Let’s review: Trust umbilical cords?

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Natural childbirth and homebirth advocates get very excited about umbilical cords, specifically nuchal (neck) cords, the medical term for an umbilical cord that gets wrapped around the baby’s neck. They get excited because they believe that obstetricians dramatize the risk of nuchal cords (“the baby could die”) when they aren’t dangerous at all. As usual, natural childbirth and homebirth advocates are wrong on this point and the reason is that they fundamentally misunderstand when and why a nuchal cord dangerous.

How does an umbilical cord get wrapped around the baby’s neck in the first place. The reason is that for most of pregnancy, the baby has a lot of room to move and the cord is relatively long. Moving around, up and down, and somersaulting, the baby can easily get the cord wrapped around itself. Most of these loops will slip off at some point, generally without causing a problem. There is the possibility, however, that even if the loops eventually slip off the baby, a true knot will have been formed but many true knots never cause a problem.

To understand the danger of a nuchal cord it helps to think of the cord as similar to the air line of a deep sea diver.

Even more likely, a loop may get stuck around the neck because it is more slender than the shoulders below it and the head above it. Contrary to popular belief, the danger of a nuchal cord has nothing to do with the fact that it is wrapped around the baby’s neck. Since the fetus does not breathe, compressing its neck has no impact on whether there is adequate oxygen in the blood. In other words, the effect of neck compression is fundamentally different than if the neck of a child or adult is compressed.

In order to understand the danger of a true knot in the cord or a nuchal cord it helps to think of the cord as similar to the air line of a deep sea diver. It’s easy to understand that if a diver moved around such that he created a true knot in an air line, it could pose a serious problem. If the knot isn’t pulled tight, there is no problem. The oxygen can pass easily through the loop. However if the knot gets pulled tight because the diver pulls on the air line by diving down deep or it gets pulled tight by being snagged on something else, the supply of oxygen can get cut off and the diver could die.

Similarly, a loose true knot in the umbilical cord is not a problem for the fetus because the oxygen continues flowing through the loop. However, if the knot gets pulled tight, either by the cord being pulled as the baby descends into the pelvis or the cord getting pulled by being snagged on an arm or leg, the baby will be deprived of oxygen and die

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This picture of a true knot (a close up of the picture at the top) was sent to me by a reader. It was noted at her 3rd C-section. It is easy to understand that had the knot been pulled tighter, the baby might have died..

If an air line got wrapped loosely around a diver’s neck, the oxygen would keep flowing through it. However if the loop or loops were so tight as to cut off flow within the line, the diver will die. Of course a diver could actually be strangled by a loop or loops of cord, but a baby cannot. Therefore, the issue with a nuchal cord is NOT the fact that it is wrapped around the neck. The issue is whether the loop is pulled tight enough to cut off the flow of blood and therefore of oxygen.

The bottom line is that true knots of cord are not necessarily dangerous, but there is no way to no beforehand whether the knot will tighten during the course of labor and cut off oxygen to the baby. Similarly, a nuchal cord is not necessarily dangerous; in fact most nuchal cords are loose and therefore do not threaten the baby. Once again, though, there is no way to know beforehand how the loop or loops around the neck will be affected during labor. The higher the number of loops, the shorter the remaining cord, and the more likely that the cord will be fatally compressed during labor. However, even a single loop can be pulled tight during the descent of the baby and the baby will die for lack of oxygen.

Ultimately, when NCB and homebirth advocates “trust birth,” they are trusting that there are either no knots or loops in the cord, or that if they exist, they will not be pulled tight. But that makes no more sense than a deep sea diver trusting that he can assume that there are no knots in his air line and not worry if the air line gets wrapped around his neck. Obviously, in the case of the air line, trust has nothing to do with it, and, in direct contrast to what NCB and homebirth advocates proclaim, in the case of the umbilical cord, trust has nothing to do with the presence or absence of knots and loops.

The only way to know if a knot or nuchal cord is hindering the flow of the blood to the baby is to monitor the baby’s heart rate. Without monitoring, the supply of oxygen to the baby could completely stop during labor and no one would know until the baby was born dead.

 

This piece first appeared in February 2012.

  • Toni35

    My youngest (#4) had the cord around her neck once and looped around her body (from shoulder to between her legs) once…. Fortunately her cord was adequate in length and it didn’t cause any issues (we had CEFM) and being a 4th time mom she was out in 4 pushes, which also probably helped…. it did cross my mind that if my oldest (or even my older 2, because the pushing phase was not much easier with #2 than it was the first time around!) had had the same issues, it may have been an emergency. The doc who delivered #4 did comment on how lucky we were that it hadn’t caused problems…. this post really hits home as to just how lucky!

  • sdsures

    I learned something new today. 🙂 I’d always thought the danger with nuchal cord was that it could strangle the baby, and now I know it doesn’t work that way. Thanks!

    • Wombat

      Same here.. kind of feel silly but always just what I assumed too. Made sense that the baby would ‘start breathing’ when exposed to air, and just be supplemented by the umbilical cord – even learning that wasn’t true later never really connected with being wrong about the cord.

      I semi-blame it A. not having been an issue/possible issue for me yet (no kids) and B. being exposed to the bad version of nuchal cord pretty early (my 2nd sibling was a semi-emergent – urgent but not crash – CS due to it). Kids just fill in the blanks and I guess I never bothered to adjust my blanks later on c:

      Also, an (admittedly purely anecdotal) +1 for umbilical cords being unpredictable and untrustworthy: In my mother’s three pregnancies she went from a too short cord (me – forceps delivery that would have been CS if he hadn’t managed to ‘catch’ me and stop what was described as ‘bungee cording’ which was probably also semi-affecting my HR, looking back), normal cord (but shoulder dystocia that was resolved and birthed vaginally, though again, CS was ‘after this try’ on the table), to a cord long enough to wrap around my youngest brother’s neck three times and either then tighten/compress or possibly hitch… not sure.

      • sdsures

        No kids yet here either.

        PS: Is there a cat GIF to the right that won’t stop replaying? Can we make it pause? It’s going to trigger a migraine, and IMO, detracts from the purpose of this blog.

  • Ardea

    A student of mine lost an arm in utero because the cord was wrapped around his forearm, and it blocked blood flow to his arm.

  • Christa

    Longtime lurker here. Also had a true knot, with my second hospital birth. Everything was fine until suddenly it wasn’t. As I started the final pushing stage the monitors indicated baby had gone into severe disress. It was so sudden and unexpected they thought that something was wrong with the monitors and switched them out. When that still showed distress everything happened quickly. In addition to the regular nurse and doctor there appeared the obstetrician, pediatrition, anesthesiologist and the head nurse. They used vacuum to get her out quickly and I pushed as hard as I could (which didn’t hurt as I had an epidural). She was out a few minutes later, they quickly checked her over, she recovered right away, they handed her over to me an we started nursing. At that point they still didn’t know what had happened, but a few minutes later the placenta came out and there was a knot in the cord that had pulled tight in the final stages of labour. I shudder to think how things might have gone down without EFM. Pretty sure I would have been considered an ideal candidate for a home birth. No thanks, not happening.

    • Nicole

      Wow, how often does something like that happen?

      My hospital has electronic monitoring, and after you do your 20-30 minute strip when you get admitted, it’s intermittent for the rest of labor and delivery.

      If it were super common for babies to suddenly go into extreme distress with no warning, why isn’t continuous electronic fetal monitoring standard in all hospitals, like epidurals? Any idea the frequency of a knot pulling tight?

  • mabelcruet

    Umbilical cords are fascinating-there is so much we don’t quite know about them. Knots are really not that common as a cause of death, looking at placentas there are other far more frequent problems with the cord that cause a bad outcome.

    The average cord is about the same length as the length of the baby, so at term it should be about 50cm long. Very short cords (less than 30cm) and very long cords (>70cm) are associated with adverse fetal outcome, but whilst we know short cords are thought to be caused by poor fetal movement secondary to CNS or muscular problems in the baby, we have no real idea why long cords happen. The longest I’ve come across was 119 cm. We also don’t know why cord overspiralling occurs-there should be one complete twist per 5cm, but if there is more than 3 twists per 5cm there is an increased risk of intrauterine death. And at the other end of the spectrum, completely untwisted cords are associated with increased risk of miscarriage as well.

    Imagine a fetus at 18 weeks-basically his heart is the size of a garden pea, and if he has a very long and very overcoiled cord, that wee heart is going to really struggle pumping blood through the cord. It would be like trying to turn the tap on full pressure to try and blast through an obstruction in the hosepipe. Mid-trimester miscarriage is common in these conditions, the fetus essentially goes into pump failure.

    Umbilical knots really only cause problems when they interfere with blood flow. The vessels are protected by Whartons jelly, and the jelly has a remarkable physical property called thixotropism. This means that when it is subject to pressure, it assumes the characteristics of fluids, and it isn’t possible to compress fluids. This means the vessels aren’t compressed even when a knot is tight. In pathology, we would only consider a true knot as being pathological if it has caused thrombosis due to turbulence or stasis in the knot

    • Sue

      There are really very short cords and very long cords? So the fetus doesn’t even know how long its cord should be? How does he/she know when to be born, then? And if our bodies know how to grow the right-sized fetus for the maternal pelvis (whatever the size of the father), how come they don’t know how to grow the right cord length?

      SOmething strange is going on here

      • mabelcruet

        That’s right. We know that babies with movement disorders like arthrogryposis or myopathy tend to have very short cords, and that can be an issue for vaginal delivery. Obviously you need a cord long enough for the baby to exit whilst still being safely attached, but less than 30 cm means a significant risk of placental detachment before the baby is out. We don’t really understand why the cord is short-I’ve always imagined it as making pizza dough or pasta-the more you handle it and move it, the longer it grows, so a baby who doesn’t move isn’t stretching his cord. But the corollary isn’t true-very long cords aren’t associated with very active babies. We don’t know why or how a cord gets very long or very overcoiled. We simply don’t understand the mechanisms yet.

        • araikwao

          Thanks for your comments – so interesting!

          • mabelcruet

            I could waffle on for days about placentas (and frequently do, my trainees avoid me now when I get going!). Amazing bits of bioengineering.

          • Rosalind Dalefield

            Interesting. My third baby who had a true knot in his cord also had a hugely long cord. My OBGYN was 6’4″ with proportional arms, and he had to extend both arms almost completely to pull the knot tight after he had cut the cord.
            That particular baby was *very* active in the second trimester but then grew big and settled down.

          • MS

            So what are the implications, if any, of the umbilical cord being attached to the placenta way off to the side, rather than closer to the middle?

          • Dr Kitty

            Depends how far off to the side.

            A cord starting near the edge is known as a marginal cord. Marginal cords (6% of singleton pregnancies, over 15% of twin pregnancies) are associated with an increased risk of abruption, pre-eclampsia, low APGARS and prematurity. They are more common with abnormally sited placentas (placenta praevia) and multiple gestations.

            Potentially, if very close to the edge of the placenta the cord could even start in the membranes. This a velamentous cord. Not good. Velamentous cords can tear, because the Whartons jelly is not produced as it should be at the origin of the cord.

            If a velamentous cord insertion is near the cervix, the cord can tear when the membranes rupture (either naturally or AROM), leading to torrential foetal haemorrhage and a high risk of the baby dying. This is vasa praevia. If identified antenatally it is an indication for an elective CS prior to term, as labour is potentially disastrous.
            https://en.m.wikipedia.org/wiki/Velamentous_cord_insertion

            I found a large, Norwegian retrospective population based study which seems to come to some reasonable conclusions, namely that marginal and velamentous cords are associated with increased risk, have common aetiological risk factors and probably exist on a spectrum, with marginal cords at one end and velamentous cords and vasa praevia at the other.

            http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3728211/

          • mabelcruet

            Some of the risks associated with marginal insertion and velamentous insertion are caused by trophotropism (where cells move in relation to food/oxygen supplies). After implantation of the placenta, the cord should be centrally or paracentrally positioned. If implantation isn’t ideal then the part of the placenta implanted in poor substrate will die off and the placenta remodels itself so the part of the placenta in the good ‘soil’ will grow and develop, and the part in the poor soil will wither and die. This gives the appearance that the cord has moved across the placenta to one edge. I’ve heard it referred to as ‘placental creepage’.

          • Dr Kitty

            Interesting stuff, so it isn’t so much that marginal cords are caused by poor placement, but that they are a sign that the placenta itself should have been much bigger and healthier than it is.

            I don’t think enough attention is paid to placentas and cords, once praevia has been ruled out at 20 weeks, in low risk women in the UK, no-one is going to check on the status of either again until the third stage is complete!

          • mabelcruet

            I agree-there are criteria for placental examination after delivery covering maternal, fetal and pregancy related complications, and overall about 10% of placentas need to be examined. However we just don’t have the resources or manpower. The assumption is that if the baby is alive then it doesn’t really matter, but there are many conditions that can recur in future pregnancies which, if we’d known about them, might impact on management. We once audited our placentas and looked at live born singletons who met referral criteria (weight less than 10th centile, ruptured membranes >60 hours etc, but all babies came out alive and in good condition). 89% of the placentas showed pathological findings. Some of these you would have expected, like chorioamnionitis in PROM, but others couldnt have been detected without microscopy.

          • Medwife

            Wow. Thanks for your comment. That is fascinating.

    • An Actual Attorney

      Fascinating. I don’t know the exact measurement, but Actual Kid had a super long cord. He wrapped it around his neck 5 times, and the OBs kept talking about it being the longest cord any of them had ever seen.

      • mabelcruet

        Wow- sounds more like a skipping rope! I always get our trainees to play with cords-they are rubbery and tough and when it’s full term, it’s exceptionally difficult to tie them into a tight knot, needs a fair bit of strength. But if you have minimal jelly, then tightening knots is a lot easier.

        • An Actual Attorney

          It sure felt like he was skipping rope in there!

    • Lurker

      Wow, this is freaking me out. One of my children stopped apparently stopped growing about week 36 (my weight quit increasing), and when she was born, it turned out her cord was skinny like you described – no one mentioned if it lacked Wharton’s Kelly.

      Baby was totally fine – no problems were found in an extra ultrasound and a couple of nonstress tests, and we had totally unremarkable CEFM during a shortish delivery. Weight was above average too.

      I did have to ask my CNM for an induction at my due date, which I felt like she should have offered given the apparent lack of growth.

      • mabelcruet

        The average cord is about 15 mm diameter but there’s a lot of variation. Whartons jelly has an odd sort of texture, it’s quite firm and when sliced it’s like cutting a pear or an apple. It gets its oxygen supply from the fetal blood, so a stressed or oxygen deprived baby isn’t going to grow a thick cord. Chronic fetal stress leads to a narrow cord, and skinny cords are generally a better predictor of long term outcome than initial Apgar scores. But having a skinny cord with reduced jelly doesn’t necessarily mean poor outcome. It’s all still a bit of a puzzle.

    • Daleth

      Very short cords (less than 30cm) and very long cords (>70cm) are associated with adverse fetal outcome, but whilst we know short cords are thought to be caused by poor fetal movement secondary to CNS or muscular problems in the baby

      They can also be caused by reduced movement due to multiple pregnancies (i.e. two or more babies in the same womb don’t have a lot of room to move). At least that’s my understanding of why my boys’ cords were only 9 and 10 inches long (23 and 25cm).

      Thank god I chose a c-section (over the repeated insistent “suggestions” and “questions” of my doctors)–I had an anterior placenta, my boys shared that placenta (mono-di twins), and with cords that short, there is no way Baby A could have come out vaginally without abrupting the placenta and leaving Baby B without any oxygen source. And quite possibly he might even have made it abrupt before he himself was safely out.

    • MaineJen

      Wow, fascinating! My daughter had a very thick cord; my husband mentioned he had to “snip twice” to cut all the way through it. After birth it took (no lie) about a month to detach. She is also the one with the “outie” belly button…coincidence? 😉

    • Nicole

      Wow, really enjoyed this comment! Answered my question above!

  • namaste863

    I have a question: at that point, since the baby doesn’t breathe, they can’t suffocate by compression of the trachea. However, wouldn’t the carotid arteries also be compressed, hindering blood flow to the brain?

    • Azuran

      I’d say, it might be technically possible to compress the carotids, but I think the amont of tension on the cord needed to compress the carotids is probably ridiculous and not something that can happen naturally in any way.
      Possibly, the Jugulars would be compressed first, preventing blood from flowing out of the brain and cause increase of intracranial pressure or cerebral oedema or something.

  • Shirley

    When my son was born, he had a both nuchal cord and a complication rare enough that I can’t find good data on how often it happens: little-to-no Wharton’s jelly, in the whole cord. Fortunately I was in the hospital and being monitored continuously, so when he started to show late decelerations we got to surgery right away. I’m sure he wouldn’t have survived vaginal birth, and I’m so grateful to the professionals for the interventions that saved him.

    • mabelcruet

      Reduced Wharton’s jelly throughout the whole length of the cord is very,very rare if the baby is normally grown. Babies who have intrauterine growth restriction often have very skinny cords with reduced jelly, but if your wee boy was normally grown but his cord had minimal jelly then that is a rare occurrence. Localised lack of jelly isn’t uncommon, and that can cause problems due to compression of the blood vessels. Also, cords with a velamentous or furcate insertion (where the vessels come out of the cord before insertion and end up lying free without any jelly around around) are also dangerous because it leaves the vessels vulnerable to pressure and during labour you can get intermittent obstruction of blood flow and consequently oxygen deprivation to baby during labour.

      It sounds like your care providers were completely on the ball and got him out at the first sign of trouble. It can be very difficult to diagnose this sort of thing antenatally and often the first problems only arise during labour. If you’re getting cord compression, then trying to progress with vaginal delivery is likely to just make it worse and risks harming the baby. But diagnosing it relies on your care provider monitoring the baby and preparing to act, which I think would be very difficult in a home birth.

      • Shirley

        He was born at 37 weeks (induced due to low fluid), and weighed 5 lb 7 oz, which I’m told is not considered small for gestational age.

        • mabelcruet

          Baby weight depends on a lot of different factors-parental build and height, maternal weight, ethnicity, birth order etc. We’re now using personalised growth charts based on multiple parameters, so 5lb 7oz might be small for dates or growth restricted for some babies, but for others it can be perfectly normal. I once worked in a department where two of my colleagues were pregnant at the same time-one was from India, and she was about 4 foot 11, and the other was Bahamian and about 5 foot 11 (with a husband well over 6 foot). The Indian lady had twins, and the combined weight of her twins was less than the weight of the others single infant-they looked like little dainty fairy babies!

        • Young CC Prof

          That’s on the small side, kind of in the zone some experts would call SGA and some wouldn’t. And low fluid can be a sign the baby isn’t “drinking” enough through the cord.

          So yeah, it’s possible your son had less optimal nutrition at the end of pregnancy.

  • Karen Teresa Reekie

    My son had a large “true knot” in his cord and it was wrapped twice round his neck. He passed masses of me indium in utero and was in distressed in labour, he was blue and rushed off with a paediatrician when he was born. He was thankfully fine but I’d rather not think of what might have been or assume that knots and nuchal cords are simply harmless and nothing to worry about…

  • Deborah

    I always use the analogy of a crappy garden hose vs a really high quality expensive garden hose. A cheap crappy garden hose will kink if you look at it funny. An expensive high quality hose won’t kink even if you wrap it around things or tie knots in it. MOST umbilical cords are fat with Wharton’s jelly and don’t kink . . . but some are thin and limp and that’s when you get in trouble.

    I see true knots ALL THE TIME. Several x a year at least. And I’ve only seen babies get in trouble from them 2 times. Honestly, most of the time when there’s severe sudden fetal distress (the kind you might like to blame on a cord, or an abruption) when you get the baby out you find NOTHING to blame. It’s just a mystery.

    • Rosalind Dalefield

      Carrying on your garden hose analogy, would it not be reasonable to suppose that the blood pressure in the cord would prevent most true knots from pulling tight, and as long as they don’t pull tight, there is no problem? My third baby had a true knot in his umbilical cord, but he had a long, robust cord and the knot did not pull tight until the OBGYN manually pulled it tight (just to prove it was a true knot) after the baby and placenta were delivered and the cord was cut.

      • mabelcruet

        Its having lots of Whartons jelly surrounding the vessels that mostly provides protection for the vessels. If you have a big juicy cord than even with a tight knot the blood can still flow. But if you have a skinny cord with lack of jelly then a tight knot can interrupt blood flow and cause hypoxia.

        I use the hosepipe analogy as well when teaching-it also holds true for overcoiled cords. Cords should have one complete twist per 5 cm length, but if its got lots and lots of coils, then you need a higher pressure to get blood flow through the cord (exactly like having a very tangled hosepipe). Overcoiled cords can cause mid-trimester miscarriage purely due the extreme cardiac work the fetus has to do to perfuse the cord vessels.

        • Rosalind Dalefield

          Thank you for the explanation.
          In a previous life (or at least it feels like it) I was a veterinarian and I now breed cats, horses, goats and sheep. Wharton’s jelly is not a feature of the cords of domestic animals, but then neither are coils in the cord. I wonder if the bicornuate shape of the quadruped uterus acts to hold the fetus so that twsting of the cord doesn’t happen? Perhaps Wharton’s jelly is an adaptation associated with the more pear-shaped uterus of the higher primates?

          • mabelcruet

            That sounds logical to me, but I admit comparative placentation is a massive field that is totally beyond me-I went to a placenta conference held by the International Federation of Placenta Associations a few years ago and a lot of it was well over my head (not much call for knowing about other mammals in my job!). Wharton’s jelly is a great source of stem cells, and stem cell research has really invigorated the whole field of placental research.

            Honestly, I know it sounds weird, but I don’t think we pay enough respect to placentas (not that I’d go along with lotus births, but just chucking them out as waste after the pregnancy seems a bit…ungrateful?!)

          • Roadstergal

            Totally. I worked in a lab attached to a major hospital for a while, and getting fresh fetal tissue was (despite the tragic source) such a wonderful thing for on-site research. It would be quite cool to allow pregnant women to consent to donating their placenta for research at a local lab.

            Not that you can get R01 grants anymore…

  • Amazed

    OT again (not quite): I just talked to Miss Impatience’s mom. Turned out that Miss Impatience was so impatient that she infected the placenta with her impatience. IOW, the placenta started detaching. I can imagine all too well what would have happened 150 years ago. Or right now. At home. Yay for emergency C-sections!

    My mom and I will have a drink tonight. To my lifelong friend and the newest addition. They didn’t get the natural birth that they only vaguely wanted. Instead, they’re here. They’re well. Let’s drink to victory!

    • DelphiniumFalcon

      Hooray for victory over what nature would have intended! Hooray for slightly grumpy baby instead of dead mom and baby!

      • Amazed

        Cheers!

  • Ellen Mary

    Here’s just one of many studies showing the overall danger & suckiness of umbilical cord knots.
    http://www.ncbi.nlm.nih.gov/m/pubmed/23523334/?i=8&from=true%20knot%20umbilical%20cord

  • Ellen Mary

    Babies with knots have a 4x increased risk of death in the womb, I read that when people told me my cesarean for cord compression which turned out to be a compound knot plus a nuchal was not necessary.

    • Young CC Prof

      In their minds, since cord knots aren’t 100% fatal, interventions in case of cord knot is unnecessary.

    • Ellen Mary

      I was also in a hospital thx to this blog & Dr. Amy, after a very successful out of hospital birth (not home b/c I couldn’t do it being a reader here), it would have made sense to do a legal Homebirth in Oregon, where it is mainstream, but because of the work exposing OR’s rates here, I could not. No one expected a third birth to turn into a necessary Cesarean at the last minute. Even if I could have transferred in from home, my Cesarean was better & safer & my baby was safer in the hospital. <3

  • Dr Kitty

    I had a plumber over the other day, who was chatting to me about babies (as one does, with heavily pregnant people).

    His second grandchild was born in England three weeks ago. EFW was 7lbs. Baby was 9lbs 11oz and his daughter had a very difficult delivery.

    His first grandchild was born in a local midwifery led unit and died shortly after birth because of a nuchal cord. He was philosophical about it, and said that the family felt that the outcome wasn’t related to birthplace.

    His youngest child has severe learning disabilities, because of prematurity.

    His wife is a midwife, who came to the profession later in life after a career as an operating theatre technician, and apparently she was horrified at the way the daughter in England was managed.

    Out of his four children and 2 grandchildren, they’ve got 3 adverse outcomes, including a death and serious disability.
    Statistics of “85% of births go well” would be useless to that family.

    • Daleth

      Holy shit. That poor family. I would sure as hell not be philosophical about it!

    • Rosalind Dalefield

      In my generation of our family, we have one woman unable to get pregnant at all (adopted two), three women unable to deliver vaginally (eight C-sections between them) and then there’s me, with two forceps deliveries due to posterior presentations, one baby requiring induction because I got to 42 weeks, and two babies (including the induction) who were persistent occipitotransverse and only delivered vaginally after a ‘dial-a-baby manouver’ on the part of skillful OBGYNS. In other words, 5 women, 14 children, and not a single completely uncomplicated birth between us!

    • Joy

      I wonder if there was something odd going on with that pregnancy on top of it all. They only do two scans in a “normal” pregnancy here at 12 and 20 weeks. Unless you are having issues, no one is predicting the size of the baby. Our local MLU is attached to the hospital, just one floor down from the Consultant led ward, but they leave you alone without monitoring. I wouldn’t go for that.

      • Dr Kitty

        At the 20 week scan you get a personalised growth chart and the midwives are supposed to used SFH to complete it, so the EFW was probably based on that rather than a scan. Personally, I think those charts aren’t worth much.

        I’ve had serial growth scans in this pregnancy, which measure this baby as anywhere between 9th and 50th centile, with SFH consistently above 90th centile, but no polyhydramnios on scans.
        At this point my OB reckons baby will be somewhere between 5lbs10oz and 7lbs, and given we have an active baby with good cord dopplers, not to worry about it.

        • araikwao

          I understand the charts are very good, but only as good as the data recorded on them, I suppose

          • Dr Kitty

            I’m a small person with a very short, wonky torso and a messed up spine. There is nowhere for this baby to go but outwards and it is sitting well out of my pelvis, with no intention of engaging, so the SFH is obviously an overestimate.

            I’ve done measurements, the midwife, OB and GP have all done measurements…SFH > 90th centile every time, but we all know this baby is going to be somewhere between “constitutionally small” and “symmetrical IUGR”.

            I’ve gained 10kg in total this pregnancy, so we don’t even have excessive maternal weight gain as an explanation for SFH weirdness.

            It is going to be interesting finding out on Tuesday!

        • Joy

          Do you? Sheesh. They measured the different areas of the baby head, leg length and all, but I was never, ever told an estimated weight.

          • Dr Kitty

            The scanners actually give an automatic EFW once you put in the BPD and AC. So it is printed on my scan pics, then you can plot it on the growth chart and follow that centile to get an EFW for various gestations.

            Except when we plotted EFW on my personalised growth chart and all threw our hands in the air when it looks like the baby has gone from 50th to 9th or 9th to 50th centile again. The approach so far has been “well, fluid and cord and placenta look good, and baby seems active and happy, so…see you next time!”

            Seriously, the growth chart looks more like a scatter plot at this point.

  • Dinolindor

    Ridiculously OT: I know some of the regulars here either are somewhere on the autism spectrum or have kids who are, and I would really like some perspectives. My son (4) just recently started I guess ABA therapy. I feel like his mild/high functioning ASD diagnosis has been incredibly difficult to wade through in terms of jargon, structures of therapy, options for services, etc etc etc. And I’m kind of disappointed at how it’s going, in terms of the quality of services we’re getting so far. Truthfully, all we’ve had is the assessment by the practice (is that even what it’s called? Or is it a company?) and 2 partial home visits, so maybe I’m jumping the gun here. But there’s the BCBA, who only comes once in awhile to check progress, and her staff who will do the 25 hours mostly unsupervised by anyone other than me. The first day, the staff did not show and apparently is now no longer with the practice (even though it was supposed to be her first day with them, not just first day with us). Today, the other staff person showed but announced that the 5 hour session would only be 2 because she forgot about a doctors appointment. Is this flakiness typical among the day to day therapy sessions for kids? While the BCBA is clearly experienced, today’s staff is this 19 year old kid and it was like pulling teeth trying to talk to her or get her to start working with my son. And there’s just like a checklist of things to ask my son. Why am I having some kid come into my home and do this for 25 hours/week? I’m having a hard time not comparing the staff’s level of expertise to that of a CPM, which may be a bit harsh… Am I missing something? Did I manage to find some awful practice with a bunch of flunkies or is this what typically happens? Is ABA even a good way to go?

    Sorry for going so incredibly off topic, but I don’t have any context for this and I trust this community of commenters. I’m at a loss for how to advocate for my son on this, which is not a pleasant feeling.

    • demodocus

      Let me get this straight, your kiddo has 1-on-1 time with someone to help him learn how to deal with the rest of the world. The actual professional only pops up now and then to see how things are going, and her staff are not required to have a college degree. You were signed up to see THREE different people on 3 different days, each of whom apparently would much rather be somewhere else.
      This is seriously unprofessional. Maybe you could complain to someone?

      • Dinolindor

        My reluctance with complaining is mostly because 1) I wonder if the lack of experience and flakiness are just what happens in this field, so what’s the point and 2) I hate confrontation and feeling like I’m getting someone in trouble…even though it is a pet peeve when “scandals” get framed as “so and so got this other person in trouble” when that other person broke the rules and got himself into trouble.

        • Who?

          Perhaps don’t frame it as a complaint. You could make some notes, practice saying what you have to say-so it feels natural-and ask some constructive questions, since you’re new to this and are keen to do everything possible to support it:

          I’d like to understand the value for my son in having multiple contacts?

          How do your staff communicate with each other to stay up to date with my son’s progress?

          My son has these challenges (A, B, C)-how has the program tailored to meet those challenges? Are staff selected for him on the basis of his needs? Will that tailoring continue?

          I’m sure there are many more. It’s good to open a dialogue anyway if you’re going to be dealing with them for a while -and if the answers are flaky then at least you can decide how long to stick with it.

          On a separate note, I know very little about paediatric therapies but 5 hours sounds like a really long time for one sitting. Even 2 hours seems long.

          Good luck with it all!

          • Dinolindor

            Thank you! And yes, 5 hours seemed crazy. But with their flakiness, and now that I’ve fired them, we never got more than 2 hours. Forget having my 4 year old deal with this for 5 hours, I don’t see how their untrained 19 year old staffers could sustain that long of a session.

        • Kelly

          My Mom was a people pleaser and had to learn how to complain and get what she needed for my brother who had a severe disability. You will develop confidence and will start to understand how to get people to do their job as time goes on. The first step is to just start. I learned a lot from my mom about how to get what is needed. I just won a fight with my property manager when normally, I would just roll over. It takes time and practice but your child needs it.

    • Cobalt

      I’ve had similar trouble with no shows, and a few therapists that seem to have no real idea what they are doing. Call the office and raise some eyebrows. There are excellent therapists out there, but also many who are just going through motions they don’t seem to really understand.

      • Dinolindor

        I think the actual BCBA could be good and my son looks forward to seeing her. But is it normal for her to only be there say 25% of the time? And meanwhile a glorified high school student does the bulk of the time with him?

        • Cobalt

          It really depends on the program you’re in, normal can be a very relative term. Different places have different set ups and getting funding for a particular type of provider beyond whatever their standard ratios are can be a nightmare. If these providers are all from the same agency, you’re off to a good start as there’s only one place to call to get answers.

          Don’t let them get away with throwing a bunch of jargon at you, the person providing services should be able to confidently and clearly describe what they are doing, why they are using that method, what their goals are, and how qualified they are. By all means, ask nicely, but get answers. If you don’t get good ones, call whoever is in charge and ask them.

          Sometimes glorified high school students with the right training and attitude can be a real asset (in a structured, supervised setting where they are following protocols directed by involved professionals), so don’t dismiss them out of hand. But if you see anything that shakes your confidence, ask questions.

          • Dinolindor

            Thank you, Cobalt. The jargon is more in terms of the role for each person in the mix, not in terms of what they are doing, at least so far. Although the “programs” they have listed on the checklist don’t seem to engage the behaviors that my son struggles with. The red flag for the staff isn’t the age exactly, but I guess I didn’t see any qualities that would offset the lack of experience in this person. She made me think of some of my past students when I was an adjunct – the ones who would regurgitate but not necessarily synthesize. But maybe it’s just that I’m too used to being in a teacher role for that age group, so it’s hard to trust them in this setting? I just know how little training my students came in with for anything! (Ugh, I was born to be a crotchety old man. Those damn youths.)

          • Cobalt

            I’d give it 2 weeks or so, then have a list of questions for the lead provider based on your observations over time. Frame it as educating yourself so you’re not feeling like you’re confrontationally busting the juniors for incompetence.

            In my experience, there are more flakes needing weeded out of the field than is acceptable. It’s an area where more standards and regulation are needed to raise quality. The regurgitation without synthesis is entirely too common, as is the impression that education and professionalism overall is lacking. I’m not sure what draws so many flakes to work with special needs kids, but the field doesn’t have a good filter for the lower level providers and it’s extremely aggravating to me.

            It’s still worthwhile to pursue the therapy, because once you do get the right providers you’ll see the benefits. It can be very frustrating getting to that point, however.

          • Dinolindor

            Yes, what is it that draws flakes to this area? I know my brother has had problems like this with finding in-home nursing care for his MIL, so that was part of my reluctance to really rock the boat right out of the gate. If this is how it is, then I’d want to strategize how I go about advocating for my son rather than fly off the handle immediately. But you’re right, it is worthwhile to pursue the therapy but only if he actually gets it! Thanks for your replies.

          • Cobalt

            As for flake-drawing, my GUESS is:

            Too low barriers to entry (education, training, experience prerequisites)
            Insufficient standards through trade association/regulation
            High demand (more diagnoses and more desire for these providers)
            Lack of public awareness of what good intervention looks like and why
            Prestige/ego (“I’m wonderful, I work with special needs kids”)

            It’s a job that looks and sounds good on a resume, pays enough, and doesn’t necessarily require a big upfront educational investment.

            That’s my theory. For all I know I’m completely wrong, but it fits well with my observations so far.

          • Squillo

            Does the program checklist include specific goals for your son?

            I would also ask them to have the courtesy to call you ahead of time if there’s going to be a significant change in the session. Presumably, they know that many people with ASD do much better with routine and may have trouble with sudden changes. At the very least, your son needs to know what to expect.

            Frequent staff changes would worry me; these are long-term therapies, and for my son, at least, it takes significant time to build up enough trust in the therapist to really commit to doing the work.

          • Dinolindor

            Yes, that’s a good point. And for my son, he’s pretty good with warming up to adults. Older teens is hit or miss, and kids are mostly ignored. They sent over a 19 year old kid who was not enthusiastic and worse, not even trained! So they are fired, and we’re waiting. It killed me how they were so “here is our binder, let’s check off all of these things, and what do you mean this doesn’t feel like play time?” My son is pretty perceptive and he clearly was taking a hit to his self esteem. I’m kicking myself that I didn’t see that immediately and stop this sooner. But on we go, to hopefully a therapist he can have a good relationship with.

          • DelphiniumFalcon

            Don’t be kicking yourself for not spotting the deficiencies right away. This is a new area for your life and you’re not specially trained so you wouldn’t know what’s normal and what isn’t. So instead of sitting back and taking the wait and see approach you found people who were experienced which was a fantastically proactive thing to do for your son.

            A lot of kids end up in these kinds of programs for years and since the whole neurodiversity movement is still rather new, parents don’t know what it’s doing to their kids’ self esteem since, at least for most ASD people I know and myself, our defense mechanism is to withdraw from what’s hurting us and try to shut it out completely. It can make people with mild symptoms appear worse and then parents think their children were worse off than they thought so thank goodness they got this therapy group.

            These days with the internet and parent support blogs, fact checking is much easier and these types of groups can be spotted and taken out of your child’s life before they can do any permanent damage.

            Your son had a couple months of people coming and going and he’ll probably only remember it if he’s the type of person on the ASD that just retains all the information, useful or not. Otherwise it’s a small blip for him and a big learning experience for you. You’ve been able to recognize when his self esteem may be taking a dive and it can be difficult to recognize that in ASD children because they don’t always react in what we consider “normal” ways.

            I’m absolutely positive if my parents hadn’t been so involved in protecting me from adults who tried to tell me there was something horribly wrong with me and still made efforts to interact with me even if I didn’t behave like a normal child (I was a rather morbid toddler that had a fascination with death) I wouldn’t be as well off as I am. They were amazingly patient with my weird behaviors including collecting toe nail clippings and were more likely to use logic to try to steer me towards “normal” behaviors than using “because I said so!”

            My “normal person, nothing to see here” mask isn’t perfect though. When I’m attacked suddenly verbally, my first instinct is to freeze and shut everything out. My ability to articulate words goes right down the drain. I can’t make my mouth form the words I want. I’m also on the verge of bawling almost immediately and would probably be screaming if it were socially acceptable. I’ve built up tolerance to this over the years but every once in a while someone will hit the bullseye and I can’t mask it. I have no doubt if I had less patient parents who got frustrated and yelled at me, I’d likely have been close to being non-verbal.

            You’re already advocating for your son because he can’t, and shouldn’t be expected to, recognize what’s actually helping him and what’s just hammering his self esteem down. He’s already in good hands from where I’m standing.

            And personally I’m so over not making waves. There’s a time and a place for not rocking the boat but outside those situations I frankly don’t care if talking about my mental illness makes people uncomfortable. The social stigma of having a mental illness isn’t going to be lessened if we continue to cringe and fall back when we’re told we make people uncomfortable. They’re uncomfortable? They’re not living with the damn condition! We’ve been politely quiet long enough but are still exploited and misrepresented in media. Obvious someone is going to have to make some noise for things to change. If I have to take the hit today so that my kids don’t have to deal with the stigma tomorrow I’ll gladly take it.

    • Mel

      Speaking as a teacher and someone who had lots of therapists due to CP as a child and an adult, keep this truism at the forefront of your mind:

      The squeaky wheel gets the grease.

      Your first, primary and most important loyalty is to your son and yourself. You or your healthcare network are paying for 25 hours of rehabilitative care a week from a service provider. That service provider is contractually required to send a reasonably competent human being over to provide said services.

      Making clear that YOU expect them to honor their terms of care is not being mean or harsh towards the employees – you are simply upholding your end of the contract.

      If a provider misses an appointment for any reason, call the company and ask how they are going to provide X hours of care for your son. Keep asking until you get an acceptable answer. If the person you are talking to can’t provide an answer, politely and calmly ask to be transferred to someone who can answer the question or their boss. If they cannot provide X hours of service that week, verify that they are not billing anyone for that service.

      If a provider can only provide 40% of the scheduled contact for any reason, call the company and repeat.

      If a provider isn’t spending X hours working 1-on-1 with your kid, gently ask if there is anything you can do to speed up the start of the therapy. Document every time you need to ask this question. If nothing has changed after 3x asking the question, call to see if you understand the expected procedure correctly. If the employee isn’t providing service correctly, start from asking how the company will provide X hours…… and continue until you get an answer you find acceptable.

      This will feel awkward as hell at first especially if you have strong feelings of protecting others from unfairness or unpleasantness. Remember, though, that the service providers have a duty to actually perform the services paid/billed for. Push through the anxiety or guilt or nervousness for your sanity and your son’s. After a while, the process feels more natural AND you will feel stronger since YOU are demonstrating that you have power in the relationship.

      • DelphiniumFalcon

        All of what Mel said.

        A good therapist will help your son function better as he grows up and understand what limitations he has and if they’re truely limitations or something he just hasn’t learned to navigate around yet.

        A bad therapist will make him feel like he’s not doing enough to “cure” himself and if he doesn’t already have depression he may develop it.

        I didn’t have this type of therapy as a kid and I wasn’t diagnosed as Asperger’s until I was nearly twenty three. I was in the era where Asperger’s first became a diagnosis and when girls with ASD were considered rare so I slipped through the cracks.

        Your son hasn’t slipped through the cracks so the first big step has been taken and that’s already going to help.

        The next step, and it’s a hard one, is to realize therapists work for you and not all therapists will be a good fit for your son. It’s important to teach him that the therapist is there for him, not someone else he needs to pretend to be normal for and try to please.

        I don’t know how your son is but I’m the type of person on the ASD that’s a people pleaser because happy people are less of an enigma to read. If I’ve pleased them then they won’t be mad at me without me knowing. I know now that’s not the best coping mechanism and that it was detrimental to my therapy sessions. I was trying to please the therapist instead of being honest about what I was feeling. It really doesn’t work to help learn how to manage symptoms and it’s stressful. So finding a therapist he feels comfortable communicating with will be a keystone in this process.

        Don’t be afraid to “fire” a therapist if they’re doing more harm than good. I’ve fired two in the past five years. One wanted to go the Freud route and blame all my problems on my mom. My mom was the only advocate I had when I kept getting brushed off as going through a phase so I ditched him asap. The other talked more about herself than listening to my problems. I’m paying her to listen so she better listen. If I wanted to pay for story time I’d pay for story time.

        Don’t be afraid to ask questions to make sure you’re understanding the process and what they’re building up to. They may just be attempting to make him comfortable with interacting with them right now.

        Be very wary of anyone who believes in a one size fits all program. ASD is a very diverse and complex disorder. To meet one person on the ASD means you’ve met ONE person on the ASD as the saying goes. I don’t think I’ve met anyone who mirrors my set of symptoms exactly. My uncle comes very close but even we have differences that cause treatments that work for him not to work on me and vice versa. Your son will have his own unique settings on the ASD that need to be addressed on the individual level. He’s already outside the box so don’t let anyone else stuff him inside one.

        • Dinolindor

          Thank you! And I just fired the company. The more I looked over what was going on so far, and then once I was able to talk to my son’s preschool director about what was happening, the clearer it became that this was not good. And after the last interaction, I also got the sense that my son was feeling like there’s something wrong with him, and I don’t have the words for the outrage I feel for that. Back to the waiting lists we go for the private companies, and hope that the school district can offer better services in the meantime. (Thankfully our state seems to have one of the better mandates for helping kids like this.)

      • Dinolindor

        Thank you, and as I replied to Delphinium below, I fired the company. Nothing was adding up, and my son’s preschool director was aghast at what had happened so far. I wanted to get opinions from people who are in the field before believing what I was observing, I suppose. From what I gather, this is a new operation in our area and there are others (which my insurance covers) that are more well established and respected. So my son is on their waiting lists while we see what the public school district can do for us. But thanks for the encouragement to not just go with the idea that this is how the field is.

  • Sue

    Great, succinct summary. It’s all about the pathophysiology.

    Like Dr Amy says, many people misunderstand “nuchal cord” as meaning that the baby would strangle, when, in fact, it’s just one of the many variants where the cord can be stretch too tight, and cut off circulation.

    How is it that these people can overrate the need for a patent cord when the baby is already born, but underrate the role of the cord before the baby is born?

    ANd how many times have we heard that the HBMW mistook the mother’s heart beat for the babies?

    In other settings, we stopped relying on manual readings of heart rate decades ago.

    • Young CC Prof

      Maybe if we started referring to cord impingement during labor as “early cord clamping” they’d take it more seriously.

      • Allie P

        Sadly that is true.

      • Sue

        Brillilant, Prof!

      • Daleth

        High five.

    • Beth

      Possibly dumb question here. I understand that cutting off air flow through the neck is not the issue because of course the baby isn’t using its lungs or trachea yet. But can’t the nuchal cord compress the carotids and cut off blood flow to the fetal brain? So in that sense compressing the neck would also be a problem?

      • KeeperOfTheBooks

        I’d be interested to see an answer to this, too. If it’s a dumb question, at least we can ask dumb questions together! 😀

      • Psychae

        I think the compression would have to be very tight (unusually so) with probably multiple loops of cord present to have that effect. The carotids are arteries so their walls are naturally firmer than veins’. I have seen abnormal heart traces with babies who have 2-3 complete loops rather than just one, but I wouldn’t go bail that this is due to carotid compression – it could also have been because of external cord compression in second stage or just tension on the cord as the baby descends. Could have been some of both though I guess!

      • Sue

        I could’t say that was imposssible, but I suspect the cord might tear or rupture if it was so tight that it could block arterial flow.

        Certainly the cutting off of flow through the cord would occur first, so the brain would be hypoxic by that route long before any carotid flow could be cut off.

      • Deborah

        Which is more compressible: the carotids in the neck or the vessels in the cord? It’s the cord. So if a nuchal cord is going to make trouble at all (which they usually don’t) it’s the neck strangling the cord, not the cord strangling the neck.

    • Daleth

      How is it that these people can overrate the need for a patent cord when the baby is already born, but underrate the role of the cord before the baby is born?

      That is EXACTLY IT! That’s exactly what they’re doing! You nailed it! The cord is somehow crucial when the baby is lying on mom’s chest breathing comfortably–“omg don’t cut the cord, we need delayed cord clamping, it helps reduce anemia!”–and yet not crucial at all when it is the unborn baby’s only way of staying alive!

  • Eater of Worlds
  • Oh man, nothing pumps the adrenaline of a NICU nurse more than running to an emergency section based on crashing heart tones….I have seen a handful of true knots that had tightened enough during active labor to become a life or death emergency. Monitors = good. Go figure.

    • Sue

      Nothing like the insight that comes from real-life experience!

    • micro

      I love this article, it first appeared 6 weeks after the birth of my daughter. And my daughter had a true knot in her cord that was being pulled tight during the delivery, leading to an emergency C-section, baby born not breathing with an APGAR of 4. Due to be in hospital, the got the expert care she needed and was subsequently doing fine with a 10 minute APGAR of 9. This happened during an induction at 40+6 weeks, and in hindsight I’m really glad that I went for the induction. And guess thanks to whom? Dr. Amy!! When my obstetrician offered me an induction, I was very skeptical, because you know “babies are not library books, they know when to be born” etc. I was about to refuse induction, because I could only find woo advice online. Then I found Dr. Amy’s blog, contacted her by email and she answered! She took the time to answer me, a total stranger! Somehow this convinced me to trust my doctors and I have now been following this blog for almost 4 years. And I have a healthy 3.5 year old!

    • I was present at a birth in the early 70s when decels began at full dilatation, and the mother was encouraged to push since the vertex was at station +2. We taped the doppler sensor to her belly [before EFM] and listened as with each massive push, the FHR got lower and lower, and then stopped. Literally a minute later, the baby was born — with an unusually short cord and true knot which had been pulled very tight. Resuscitation was unsuccessful. Vaginal delivery actually killed that baby.

  • Spellcheck

    Third para from the end: “to the bay.” should be “to the baby.”

    • Amy Tuteur, MD

      Thanks!

    • Alcharisi

      “Open the pod baby doors, HAL…”

  • Amazed

    OT: Remember little Miss Impatience I told you about a few weeks ago? The one who tried to escape a month too soon and had to be restrained to stay inside until they made it to month 9? She’s here now! They’re both well. What a relief! Not that I ever doubted it but still.

    • The Computer Ate My Nym

      I can’t “like” since I haven’t got an account, but yay! Congrats to all!

      • Amazed

        Thanks, thanks. Her mom is my oldest friend, we were toddlers together. What a joy!

        She’s also 3.200 kg. Quite good for someone who was expected to arrive on September 5th!

        • KeeperOfTheBooks

          So in American, she’s just about 7 pounds even. Little chunker for a month early! Welcome to the world, Miss Impatience, and many congrats to both her mom and Amazed! Got get some of those lovely newborn snuggles!

          • Amazed

            Thanks to you as well, KotB! I can’t keep smiling.

        • The Computer Ate My Nym

          Wow. My critter was 3.5 on arrival at 40 weeks 5 days. Glad she and her mom are both healthy!

    • Megan

      Congrats!!

      • Sue

        WOnderful – best wishes to your friend.

    • Cobalt

      Congratulations! Glad it all went well, even if that wasn’t nature’s plan.

  • Houston Mom

    OT, but Dr. Fischbein was on the radio here in Houston Sunday
    night on our Pacifica station’s mothering quackery show. His interview is recorded here – http://wholemothershow.com/allshows/feed/

    Synopsis: He talked about the mammalian birth model, how hospital birth is unnatural, frightened women have complications due to fear. Breech and twin homebirths are fine. The increase in c-sections since 1970 has come with no decrease in morbidity or mortality. He trumpeted his new paper on
    view now at birthinginstincts.com, a record of 135 homebirths he has presided over. Said delivering a VBAC requires no extra skill like breech or twins since it is just the absence of doing something. He has an 84% success rate at vaginal breech delivery. You will have better luck delivering breech at home than head-down in hospital (in terms of chances of getting a c-section). Fewer complications in labor if woman is allowed to move. He has a c-section rate of 5%. He and the homebirth midwife host had a good
    chuckle that an increased rate of a rare event is still rare. Epidurals cut off the hormonal communication between mother and baby during labor and the baby gets in trouble. No one is taught this in residency or medical
    school but midwives know this. Spoke approvingly of pregnant women refusing late term ultrasounds if large baby is suspected. Gave a shout out to social media’s utility in “educating” women about birth. Birth works really well 85% of the time. Feels that there needs to be an alternative
    model between home and hospital. Recommended listeners go to betterbirth360 to listen to some interviews with more quacks. http://www.betterbirth360.com/
    Other recent guests on this program have included Jen Kamel (4/26/15) and Peggy O’Mara (5/24/15) who helpfully explained how measles is not a dangerous disease.

    • DelphiniumFalcon

      Yup. My mom just feared an excess of amniotic fluid, her gallbladder backing up into and damaging her liver, delivering two weeks early after nearly prematurely delivering near six months previous, and my sister’s weight of over nine pounds into reality.

      Sounds legit.

      • KeeperOfTheBooks

        Totally. *rolls eyes so hard they stick*

    • Amazed

      Any cause that has Dr Fishy supporting it has already failed. I can only imagine the mad dash for anyone important-looking to support them. Beggars can’t be choosers.

      • Young CC Prof

        Dr. Fischbein, and a bunch of anti-vaxxers. Some people are their own worst enemies.

    • Cobalt

      “Birth works really well 85% of the time.”

      I’m not liking the odds of being the one in seven it doesn’t go well for. Yikes!

      • DelphiniumFalcon

        More of these NBC and Lactivist and so on need to play DnD or another d20 system.

        Hear me out.

        I’m notorious in my tabletop gaming group for rolling 1s. If I manage to only roll a 1 once in a session, it’s a miracle from the Dice Gods. I roll them often enough that entire story arcs for that session had to be modified.

        That’s a 5% chance to roll a 1 on a 20 sided die. Five percent seems so insignificant until you miss your save and you lose your weapon. Or fall into the jellyfish trap. Or get impaled on the spike trap of. Or get your mind taken over by a necromorph overmind and shoot your only other tech guy in the head while cackling “They want our bodies!”

        5% is too much of a risk so I build my characters with insane saves and to hit rates.

        So 85% chance of success is a 15% chance of going wrong. I have accidentally royally fucked over a game enough times with only a 5% chance of it happening that 15% just might give me a nervous breakdown with how likely it is that I will roll something terrible.

        A 15% chance of birth complications terrifies me now. This isn’t a tabletop game with imaginary characters and uterii can’t take Feats to improve their success rate! There is no +1 Uterus of Trust Birth!

        Fuck 15%, it’s not worth it!

        Put these midwives in a DnD game and modify everything with a 1-3 roll equals critical failure. See how long it takes them to complete a campaign. And for shits and giggles, throw the Book of Erotic Fantasy in there for pregnancy and childbirth. See how many imaginary babies they manage to kill while we’re at it and see if it sinks in yet. They won’t ever leave the room because they will never complete a campaign.

        • The Computer Ate My Nym

          There is no +1 Uterus of Trust Birth!

          No but there is a saving role: obstetrician which uses about a D1000. Actually, if you start labor with a healthy mother and baby, it’s a D10,000 with something like 1-6 being critical failures.

          • DelphiniumFalcon

            Brilliant! Lol

            But obtaining the Obstetrician class takes multiclassing and a prestige class and I want to delivery babies noooooowwww! I don’t want to do all that work, I want to be awesome!

            …ugh never realized Midwives are like the munchkins of childbirth.

          • The Computer Ate My Nym

            Non CNM midwives don’t have any equipment but have a Really Impressive Title, +3 for fighting imaginary monsters?

          • DelphiniumFalcon

            I never said they were very good munchkins!

            See they put all their ranks in Bluff instead of Heal. And blew all the money on components for spells that sound really impressive but don’t work.

          • Anj Fabian

            “I use my Cantrip of Heal Scratches!”
            The blood flow seems to slow…
            “It’s working!”
            ….but then continues unabated. You notice the patient is pale, shivering and her eyes are closed. What would you like to do?

            “I can cast Heal Scratches for no cost. I’ll use it again!”
            There’s no effect. The pool of blood is getting larger.
            Would you like to do something different?
            “Heal Scratches again!”

          • The Computer Ate My Nym

            Next up, roll a new character because for no obvious reason this one’s now got a bad reputation.

        • mythsayer

          For real. I actually sat out a couple games because I was recovering….because I should have been dead by my friend doesn’t play that way. So I recovered, unconscious, for an entire weekend. We used to play 20 hours or more over Friday to Sunday’s. So yeah…I was out awhile.

          You’re so right. I am shivering at the idea of rolling a critical failure now and I haven’t played in probably 10 years. No thank you with real life.

          • DelphiniumFalcon

            PTDS?

            Post Traumatic Dice Syndrome?

            All kids should learn to play tabletop games in school to understand probability. But then we’d have an entire generation of superstitious dice rollers. I knew a guy who microwaved his notoriously bad d20 and lined up his other dice to watch so they knew what would happen to them if they started rolling continuous ones.

        • AirPlant

          Dude. Buy a new d20, your is obviously broken.

          • DelphiniumFalcon

            I have four complete die sets of different styles. They all roll that way. A friend let me roll his d20s for a session. Still ones. And then the people sitting next to me started rolling ones disproportionately. Only my husband and a few other players dare sit next to me. I’m just cursed by the Dice Gods.

            Keeps the game interesting!

            And at least I’m not like my husband’s old roommate. He critically failed on an acid orb. Then critically hit and rolled max damage on his face when he rolled for if he hit himself instead. I think he had to roll a new character.

      • Sue

        AND this is in their select population of home-birthers. If it goes badly for 15% of their hand-selcted candidates, what about the total population?

        Too much cognitive dissonance right there.

    • Rosalind Dalefield

      “Epidurals cut off the hormonal communication between mother and baby during labor and the baby gets in trouble.” Completely impossible since hormones are carried through the bloodstream. What a quack.

      • Houston Mom

        There are lots of natural birth websites saying that oxytocin levels in the mother are lowered if she has an epidural. Don’t know if that is true. I wouldn’t take anything Dr. 85% says at face value.

        • Rosalind Dalefield

          I’ll believe it when I see several (not just one) peer-reviewed research papers in the medical literature that show that it is true.

    • Mel

      What is the mammalian birth model? I’ve never heard of that in any of my undergraduate or graduate school classes, so I’m assuming it’s mostly made up from snips of actual science divorced from reality.

      After all, I’m pretty sure vets need to learn about more than one style of giving birth. Cows and horses are fairly similar, but substantially different from pigs, cats and dogs.

      I am willing to bet that it involves a mistaken understanding of mammalian bonding. The trick in bonding isn’t bonding the baby to the mom; it’s bonding the mom to the baby. Mammalian babies need a maternal food source much more than a mother needs a baby for survival. Babies of all sorts are born with some basic instincts to figure out what of the strange objects around them are mom and then proceed to try and convince said mom not to abandon them.

      In the cows, we’ve seen calves attempt to bond with their actual mother, a cow they’ve decided is their mother, my husband, a large round bale of hay, a large green dumpster, and a log. Watching a calf try and get milk from a non-lactating cow that is trying to avoid the calf is really amusing. A few are so persistent that the non-mom cow gives up and starts caring for the calf out of what appears to be a sense of resignation to the inevitable. On the flip side, finding a calf that escaped the barn cuddled up next to the dumpster – or the skid steer- lovingly nuzzling the metal is really pathetic.

      In sheep, doing everything right is critical to get the mom to bond to the new lamb. They have a really short and really finicky window of maternal bonding.

      Humans aren’t sheep. There is no critical period for bonding. This should be pretty obvious from the fact that adoption in humans is far more common than any other known animal AND our fondness for keeping pets.

      • Houston Mom

        He was trying to make the point that birth needs to occur in a quiet secluded atmosphere like how cats will go somewhere quiet to deliver. I would imagine animals go somewhere secluded because labor/birth/immediate post-partum period would be a vulnerable time for them and their offspring, not because they have some instinct that fear = bad birth outcome. Home birth with a midwife, apprentice, doula, birth photographer etc. isn’t following his “mammalian model” anymore than a lady delivering in a hospital.

        • Mel

          Based on what I’ve seen in cattle, fear and bad birth outcomes are not correlated. Some cows-especially first calf heifers – are clearly freaked out during the whole process and give birth easily. On the flip side, we have a 8th calf cow who bellows like she’s being killed during every delivery and she always produces a healthy calf without needing a hand. Another cow is absolutely silent and calm – but has an entrapped calf.

          It’s not a correlation let alone a causation.

  • attitude devant

    The other thing that we see is a cord that for one reason or other is more likely to be compressed because of issues in the cord itself. If the jelly that fills the walls of the cord disappears and the cord becomes thin and floppy it can be easily pinched. This is a particular hazard in post-dates pregnancies. Or, more common in my experience are cords that are coiled too tightly and as the cord gets pulled on as the baby descends the blood flow is shut off.

    • Young CC Prof

      IUGR babies are also more likely to have cord issues. One of my IUGR mommy friends had two true knots, another one the jelly was really thin, another one there was no jelly at all on one part of the cord.

      Yet another reason why IUGR babies are more likely to go into distress during labor.

  • Guest

    My son was born with a true knot. Thank goodness for EFM. We had agreed to do controlled pushing until his heart rate plummeted into the 40s as I started pushing (aka when the knot pulled tight). My CNM told me I had to get him out with the next push or she was calling an OB to vacuum him out. We had him out in less than a minute and he’s a wild and healthy 2 year old today. I shudder to think what could have happened if his heart rate wasn’t being continuously monitored.

    • Kelly

      That is terrifying but thank goodness for EFM.

    • Sue

      Now THAT is a competent, collaborative midwife. I suspect the vast majority of competent hos pital-based midwives understand what it means when the heart rate drops with pushing.

    • Wren

      I had a similar issue with my daughter, except it was the cord around her neck repeatedly (2 1/2 to 3 times, depending which midwife). I was pushing, looked up and the room was suddenly full of people. I was told I had to get her out now, so I did. She was fine but I was so grateful to be somewhere that there were people to help and to have midwives (one newly qualified and one senior) who were willing to ask for help.

      • Guest

        My epidural failed, so that moment of “you have to get this baby out NOW!” is really the only thing I remember – but my husband told me that within seconds the room filled up with doctors and nurses. If something had gone wrong, he would have been in good hands – immediately. Yet another reason I’m so grateful he was born in the hospital with continuous monitoring.