Why do we clamp or cut the cord at birth?

If you are a medical student, resident, doctor or L and D nurse, have you ever wondered why we are so quick to cut the cord? Is there evidence or proof or a serious reason or any thinking at all behind this nationwide medical tradition?

I was told during medical school that we cut the cord to prevent the baby from getting too much blood and being iron overloaded... Made perfect sense at the time and I never questioned it again until about two years ago when it dawned on me that there might actually be benefits to NOT CUTTING the cord immediately at birth. I'm not particularly thoughtful or insightful, I just hang out with midwives and doulas and one is bound to get some common sense knocked into your head if you are quiet long enough to hear a thought outside of your own narrow training.

Is there any evidence that not cutting is harmful? Not that i've ever seen and i've asked alot of experts as well. There is a new research article out that demonstrates delayed clamping of the cord (3 minutes instead of 15 seconds) can prevent neonatal anemia and only raises the hematocrit within normal range. No dangers at 3 minutes. According to the article, this is a highly controversial topic. What amazed me is not that it is controversial, but that no doctors seem to even talk about it. It's not controversial, it's another medical taboo. These guys probably did a lit search and they also say there is no research stating that it is dangerous to delay cord clamping. (http://www.pediatrics.org/cgi/content/full/117/4/e779)

I challenge medical students and residents to push the envelope on this one and question your teachers. You will learn alot about how medical opinion is formed and protected. First elicit your teachers expert opinions. "Why do we cut the cord right away? Is it harmful if we don't? What benefit is there? Is there a situation when it might not be necessary?" Then ask them to share with you the research evidence that supports this practice. And then report back here what you find.

Now take a moment, trust nature, and think about the physiology of birth. Isn't the cord how the baby "breathes" in the womb? If the baby is blue and not breathing right away (assuming the mom was relatively healthy and the cord isn't falling apart in your hands from infection or IUGR or mec staining) and there is a strong pulse in the cord, wouldn't the baby be better served being placed on mom's belly with the cord attached, receiving warmth and oxygen for a few minutes while it acclimates to the physics of it's new surroundings?

And for normal healthy babies that come out screaming, what harm is there in letting the kid transition for a few minutes while the physiology of the placenta and cord figure out it's own end moment? Why do we need to put a human touch tainted by an aggressive relationship with time into the birthing matrix?

I'm so curious why we intervene in a normal process and more curious what a comparison trial would show for blue babies who are whisked away in the first 10 seconds to intubation or blowby O2 compared to blue babies with a healthy cord pulse given a few minutes to acclimate while still attached to it's natural O2 source.

Fear will probably never let that trial happen, with the assumption that we would be placing the baby in harm's way... I'm not sure. I think it's worth a serious conversation between MD's, midwives and birth assistants. We might even have to invite the opinions of doctors, midwives and birth assistants from countries that aren't completely dependent on technology to get a more grounded and physiological perspective.

andru

Topahkal Clinic growing and moving

November 2006

We are approaching the beginning of our third year of business as a fair priced, hassle-free, primary care clinic offering holistic same-day medical services to low-income people in New Mexico. Our patients have come from as far away as Juarez, Mexico and Denver, Colorado, people referred to us by family or friends. We are seeing 20-25 patients daily, totaling about 5,000 visits each year with 1-3 hour wait times. We've collected over 95% of our fees and made the up other 5% by small and large donations from patients and friends. We started working with medical students and residents at the local public hospital and we are developing a staff of work-study students who are mostly pre-med and pre-nursing students helping us as health workers and medical assistants.

All in all, it's been an amazing two years for me. My patients have been kind, considerate, appreciative, and gentle with me when i've made mistakes. We have a diverse patient population with problems ranging from substance abuse to miscarriage to complex gynecologic issues to dermatology, wound care, chronic pain and chest pain. We've sent 5-6 patients to the Emergency Room for serious illnesses including stroke from brain cancer, subtle myocardial infarction, new diagnosis of acute leukemia, profound cholecystitis requiring a 9 hour surgery, and wolf parkinson white syndrome.

We have outgrown our little casita and have a daily whirlwind of too many cars trying to fit into too few spots.

It's definitely time to move! We searched for over 8 months to find an appropriate location and will be moving the clinic right around the corner to a building that was originally built as an urgent care in the 1980's. It was built small (but is three times larger than our little house) and abandoned by the hospital that built it for a much larger building futher down the road. Parking is GREAT. Location is GREAT. The building is kinda dumpy and constructed with no windows. i'm still wondering if that was for security or privacy or to save money.

We have a plan in place to remodel. Tile the floor, cut in windows, paint the walls, landscape, decorate, tea and footbaths. Transform the building from a windowless office to a homey, welcoming, warm, holistic clinic. That work outlines the entire month of december and probably well into the future.

We have to leave our house clinic. Our neighbors have had enough, and rightly so. The traffic is overbearing, the parking is spilling out to neighbors yards, the trash is piling up from all the sodas and bags of chips that patients eat before they come into the clinic and are told they have diabetes. Our last day in our little casita clinic is Decmber 22. We open in the new building January 3rd, 2007.

Wish us luck, this is gonna be quite a journey to get that building ready in so short a time.

andru

Shock and Awe: thoughts on the UCLA taser incident

My friend Vivek is a law student at UCLA and writes at a wonderful blog called Your Good Name. He participated in a protest organized by UCLA students, on the issue of a Persian-American student who was tasered (stunned by a stun gun with 50,000 volts) several times by community police in the university library. And he had this to say about the framing of the protest:

But after attending the protest today at UCLA, where the messaging was around public safety rather than police brutality and race, I realize that we do not have much time. We don’t have time to obfuscate, to skate over the issues that dig deep into us and threaten to rip us all apart.

If we don’t call things as they are - that Mostafa was targeted because he was a Persian male, that he was cuffed and then tazed more than four times because he was a person of color, that the UCPD’s actions have created a climate of fear for people of color all over campus, that ’safety’ as a message only means more cops and no change in accountability - then we all suffer.

We don’t have time to call things otherwise because eventually we all are going to be hit by this. And it will hurt like hell when it happens to us or to someone we love.

Amen. I agree with that. Here's to calling it like it is, for our kids' sake. Good analysis, Vivek.

Now, for some other thoughts on the tasering incident:

[1] I'm so impressed by the actions of the student who was tasered in this incident. I mean, he fell to the ground, limp (in true civil nonviolent disobedience style) when the police wouldn't let go of him. He called the police out on the Patriot Act while they had their tasers pointed at him. He repeatedly explained to the police that he wasn't attacking them. Do you know what a taser does to you? It's 50,000 volts of stun gun. Makes you lose bowel and bladder control in many cases and literally stuns you into paralysis for a few minutes. And all that time, between the taser shots, Mostafa Tabatabainejad was telling the policemen like it was. I don't think I could have been so courageous.

[2] Don't know what i'm talking about? Haven't checked out the YouTube video yet that was shot on a cell phone videocamera? Indymedia has a link to the video here (disturbing) -- [link]. Upon seeing this video, I was shocked (no pun intended) by how brazen the police were, KNOWING very well they had an good sized audience of undergraduate student witnesses (and maybe they even saw the cell phones pointing at them, shooting video). I mean, how do you do this with an audience? How do you not think twice about the brutality of it? I wonder how brutal they would have been if there was NO audience. Can you even imagine? And in the last minute of the video, a police officer tells students to leave and then threatens "or we'll taser you too" after they ask for his badge number. Wait, i thought we at least ACTED like we live in a democracy... (and by the way, how brilliant that that was caught on video)

[3] It made my day to see, on the front page of the LA Times, impassioned students marching with signs taped to their chests saying "I'm Studying, Don't Taser Me". More often than not, the mainstream media picks up an outlier at a rally doing something really weird, to place as their photo representing an event. And if the event even gets a photo or article, it's usually nowhere near page 1. So thanks LA Times for placing the photo and article front and center. Did I just "thank" a newspaper for representing the peoples' voice?

[4] Back in 2004 (so long ago!) there was talk of tasers becoming available to the public for consumer purchase (yes, we're talking negotiations between taser manufacturers and the retail shop The Sharper Image. I wrote a post on this blog, and compared our society to that in Minority Report (Department of PreCrime).

[5] If it was a white boy who was asked to leave the library? He wouldn't be tasered, first of all. And second, if he was tasered, there would be no talk of well...maybe...why didn't he just leave...why cause trouble...maybe he deserved it...well not deserved it...but he was kinda asking for it... maybe he wanted publicity... and all the other twisted arguments I've heard.

[6] I love you cellphone videocameras. And I love you YouTube. There's nothing like you two. You've done so much for documenting and sharing in this world, and you are yet so very, very young.

(cross-posted at Los Anjalis)

Angels and Children

Hanging from the light in my exam room is a "flying angel" made of wood. Most people don't look up much, and if adults have noticed it, they haven't said anything. It's there as a message to spiritual and religious people to let them know they and their beliefs are welcome in the clinic, that we honor angels and mystery, of all kinds.

Twice now children have noticed the angel and have had really funny reactions.

One was a 2 year old who was playing with his mom's keys. He looked up, saw the angel, dropped the keys while his mouth opened wide in joy, and he just smiled the biggest smile i've ever seen on a two year old. He started jumping up and down pointing to the angel. The visit was about to end but he didn't want to leave so his mom picked him up and let him touch the angel, which seemed to calm him down.

Last week a four year old girl was hanging out during the visit with her mom. She was sitting on the floor and when she looked up she saw the angel and jumped to her feet and put her arms out like she was flying. She kept repeating, "un angel, un angel," while smiling and laughing.

:>

It's not a usual part of a clinic, most docs shy away from expressing spiritual beliefs. I've felt it to be an essential part of creating my practice. I don't claim any particular religion although I have a fancy for the Quakers approach to god and life. If only I could sit still for an hour i'd probably go to more of their circles. In the clinic, we all stay neutral, to be sure. There are alot of Mexican symbols, the Virgin Mary adorns the wall. With 80% Mexican patients, that seems relatively appropriate. But even so, we welcome Catholic, Evangelical, Traditional, Atheist, etc patients. I'm not sure what all the fuss is all about, I haven't had a conversation with other docs in quite a while about this but it seems that people are simply afraid to express their beliefs.

I'd love to hear other people's opinions on spirituality and religion in medicine.

andru

Family Practice Office UPDATE - Successes and Moving

Our little boutique medicine clinic for poor people has taken a few interesting and big growth steps over the past few months. I'm personally shocked and pleased that things are working out so well. I almost feel like we are defying gravity, breaking some physical laws of the universe but as I watch the patient volume grow by word of mouth, the complexity of medical disease increase, the flow of money continue to grow, and the interest in what we are doing in our community soar, it seems we aren't breaking any physical laws of the Universe, just alot of social and economic myths.

A look back at the last two years of patient volume shows the first six months with an average of 3-4 patients a day, the second six months with an average of 10 patients a day, the third six months with an average of 15 patients a day and the final 6 months up to now with an average of 20 patients a day. We had an all time high last week of 36 patients in a single day. don't ask me how we saw that many people in a tiny little house at the end of a dirt road with parking enough for about 5 cars, all in 6 hours. We are routinely now seeing 25 patients at least 1-2 days a week.

This has given us our first major problem - the wait time. Some patients are now waiting over 2-3 hours to be seen. So far everyone is very respectiful and thankful but you can feel the frustration mounting. The only solution is to bring on more practitioners or limit the number of patients we can see to 15 a day, which isn't going to happen. Out of everything that is going really well, the one thing that isn't is trying to find another practitioner to work with us.

On the financial level, the clinic is doing great. We have had an increase in expenses as our patient volume soared, paying for some office help, but we've been able to pay for it just from patient revenues to date. Both the nurse practitioner and I are making enough at the clinic, part-time, that we don't need other jobs anymore. I'm working my last two shifts at the Hospital this month and then I'm going to be able to focus all of my efforts on the clinic because the income is becoming more than I even wanted to earn in a year. I haven't done the full analysis yet but my hunch right now is that the money earned is roughly equal to what i'd make working for a big clinic system as a primary care doc.

With all this growth we have decided to move the clinic to a new location. We spent a year looking around for the perfect building and found a wonderful site just down the road. It's on a main intersection, a building that was initially built by a large hospital system in Albuquerque year ago. They outgrew it and moved down the street to a bigger buliding. So it used to be a clinic, it has a lead-lined room for an x-ray machine and is set up for most of our needs. Of course when they built it in the early 1980's they weren't thinking outside the box. They were so in the box that they built it with NO WINDOWS. Some notion of patient privacy, building security, something like that. We have some serious work to do to renovate/remodel the building but we are all really excited about the move. We will do all the work of renovation over the next two months and then open our doors at the new location in early January. The current owners of the building are a non-profit group called the Rio Grande Community Development Corporation (RGCDC). They are a great group of visionaries who have come together over the years to do economic develop projects but in their wisdom they recognize that without health, economic development doesn't go very far. And in our wisdom, we recognize that without economic development in this society, health doesn't go very far. It's a great beginning to a hopefully long partnership in bringing our efforts together for deep social transformation.

The really exciting part of the move is that the Kalpulli Izkalli traditional medicine practitioners are moving in with us and setting up an Altar. We are going to attempt to truly integrate the health services at our clinic by bringing togeher practitioners of very different kinds of medicines to see what we can do together for our patients. And on this note, we just found out that we were awarded a grant from a local foundation called "Con Alma" which means "with soul" in Spanish. The grant was written to help our groups come together over the next year, to provide some foundational support to the complex process we are engaging in.

So iive got lots more to say but i'll wait to post in another message. i'm trying to get back to sharing some of the good/bad/ugly of the clinic and the political work going on here.

andru