is full of antioxidants, has anti-inflammatory properties, vitamins and minerals and more. From the ginger, onions, garlic, carrots and curry spice, combined with homemade chicken broth. Wow!

It's grounding. What does that mean? Well, the sacral and root chakra are key players in reproductive health. If your energy is blocked up in either of these chakras, our reproductive organs will suffer. The carrots, onions, garlic and ginger are all roots and thus, very grounding. This is a wonderful energetic cocktail for anyone needing to come down to earth a little.

It removes excess hormones. The soluble fibre in the lentils will help your body to digest recycled hormones hanging around in your bile. The broccoli and cauliflower also aid the removal of excess estrogen which is a problem for most of us today, especially if you experience a lot of stress. Plastics, pollution and other environmental factors are all contributing to problems with hormonal imbalance. Cruciferous vegetables like broccoli and cauliflower are our friends, especially during the luteal phase (after ovulation but before menstruation). Eating extra cruciferous at this time should reduce your PMS symptoms.

It's MSG free. I loathe MSG. It's really, really hard to find a good soup or soup recipe that does not have boullion and/or MSG in it. This soup is delcious despite the absence of this neurotoxin. With the curry spice and Real Salt, this soup is delicious even though it's made completely from whole unprocessed foods.

It's seasoned with Real Salt. Real Salt is a brand of salt that I can not live without. It's unprocessed and there is no added iodine. All of that talk of "lower your sodium" that we're so bombarded with, refers to highly refined and processed salts. Real Salt is raw and good for you. It's an excellent source of minerals and you can season your soup to taste, guilt free.

I don't find this soup to be overly spicey, just full of flavour. It should also reduce morning sickness and nausea during pregnancy with the ginger which stimulates the liver and legumes and vegetables that remove excess hormones. The grounding, alkalizing and immune boosting properties will benefit everyone, including pregnant mamas.


Monday, November 25, 2013

Unexplained infertility

The majority of my fertility clients come to me having received a diagnosis of "unexplained infertility" from their medical doctors. Most people working in alternative medicine do not believe in unexplained infertility as a diagnosis including some doctors in the medical field like Dr. Sami S. David MD, the author of Making Babies.
The way fertility medicine runs these days, the diagnosis is seen as almost inconsequential. Why figure out why she's not getting pregnant, the thinking goes; we're just going to give her drugs anyway.
Like any disorder, infertility is a method of the body speaking to the person, a warning of an imbalance. Usually not being able to conceive is accompanied by a series of other seemingly unrelated symptoms affecting digestion, body temperature, cravings, emotions and more. By looking at the whole picture, we can piece together the story and help to bring the body back to where it wants to be, which is a much better place to be growing another human anyway. This is the thinking involved in holistic medicine.

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