Lotus Birth: The Answer or Just Another Fad?

Have you heard of the latest birthing fad?

It’s called the “Lotus Birth”. I thought it had something to do with the lotus flower, but apparently it’s just the name of the first woman to encourage the practice.

What is Lotus Birth?

A Lotus Birth is one where the umbilical cord isn’t clamped once the baby is born. Unlike delayed cord-clamping, the cord and the placenta remain attached to the baby until it falls off. This can take anything between three and ten days.

What are the claimed benefits?

The biggest reasoning given for this concept is based on the fact that the placenta is formed from the same egg-and-sperm that gives rise to the baby, and therefore it is part of the baby, and therefore it must not be violently severed from the baby.

There’s a largely metaphysical argument, relating to the baby being calmer, being more gently introduced to the world, and feeling closer to its mother.

(Hey, here’s an idea: practise Kangaroo Mother Care. That should help Baby to feel REALLY close to Mom.)

I could say that my cord was clamped and I don’t experience lingering trauma; but that would be as unscientific as the evidence for LB.

What are the health implications?

What really gets my goat is the so-called health benefit of lotus birth. Proponents claim that it reduces risk of infection, because there’s no open stump.

No. You’re right. There’s no open stump.

THERE IS A FREAKING OPEN PLACENTA!

Have you seen a placenta lately? The whole thing is a portal for infection.

It is said that the placenta must be liberally covered with coarse salt to prevent infection. Why, pray, is that then any better than protecting the stump from infection?

Isn’t it better for the baby in the long run?

Studies show* that babies with delayed cord clamping have higher intermediate-term HB, which is great. These babies are also, however, at risk for complications from polycythaemia, including jaundice.

Nevertheless, delayed cord clamping has some health benefits. But only when the delay is up to a 10-20 minutes, after which the cord clamps internally and stops pulsating. So then it literally is just a dead weight. Like a necrotic toe that’s really no use. And a risk to the remaining living tissue.

For bonus marks: What’s wrong with this picture?

That’s right. The baby is above the cord. Which means if the cord hasn’t been internally clamped yet, there will be a retrograde flow into the placenta and Baby actually loses blood.

If it’s after ten minutes, the blood in the placenta itself has started to clot and is of no benefit to the baby.

Also, have you smelled a placenta recently? It stinks really badly. It’s impractical to carry around. It’s a piece of raw meat.

Conclusion

Delayed cord-clamping has some proven health benefits, whereas Lotus Birth has none. You want to do something on a whim, believing that it will make your child happier in the long run, fine by me. But do not go around claiming that keeping your child connected to it placenta til it rots off is a health benefit. You will just irk anyone with some understanding of basic life sciences. Albeit an as-yet unqualified opinion, I would not encourage this practice – and I have received similar feedback from my consultants.

*References:

1. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes,Susan J. McDonald & Philippa Middleton, Cochrane Pregnancy and Childbirth Group
2. http://www.lotusbirth.net/

Pouring My Heart Out About Birthing Plans

I’m not going to whine today. I’m not even going to be diplomatic.

Because I’m annoyed.

Because I believe in the rights of the patient, and because I love obstetrics and neonatology I’ve been reading a lot of blogs where women share their birth stories.

And a lot of them write about how they felt cheated out of a normal vertex delivery. Because their labour didn’t progress. Because the CTG showed decelerations. And so the doctor rushed them to theatre, and delivered their baby in one piece, and saved Mommy and Baby’s life.

And that makes Doctor horrible. For saving two lives.

I believe in listening to a patient’s wishes. I believe in trying as much as possible to stick to a mother’s birthing plan. But I also believe in saving lives. And I will not stick to someone’s birthing plan if it will cost their life, or impede in any way upon their or their unborn child’s livelihood.

Dear mothers, if you do not like your doctor’s opinion, get a second opinion. If a doctor saves your life, or gives you a live healthy baby, try to see the bright side. It’s not that difficult.

Women and their babies DIE daily in developing countries because they don’t have access to theaters and C-sections or even the knowledge that a section is required.

If a doctor ignores your wishes without good reason, if he is a paternalistic arse, find another doctor.

Just know that had something gone wrong, you would have blamed the doctor, and would quite likely have good reason. So be grateful for your happy bouncy baby child. Please.

A Lesson in Strength

They have decided to unleash me upon the baby wards again.

I find this funny. My friends joke that they will need to check my handbag before leaving the hospital. Hah. Hah. They have sensors these days that trip an alarm if someone tried to steal a baby. Not that I’d steal a baby. I’m not that broody.

We are in the Neonatal ICU for two weeks. I think I saw a single term baby today – the others were all premature.

Did you know that prone position is best for a preemie’s lung development? But prone is also more associated with SIDS. And did you know that they sometimes give a baby caffeine for lung maturity? I didn’t.

They are so tiny. Their eyes closed tightly against the light, their hair dark and sticking to their scalp, their skin wrinkly, their little fists balled in defiance.

They are strong. They cling to life with a determination I wish I could see in myself.

Delivery in the Lab

A page from William Hunter's 'The anatomy of the human gravid uterus exhibited in figures', published in 1774.

Our last day of autopsies today and I finally took a deep breath and asked my question: “Do you ever get pregnant mothers? Do you look at the babies?”

Yes.

Sometimes the pregnancy is an incidental finding, tiny 12-week old fetuses.

Sometimes they pregnancy is almost term.

They won’t usually dissect the fetus, but they look at it: take measurements and inspect the placenta.

Coincidentally, there was such a mother today. She died at home of massive haemoptysis (most likely TB-related) and the healthy baby died along with her.

They brought the uterus to us, unopened. Another amazing bit of anatomy, seeing it lying in relation to the other organs.

An incision was made as if a normal caesarian section. There was something heart-breaking (call it my own broodiness), when baby’s head popped out, covered in vernix.

The forensic pathologist announced, “It’s a girl” and my heart ached for the father (if he is around) and the deceased mother, and even for the baby girl who was never held.

The Aftermath of Clinicals

For four weeks, my friends and I woke up at unearthly hours and worked, scutmonkeys, throughout the day – and often the nights.

In obstetrics we had 24-hour-calls. We learnt soon just how unglamorous birth could be. We dealt with patients who came in drunk or hungover, patients who expected their baby to simply pop out with no effort, patients who were often rude, or those who seemed to have no comprehension of any language.

When the pain and the heat became unbearable they would strip down, and we were caught between nurses ordering that the patients MUST wear their gowns, and the women who simply refused.

Birth was messy. Somehow the fact that one was wearing gloves just didn’t make the fact that you had faeces, urine, meconium and amniotic fluid all over your hands any better. Now you did not only have to protect your patient’s tracts from external insults, but also from her own potential sources of infection.

We returned to campus after sunrise, stopped droopy-eyed at McDonalds, and laughed at the events of the night, reminisced about the good; about the adorable babies.

[Funny story: In second year, McDonalds was what you ate the night before a big test, in the hopes that you could stay up a little longer. In third year, McDonalds is what you eat after call, and no matter the time of the day, you call it: Supper. Because you are about to go to bed.]

Everything tastes like amniotic fluid and smells of placenta after a call, by the way.

Those were a tough four weeks.

But they were amazing. And now we are back in class and I get to sleep until 07:00, and go back to bed whenever I want.

Psychiatry. Which should interest me immensely. But it’s theory.

Obstetrics had theory. After the long day, you would read up in your textbook; maybe about hypertensive disorders of pregnancy if you had a patient with pre-eclampsia. But that’s not the same as sitting in class.

This week, I have attended very few lectures. Which is BAD, because I promised I would be a better student this year. Did you know that untreated major depression literally causes the grey matter of your brain to shrink? We learnt how to classify suicide risks. And all the cool effects of chemicals in your brain, and why they can cause trouble if they go rogue.

But for four amazing weeks, I never once wondered if I was studying the right course. I just knew.

So theory is just not the same.

Delivering the Children of Positive Patients

In medicine, every single patient potentially has HIV.  You can run tests, but the chance remains that your patient could be in the window period. So you don’t know. And your patient may tell you that she doesn’t sleep around, has a faithful partner (who has also been tested), has never been raped and never, EVER shoots up. But as everyone’s favourite MD says, “Everybody lies” and so, you just don’t know.

Thus we take precautions, even with the doe-eyed religious married young women.

In obstetrics we wear goggles and gloves and, if the temperature allows it (which it doesn’t, in South Africa), we cover every inch of skin in thick green sterile coat.

But what if your patient is positive?

What do you do when a woman at term walks into the ward, presents her antenatal clinic card and next to RVD-test accepted, it also says Treatment Given, along with a CD4 count?

As health care professionals, even at the most junior and insignificant level of a third year medical student, we have an ethical and moral obligation to provide health services without discrimination. Fear of contracting HIV should never be used as an excuse for allowing someone else to handle the delivery.

And so you take the extra time to wear not only goggles, but a visor. You wear double gloves – which is probably one of the most taxing things to do, especially with unpowdered gloves.  No matter the heat, regardless of whether the ward has air-conditioning, you wear that thick theatre-coat. All the while behaving in such a way that your patient does not feel discriminated against, diseased or repulsive.

Because she is not. She is a woman about to go through the worst pain imaginable in order to give life to a tiny human. And she will then proceed to take care of this child, all the while preparing for that day when HIV becomes full-blown AIDS, and someone else must take care of her flesh and blood.

During my three weeks of delivering babies, three of my patients were HIV-positive.

One of them had defaulted from her AZT treatment six months ago, making it certain that her viral load would be high and almost certain that her child would also contract the disease. The delivery progressed at such a speed that there was no time for me to double-glove or get all covered up. And when we delivered the shoulders, a huge gush of amniotic fluid spewed all over the place – soaking the assisting nurse’s shirt and leaving me untouched.

A rapid progression in labour is beneficial when one is trying to minimise mother-to-child-transmission. Unfortunately it also meant that this patient received only one stat dose of ARVs, at the beginning of labour. By the time three hours had passed for the next dose to be administered, Baby was already delivered.

Another time, we were trying to deliver the placenta of a positive mother. It was difficult, and when the placenta finally appeared at the introitus, a splash of blood arched onto my sleeve. The assisting nurse’s eyes stretched wide and although it clearly had not touched skin or mucosal surface, she ordered me to go change. A fellow student made me turn in circles so that she could inspect me to ensure that I truly had remained untouched. Only then could I return to my patient.

I was fortunate enough not to have a single mucosal splash, needle prick injury or any other insult that may have exposed me to RVD – our nice PC word for HIV.

But the truth is that you soon stop thinking about Mommy in labour as Mommy with an infectious disease.

You simply think of this mother, who has carried her child for 9 months and that this completely unglamorous process of giving birth must somehow be made as pleasant as possible.

Delivering the Children of Children

They arrive in jeans and flowery T-shirts, or Disney pyjamas.

Some hold their shoulders up straight, their body language aggressive or protective at the least. Their gaze defiant. “This is me, this is my body. You do not get to judge me.”

Others make themselves small – and become more so because they already ARE small – averting their eyes, staring vacantly at the ceiling when doctors and nurses prod and poke their bodies. You think, how did this child even manage to have sex?

At their side, the protective lioness: Mom, Mammie, Ma.

Pull up their gowns for internal and abdominal examinations and you are met by little feet in school socks, panties with girly designs and cute slogans.

Their bodies are not equipped for the pain, even from the first stage of delivery. They curl up on their beds and beg for back rubs. They are anxious and require constant soothing; constant reminders that this unnatural pain is completely normal.

When the time comes to push, their tiny bodies struggle to coordinate such powerful movements. Nurses shout at them and they beg forgiveness. They cry.

Eventually their bodies let go of the child. Drenched in sweat, blood and amniotic fluid, they sink back. Ask what the child is. See the child. Comment that it looks like its father, or its granny. Never like themselves.

They struggle to breast feed, comment honestly that it hurts, that it is weird.

When the ordeal is over and they have washed, they play doll with their baby, dress him up in pretty clothes brought along beforehand.

They say that their child is beautiful, the most beautiful.

At this point you can no longer wonder what happened, or question the decisions made. You can simply respect their perseverance.

And wish them well as you think,

“The ordeal has only just begun…”

 

Why super-specialists should have compulsory clinic duty

We were on call again last night. The CHC was going through a quiet patch (the last delivery had been just past 01:00) and my friends and I were sitting in the students’ room eating cookies, scaring ourselves by looking at all the additives and making silly jokes that are only really funny when you have been awake for that long.

At about 03:45 a nurse told us that she had a patient for us – a 37-year-old grand multipara! This means that she has given birth to at least five previous infants. She was progressing fast and the nurse in charge decided that there was no time to suspend labour and refer to a level 2 or 3 hospital.

We started readying her for delivery, checking up on her periodically. She warned us that she could feel the baby’s head, and we saw that she was crowning. One of my friends ran to get the nurse and I got the gloves on just in time to support the perineum. Out came baby’s head and nurse was still not there. Third year medical students are not supposed to do these things without supervision. It was quite easy to deliver the shoulders though, and then the rest of the 3200g baby girl just popped out.

She cried well, had passed no meconium and was moving around very well. The umbilical cord had a lot of false knots, which I’ve looked up and it seems it is just a normal variation.

The mother lost more blood than any of my (or my friends’) previous deliveries, but there was no active bleeding and it subsided very quickly once we administered oxytocin for the third stage of labour. The uterus was also well contracted and her blood pressure remained stable.

The baby seems to have epicantic folds, which is a feature of Down’s Syndrome, but the absence of hypotonia, other facial dysmorphologies or a simian line leads me to believe she’s fine – my clinical group and the nurse think so too. Also, we don’t know what the patient’s husband looks like, so for all we know he is Asian.

This morning, less than an hour after our shift ended, I presented the patient to a consultant (an “attending” in American-speak). I was still on a bit of a high, but she brought me down real quick. She accused us of placing the woman’s life in danger by not referring her to a hospital. Really? Firstly, the woman was 8cm dilated! Secondly, we work on orders from the nurse and have no right to tell her how to do her job. The nurse has been doing this for much longer than we have – who were we to question her judgment? Thirdly, our theoretical module did not at all prepare us for the management of a grand multipara – in fact, it did not even offer a definition for a grand multipara. So if we knew nothing about the high risk for this patient, we truly had no ground on which to doubt the nurse’s judgment.

I do not pretend that I am right and the consultant wrong – I am not that stupid. She told us that the patient could have suffered a fatal post-partum haemorrhage. She is right, but we had never been taught that (that I can remember). What I do think is that she displayed no insight, no sensitivity and consequently displayed characteristcs not befitting someone of her high intelligence.

This consultant gave an excellent tutorial on the management of a grand multi, but I have to wonder when last she spent a night shift in a CHC. During her reprimanding of us she showed absolutely no insight into the problems encountered by CHCs on an average night, nor into the method of running such a clinic or the efficiency of the staff on sight.

She was also extremely judgmental of the patient’s situation, claiming that she was probably a disinterested mother with no comprehension of contraception and who’s children would suffer the consequences of her multiparity.

Not once did she ask us if she was right. In fact, our patient was a respectable Muslim lady who has spaced her children two years apart each – except for the first two, who are three years apart. They are all of excellent health and when she talks about them you can see that she far from disinterested. This is her last child, as was decided by herself and her husband.

My friends and I have gained such perspective after reading so many pregnant women’s charts, and I am disappointed that a consultant as brilliant as this one does not have that respect for a woman’s life story.

I know I am supposed to have some kind of reverence for a consultant, but at this point I just… don’t.

At least the next time we have a grand multi, we will be able to manage the patient more safely…

I have to keep reminding myself that I did the best job that I was capable of, and the best job for which I had received instructions. I had an amazing evening and I can’t let a tactless consultant ruin that for me and my friends.

My First Delivery

My clinical firm and I were on obstetrics call yesterday.

We arrived at a Community Health Clinic (CHC) at 19:00. We had been at the clinic for the day shift, but were sent home since the B.Cur (Nursing) students have preference during the day.

The night shift nurses were very nice. A 20 year old primigravida had come in with mild contractions at 18:30.

It was decided that I would do her delivery.

She was slightly uncompliant as she was bearing down at this point already, being only 3cm dilated.

For maternal and foetal well-being, a mother should not bear down until she is fully dilated.

She was in a lot of pain – here I learnt my first important lesson about CHCs: a woman in labour will hardly ever receive analgesics.

We were taught that a primigravida who is anxious and in pain can receive analgesics. Whether the CHC was simply out of stock I do not know.

The patient’s membranes ruptured spontaneously at 19:30. She was convinced that “the baby’s coming”. I believed her for some reason and got ready (in such a rush that I tore my first set of gloves).

Sure enough, a healthy baby girl was born at 19:45. She weighed 2710g. Upon being told her sex, Mommy said, “Damn, I wanted a boy.”

Surprisingly, the patient had no tears – not even first degree. Notable considering her bearing down at such an early stage.

In post-natal later, when I checked up on her for observations, she had fallen in love with her daughter. She asked if her baby is healthy and she thanked me for helping her.
I have heard that delivering your first baby is a life-changing event. Not quite, I don’t think. But it does feel good.