Optimal cord clamping and meconium stained liquor

Twitter: @GeekFatimah

I am very pleased to introduce student Midwife Fatimah Mohamied. I am incredibly fortunate to have Fatimah join the BloodtoBaby team. Fatimah has previously been a clinical respiratory physiologist, she has a passion for women's health, spirituality and the environment. She is particularly interested in intact cord resuscitation and wishes to contribute to BloodtoBaby for the advancement of neonatal health, women's birth experience and nourishing family relationships.

A Reflection in Practice

Recently I assisted at the delivery of a child of a low risk women who chose to birth in a birth centre. Her beautiful baby made its entrance into the world by bringing copious amounts of meconium stained liquor along with it. The baby was rather rude in only introducing us to this meconium stained liquor at the point of delivery. I use the word 'stained' deliberately. The liquor was not the concentrated pasty consistency that is usually associated with thick meconium, but rather a dark green transparent status, like badly mixed water colour.

Being a student midwife, some will consider me arrogant in stating that I didn’t feel concerned. This feeling was not shared by the midwife present, who promptly clamped the cord as I enquired into the possibility of delayed cord clamping. The answer I received was a simple statement of "thick meconium", the midwife then cut the cord even though the child was breathing and had been breathing since the moment of birth.

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As I (perhaps annoyingly) mentioned - the baby was breathing, the midwife swiftly moved the baby to the resuscitation platform, explaining to the mother that she only wanted to assess if baby was breathing okay. A mere 5 seconds was all it took for the midwife to confirm what I had said was true, she then returned the baby to its rightful place: on its mother’s chest.

The opportunity for a placental blood transfusion via delayed cord clamping is a once in a life time opportunity for all of us. It should not be disregarded as a disposable event but an important ritual that symbolises the first, in many steps, of independence a child takes in life. And like all steps towards independence, parents are usually there to help.

In this situation, the placenta aids the child in stabilising its cardiovascular and pulmonary function as it adjusts to breathing for itself (Niermeyer and Velaphi, 2013).

The sight of incredibly watered down meconium should not be a cause for immediate and artificial hastening of this important ritual.

If healthcare staff viewed the placenta as a third ventilating lung, we would not be quick to cut access of the child from this life line, which could be argued is nature’s way of assisting the child in this precarious position (Evans 2012).

On the contrary, if the child was indeed in some danger of meconium aspiration, the provision of an oxygenating organ would continue to provide vital oxygenated blood and reduce risks of increased hypoxia and hypoxic insults (Katheria, Hosono and El-Naggar, 2018).

Usually meconium aspiration syndrome occurs when an already hypoxic baby gasps before birth, and inhales meconium into its lungs; a healthy baby does not inhale amniotic fluid during labour (Davies, 2011). With good fetal heart tones and a normal labour, even thick meconium is rarely a problem (Hart, 2006).

In addition, some guidelines suggest not stimulating babies born through meconium stained liquor, at birth, to avoid aspiration but as Hudson (2015) critically points out, obvious stimulation resulting from early clamping and cutting the cord, leaves a baby with no choice but to inhale. Perhaps as we move towards the next decade we might see further development of guidelines to support intact cord resuscitation with babies severely compromised by meconium stained liquor.

In this scenario there is no benefit except for the midwife’s comfort, in separating the mother and child prematurely and ceasing the possibility of delayed cord clamping, which, after all, is a once in a lifetime opportunity.

References

Davies, S (2011) AIMS Journal 'High Risk' When does a label become a self-fulfilling prophecy? Vol. 23, No. 4

Evans A, (2012), Neonatal resuscitation with intact umbilical cord, Midwifery Today, 102:42-43

Hart, G (2006) The Problem Is Induction, Not Meconium. Midwifery Today No. 80:15

Hudson, J (2015), Facilitating normal physiology in the presence of meconium stained liquor 2015; 18(6): 16 - 19

Katheria, A, Hosono, S, El-Naggar, W, (2018) A new wrinkle: Umblical cord management (how, when, who), Seminars in Fetal and Neonatal Medicine, 23(5):321-326

Niermeyer, S and Velaphi, S, (2013), Promoting physiologic transition at birth: Re-examining resuscitation and the timing of cord clamping, Seminars in Fetal and Neonatal Medicine, 18(6):385-392