Guest Post by Christina Szrama
Getting to the birth of your child took a dozen medical decisions at least, some small, some large. Well, your baby’s been born, you’re recovering (or trying to), and the decisions just won’t let up. Welcome to parenthood! :)
Let’s walk through each of the 10 decisions you will probably be asked to make before leaving the hospital, birthing center, or at your child’s first pediatric visit (if you delivered at home). I’ll present each issue, ask the questions “Why would you want this?” “Why might you decline this?” and then offer several options.
1. Cord Clamping
At some point between your child’s dramatic exit into the world and his first bath, you’re going to have to physically sever the link that kept him alive in your womb for so long: the umbilical cord. Many doctors or midwives don’t think twice about clamping and cutting it within the 2 minutes of birth, often sooner for a baby struggling to breathe. There is also the new pressure to collect your child’s “cord blood” stem cells, either for your family’s use or for donation to others.
Why might you want to cut the cord early?
Stem cells in umbilical cord blood carry the potential to treat several forms of cancer, blood, immune & metabolic disorders. To obtain enough blood to harvest these stem cells, the cord must be cut & clamped very soon after birth. If a family member has these diseases (and your child doesn’t) this is an option you may want to explore. This is from the AAP's 2007 statement on the topic:
Cord blood donation should be discouraged when cord blood stored in a bank is to be directed for later personal or family use, because most conditions that might be helped by cord blood stem cells already exist in the infant’s cord blood (ie, premalignant changes in stem cells). [...] Although not standard of care, directed cord blood banking should be encouraged when there is knowledge of a full sibling in the family with a medical condition (malignant or genetic) that could potentially benefit from cord blood transplantation. (emphasis mine)
Why might you want to wait?
Cord blood is actually the baby's blood, usually about 1/3rd of the baby's total blood volume- throughout pregnancy the baby's blood is filtered through the placenta/umbilical cord and then pumped back into the baby. After birth, the blood is flowing back into the baby as long as the cord is pulsating (a safeguard in case the baby doesn't breathe right away- the placenta is still oxygenating their blood for them).
Delaying the cord clamping 4-10 minutes, or until the umbilical cord stops pulsating, offers many benefits to the baby, while early cord clamping can be very harmful to the child- particularly if the baby has been born early or is on the small side. As this article points out "delaying the cut could protect against anemia and irregular breathing for weeks and months after delivery." Dr. Sarah Buckley outlines the risks of early cord clamping here. Other parents opt for a "lotus birth," never cutting the cord at all, but instead treating the placenta with salt, wrapping it in a bag and allowing the cord to dry up and fall off at the belly button on its own. Please note that all of these options ARE equally available for mothers delivering by cesarean (you just have to state your wishes).
Your options: cut & clamp immediately for the purpose of cord blood harvesting/donation, delay the cord severing for 5 minutes, delay the cord severing until it stops pulsating (indicating that the vast majority of the baby's blood is back in his body), delay the severing until the placenta is delivered, or allow the cord/placenta to fall off on its own in a matter of days.
2. Washing, Weighing, Swaddling Immediately v. Kangaroo Care
In many hospitals, the norm is to take the baby after birth over to a scale to be weighed, rubbed down, assessed using the APGAR scale at 1 & 5 minutes old, swaddled & hatted, and then returned to the mother.
However, this has lately been challenged and "kangaroo care" is the new buzzword. Many mothers are now encouraged to hold their babies skin-to-skin immediately after birth, covered with a clean blanket to keep them warm. The APGARs can be done in the mother's arms, the baby can be rubbed clean & dry, and will usually attempt to breastfeed on his own soon after birth.
Why might you want the standard care?
If you require many stitches after birth (or any emergency measures), if you've had a particularly exhausting labor, or if a c-section means you are heavily medicated, you may not be physically able to keep a good hold on your child. In this case, the father or other family member could step in, often holding the baby at your head near your eye level, allowing the baby to see you and smell you.
Why might you want to opt out in favor of "kangaroo care"?
Many new moms don't want to let their babies, the prize of their labor pain, go! I think I probably would have bit, scratched or punched anyone who tried to take my daughter from me that first hour after she was born! A 2007 pilot study indicated that babies placed skin-to-skin with their mothers held their body temperature better, and most "crawled" to their mother's breast & began nursing on their own within 75 minutes of birth.
Most newborns are quietly alert and eager to nurse, learn their mother's face, and bond with her for about 2 hours after birth, becoming sleepy (usually for the next 2 weeks) after this unique "sensitive window" is passed. Baby (and mom!) have just gone through tremendous changes and Mom's familiar smell, heartbeat, and voice are tremendously comforting to this new little person who is suddenly being asked to breathe, maintain body heat, pump blood, eat, digest and poop on his own for the first time.
Your options: Honestly, kangaroo care has so many benefits (and no drawbacks) that if you are unable to perform it yourself after birth, it would be recommended that your husband would hold the baby skin-to-skin on his chest, comforting and speaking to his baby until you are able to do so.
3. Prophylactic Eye Ointment
You're probably familiar with the pictures of newborns in those striped hats, eyes smeared with some kind of clear goop. That "eye goop" is usually administered within 1 hour of all births, and is generally either erythromycin or tetracycline (both antibiotics), or the older silver nitrate solution.
Why might you want this?
The intention of the eye ointment is to prevent newborn blindness from infection after birth ("opthalmia neonatorum"). If the mother has gonorrhea, it can be passed on to the baby during a vaginal delivery and can cause blindness if left untreated (chlamydia is similar, as well as herpes). To avoid this, states passed laws throughout the 1900s mandating that all newborns receive silver nitrate, assuring that any infections would be caught & treated. This eye-irritant is still administered in some hospitals, but most now use the gentler antibiotics. If you know that you have an STD and you deliver vaginally, you will want to protect your babies eyes. In this case, you can request the gentler tetracycline drops.
Why might you opt out of this?
For one, having a C-section negates the need for this completely. Anything placed in a baby's eyes interferes with his vision, blurring it and usually causing swelling & irritation. Blurred vision interferes with the "sensitive window" right after birth when baby is alert & awake, so crucial in mother-child bonding as well as the establishment of breast-feeding.
Silver nitrate is only effective against gonorrheal infections, and is such an eye-irritant that it can actually cause chemical infections (read a good paper here). It has mostly been replaced by less-painful antibiotics, however these antibiotics carry their own risks. As this study showed, babies actually need the bacterial exposure they receive from their mother's birth canal to correctly populate their digestive tracts and build up their immune systems:
"In a sense, the skin of newborn infants is like freshly tilled soil that is awaiting seeds for planting -- in this case bacterial communities," said Fierer of CU-Boulder's ecology and evolutionary biology department. "The microbial communities that cluster on newborns essentially act as their first inoculation."
Antibiotics upset the bacterial balance in our bodies, wherever they are administered (we've all heard about the dangers of over-using antibiotics). If a mother is known to be disease-free, there seems little reason to administer any ointment at all. A randomized 1993 trial in Washington State states
"The results suggest that parental choice of a prophylaxis agent including no prophylaxis is reasonable for women receiving prenatal care and who are screened for sexually transmitted diseases during pregnancy." (emphasis mine)
Your options: Be tested for STD infection in your 3rd trimester (this is state law anyway). If positive, find out if intravenous treatment can eliminate risk of transmission to the baby during birth, and/or choose the eye ointment best suited to your infection. If negative, you may delay administration of the eye drops until after the sensitive 2 hour period, choose the gentlest eye-ointment you can, or refuse the ointment completely. (Note: in my state, KY, hospitals are required by law to administer an ointment of some kind, and some try to threaten parents with Child Protective investigations, etc. However, when I made my own calls to various hospitals as well as our Child Safety office, I found that these were 100% intimidation tactics. Research the penalties & state laws in your own state) Have others wash their hands when touching your baby to minimize exposure to external bacteria.
4. Hepatitis B Vaccine
The CDC recommends that all infants receive the Hep B vaccine before leaving the hospital after birth, then receiving 2 more doses.
Why might you want the shot?
If you have hepatitis B, which is a serious infection of the liver, you probably want to do everything you can to avoid passing it on to your child, including a special hepatitis B immune globulin shot as well as the HepB vaccine.
Why might you want to opt out?
Unless you have hepatitis B, it is almost impossible for your child to contract it. It is a sexually transmitted disease (also transmitted through blood, as in needle sharing) for which babies are not at risk. The hepatitis B vaccine has many side effects, and newborns are extremely fragile. (Read ThinkTwice!'s info page here.) It makes little sense to submit a developing nervous & immune system not at risk of infection to such an attack.
Your options: If your child is not at risk for Hep B, you can delay the vaccine until later, or refuse it all together (it is not required for school entry in many states).
5. Hearing Test
For most babies, a hearing test is the first test they'll ever have (and quite likely will pass with flying colors). All states require that parents at least be given the option of having their child's hearing screened, and most have a policy of universal screening.
Why might I want this?
Hearing loss is one of the most common birth defects, affecting ~3 out of 1000 babies. The screens are non-invasive and inexpensive ($10-$50), and if hearing loss is caught and treated early, long-term consequences such as language delays can be minimized.
Why might I opt out?
You may want to simply observe your child for hearing loss on your own. In 14 states this is a simple matter of parental preference. During some types of tests babies may be given a mild sedative to which you may object. Also, some may be responsible for paying for the test and find the cost prohibitive.
Your options: Have the test done after the "sensitive window," when your baby is sleepy and unlikely to need a sedative-- perhaps right after a good feeding. Or, if your child has no risk factors for hearing loss, opt out of the test and be especially vigilant for any signs of hearing deficiencies (this checklist is a helpful in this).
To be continued on Saturday...