Rachel, I enjoyed your synopsis, and had a little chuckle at the end.
I have reflected on the scenario that I wrote about and it caused me to
think about an issue that came up at the time and I believe would like to
see some discussion by this group.
After this birth I wondered why the midwife had not decided to cut an
episiotomy to facilitate the birth. The baby was emerging VERY slowly (the
last heard FH was about 80 bpm) and the perineum was very long, and
unyeilding. We debated this afterwards as we debriefed. At about this same
time there seemed to be a 'cluster' of women experiencing rather nasty
anterior tears - lateral lacerations on the labia minora, tears in the
clitoral hood and splits along the margins of the labia minora , bucket
handle tears to name a few, while the perinea remained intact.  The question
I posed then and again to the list is - are we (midwives ) contributing to
these anterior tears (and what ever the long term effects are) by being
almost steadfastly  resistant to cutting the occasional episiotomy. Has the
pendulum swung too far on this issue. I know of midwives who consider that
they have failed miserably if they do not acheive an intact perineum at the
birth. What if any research do you know of is there into this particular
area? I think it warrants some research.
Look forward to your responses.
Cheers, Robyn
----- Original Message -----
From: "Rachel Myr" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Saturday, January 25, 2003 11:33 PM
Subject: nuchal cords and culture


> Skip this if you have had enough of the cord discussion; I haven't yet.
> This is a synopsis of some of the discussion on the topic, and I hope at
> least some of you find it as intriguing as I do.
>
> First, could someone, preferably Trish Payne, reply to Jette's query, on
the
> list?
> Here is the question Jette posed:
> "Trish do I really understand you in the right way? Would a section be
> performed after the delivery of the baby's head on the indication
> decelerations?"
> After Trish had written:
> "In about a 1000 births I think I've done it (cut the nuchal cord on the
> perineum- rm) once because if it's that tight there will probably be
> significant decels and this mom may end up with a caesarean birth."
>
> Marlene Sinclair wrote:
> "The risk of having a short cord, wrapped round 3 times or so
> (tightly) and leaving it in situ until the woman delivers the rest of
> her baby could cause premature shearing of the placenta..."
>
> I am being VERY nitpicky here.  A 'short' cord (defined in Norway as less
> than 40 cm or 16 inches) could not get wrapped 3 times around a baby's
neck.
> I agree that a nuchal cord that impedes labor progress must be dealt with.
> In my experience such cords manifest themselves much earlier than the
birth
> of the head: either no descent, or FHTs that scare the living daylights
out
> of professional birth attendants in any setting where CTG has any footing
at
> all, or both.  The nuchal cord that permits spontaneous birth of the head
is
> almost never a problem, as several posters have mentioned.
>
> I have seen on a couple of occasions cords that have torn at the time of
> birth, and this has happened about 15 cm from the baby so it was noticed
as
> the legs were born.  I was not the primary midwife either time, and I
don't
> remember whether there was a loop around the baby's neck.  In neither case
> was there anything else unusual about the births, nor were there any
> complications.
>
> And Robyn Maude wrote:
> "However I was the supporting midwife at a birth where the baby took a
very
> long time to
> crown and eventually birth its head, despite good maternal effort.The cord
> was very tight around the neck x 3 times. The attending midwife clamped
and
> cut and unravelled the cord and the baby was pulled out. It was virtually
> lifeless and needed extensive resus. I always felt uncomfortable about the
> clamping of the cord in this situation. What if the baby had gone on the
> have shoulder dystocia?"
>
> In that case, it seems the midwife's judgment was that the cord was
> preventing the baby from being born, and it may well have been necessary
to
> cut the cord in order to allow the baby to emerge.  Shoulder dystocia
would
> have made matters worse, but what choice did the midwife really have in
that
> situation?
>
> Then comes Susan James' delightful account, concluding thusly:
> "and she was right, the anterior shoulder was there, but the woman could
not
> budge that baby. And around the neck was the cord three times so tightly
it
> almost looked and felt
> like skin folds. She clamped and cut and the baby flew out. He did need
> a little resuscitation but was crying lustily before the woman's partner
> had even finished spelling out their name to the 911 dispatcher. We
> cancelled the call."
> No further comment needed here, except BRAVO for a great 'midwifery tale'.
>
> Cecilia Jevitt, a midwifery educator in Florida, writes:
> "I can't imagine a midwife who doesn't check for a nuchal cord. We
consider
> it an essential hand maneuver for birth."
> But you don't need to use your imagination.  You can come see thousands of
> us, professional midwives who spend most of our working time catching
babies
> and hardly ever check for a nuchal cord, unless there is worrisome delay
> after the birth of the head.  And if I showed up at my workplace with a US
> textbook on midwifery, I would be laughed right out of the room,
scornfully.
> Don't I think *we* are good enough or something?!  (This is the worn voice
> of experience talking now.  The background is the strong, proud -probably
> too proud - unbroken tradition of universal midwifery care at birth, by
> formally trained midwives, for about 200 years here in Norway.  I am also
> among the first to admit that we are far from perfect, but I am not
> convinced that adopting routine practice from the US would be our best
> strategy to strengthen our role.)
>
> This topic is pointing up some fascinating differences in what midwives
> consider essential birth care, and obviously since our outcomes
> (midwife-attended births in the UK, N. America, Denmark, Norway, NZ) are
not
> very different, it is unlikely that our success rates have very much to do
> with routine palpation of nuchal cords, or lack thereof.  Maybe we should
be
> looking somewhere else for the answer about why supporting normal birth (=
> practicing midwifery, and if this definition of mine sparks more
discussion,
> so much the better) seems to be such an effective tactic for good
outcomes.
> I don't know the folklore of all cultures; where I live, the nuchal cord
> enjoys an imposing position in the minds of expectant parents.  I have
even
> heard parents tell how glad they were that they had their baby in a
tertiary
> care center, because 'the cord was around his neck, and they didn't find
out
> until after he was born, and imagine what might have happened if they
hadn't
> been somewhere with full acute care services, like a smaller hospital or
AT
> HOME' - and this is after having experienced an entirely spontaneous
vaginal
> birth with a baby who needed no special care at all, to get out or to get
> started breathing.
>
> If you have read this, far you must be interested.  Thanks for your
> perseverance and for bearing with me in my ruminations.
> Rachel Myr,
> Kristiansand, Norway
> (US-American woman, Norwegian midwife)
>