Than you for this information Judith.
Rose
----- Original Message -----
From: Judith Mercer <[log in to unmask]>
To: <[log in to unmask]>
Sent: Monday, February 03, 2003 5:43 AM
Subject: Re: palpation for nuchal cords
> All new midwives in the US are not taught to cut and clamp a nuchal cord!
> The preferred method is to 1) reduce the cord over the baby's head if it
will
> go easily or 2) reduce the cord back over the shoulders as the baby is
born
> and deliver the body thru the cord, or 3) if it is tight, a somersault
> maneuver can be used as described in an article by Schorn (Schorn MN,
Blanco
> JD. Management of the nuchal cord. J Nurse Midwifery 1991;36:131.).
>
> In 1998, we completed a questionnaire of American nurse-midwives and cord
> clamping practices. (Mercer, J., Nelson, C., Skovgaard R (2000).
"Practices
> and Beliefs about Umbilical Cord Clamping of American Nurse-Midwives"
Journal
> of Midwifery and Women's Health, 45(1), 58.) Some notes -- "When
questioned
> about management of nuchal cord, fifty-seven percent of the respondents
chose
> the option "Clamp and cut only when very tight." The somersault maneuver
> (Schorn, 1991) was selected by 40% of the participants as their best
option
> for managing nuchal cord and only 3.2% stated that they clamp and cut in
most
> cases of nuchal cord.
>
> When confronted with a nuchal cord, 96% of the CNMs avoid immediate
clamping
> and cutting of the cord. This practice is well supported in the
literature.
> The umbilical vein walls lack the muscular layer found in arteries and is
> more easily compressed. Blood is pumped by the driver of the system, the
> fetal heart, to the placenta from the fetus via the arteries, but
compression
> of the vein prevents the oxygenated blood from returning to the fetus.
Thus
> a nuchal cord may result in a fetus to placenta transfusion. With
immediate
> clamping, a neonate having a nuchal cord is at risk of hypovolemia and
anemia
> (Cashore WJ, Usher R. Hypovolemia resulting from a tight nuchal cord at
> birth (Abstract). Pediatr Res 1973;7:399).
>
> Another issue related to the management of a nuchal cord is the risk of
> shoulder dystocia following the cutting and clamping of a nuchal cord.
Iffy
> (Iffy L, Varadi V. Cerebral palsy following cutting of the nuchal cord
> before delivery. Medicine & Law 1994, 13:323-30) reported 5 cases of
cerebral
> palsy after nuchal cords were cut and shoulder dystocia delayed the birth
by
> as little as three minutes. These facts make it highly advisable to avoid
> cutting the nuchal cord before delivery whenever possible. Schorn
describes
> the somersault maneuver which keeps the neonate's head close to the
perineum
> to decrease tension and allow the cord to be unwrapped after birth. It is
> preferable to allow these babies to reperfuse and to be resuscitated if
> needed at the perineum. Those at risk of hypovolemia present with white,
> "drained" bodies (or mottled blue and white), no tone, and no reflexes.
> However, they usually have heart rates above 100 and will reperfuse,
> correcting any acid-base imbalance that exists as evidenced by the return
of
> tone about the same time that the baby begins breathing (Mercer, cases in
> progress). If the heart rate is not above 100, resuscitation can be done
at
> the perineum without clamping the umbilical cord of the obviously
hypovolemic
> infant. The infant can be dried and put on clean pads at the perineum or
> skin to skin on the mother's abdomen to keep warm. Theoretically, the
only
> time that this process would not work is if the placenta separates
> immediately.
>
> Two other articles that shed light on this whole issue are: 1) Mercer, J.
> Skovgaard R. "Neonatal transitional physiology: A new paradigm."
Journal
> of Neonatal and Perinatal Nursing, 2002;15(4):56-75.
>
> 2) Mercer, J. (2001). "Best evidence: A review of the literature on
> umbilical cord clamping." Journal of Midwifery and Women's Health,
invited,
> November/December 2001;46(6):402-414. This article was reprinted in
MIDIRS
> in Summer of 2002.
>
> This is my area of research and would be happy to share more info with
> interested parties. Have just been funded by NIH (starting 3/1/03) to
begin
> a research project on this issue and will have more time to participate in
> this sharing once I get started!
>
> Judith Mercer, CNM
> Director, University of Rhode Island Nurse-Midwifery Program.
>
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