Delivery

You made it! Baby is here (almost). Here are some things to keep in mind when delivering an ISO baby. If you haven't already, it is helpful to keep a notebook and write down all your questions (and the doctor's answers) about birth and the hospital's processes. Also, make sure they will have antigen negative blood ready for baby. If you've got anti-Kell, baby needs kell negative blood. If he needs a transfusion, you don't want to wait several hours and risk brain damage while they find blood. You will want to read about the testing that needs to be done after birth. Cord blood needs to be drawn, and it is helpful if a support person can remember to ask to have that drawn. Don't forget to pop over to the Printables page for a copy of the Baby Pack to help you keep track of all the test results. You'll also find the pages on complications and interventions helpful.


Delivery

Induction

Delayed Cord Clamping

Vaginal Birth

Cesarean Birth

Special Care/NICU


Induction

Depending on the severity of your ISO, and other factors in your pregnancy, you will probably be scheduled for an induction. These can occur at any number of weeks, but are typically 32-37 weeks. Generally the doctors will try to time the last IUT around 35 weeks. The goal is to get to 35 weeks for delivery. At 35 weeks the survival rate is over 95%, and there are less risks to delivery and transfusing a baby vs the risks from an intrauterine transfusion. Women delivery at 35-37 weeks have usually had at least one IUT or they may have had higher numbers on the MCA scans. If you get a MoM of 1.5 at or after 35 weeks, they will just deliver baby instead of trying to do an IUT. Most women with antibodies deliver at 37-38 weeks. The ACOG Practice Bulletin 192 says that it is reasonable to proceed with the induction of labor at 37-38 weeks if signs of mild hemolysis is present. "Mild hemolysis" isn't defined in the document, but an MoM of 1.3 or higher is considered mild anemia. A rise in titers, even if they do not reach critical may signify an affected baby and could be considered mild hemolysis. Most doctors will induce at 37/38 weeks even if titers are stable, especially if they are critical, but why do we induce?

Inducing a woman with antibodies early takes many things into account. MCA scans aren't as accurate after 37 weeks. The risk for false positives gets higher. It is also harder to get a clear reading on baby. As baby turns head down and settles by the pelvis, it can be very difficult to get the correct angle on the top of the skull for the MCA scan. Using angle correction can lead to an anemic baby appearing to be not anemic. If we don't have MCA scans to monitor baby, then we are left with blood work and non stress tests. 


Titers aren't necessary after they've hit critical and you've begun scans. Once critical titer has been reached, you should always be treated as if you have a critical titer, even if it goes down. If titers take 1-2 weeks to come back, then you are already getting old and outdated information in the last 4 weeks of pregnancy. Things can change quickly these last weeks (that's why weekly titers are recommended) because the pregnant woman's blood volume increases dramatically. Most of this is plasma, which is where the antibodies are found. Baby's blood volume increases as well. This means more fetal blood, and more of it getting into mom's system where the antibodies can find it. This can cause her to make more antibodies that can then cross the placenta and attack baby's blood cells. Additionally some antigens aren't fully developed until a few weeks before or after delivery. The c antigen is one of them. This means that a woman's body may be seeing more of the antigens than before and either make more antibodies or there will now be more antigens on the blood cells for more of the antibodies to bind to (more chances to cause anemia). If titers haven't been drawn regularly, then there would be no way to know if they had increased in the last couple of weeks, so the information learned from drawing them again on a woman who has already been receiving scans would be minimal. Titers are not an indication of how baby will do after birth. 


Non stress tests are great for checking on baby. They see how baby is responding to contractions, but unfortunately they do not show anemia. They will show a faster heart rate, but some babies have higher heart rates normally. The NST will show a slower heart rate. Iso babies can compensate for the anemia. This makes it so that it is possible for baby to still pass an NST and still be anemic. If anemia shows up on an NST, it will be at or past the time when a transfusion should have happened. 


Some women notice decreased movement as a sign that baby is anemic. If you notice decreased movement, always get it checked out and notify your care provider and/or labor and delivery if you notice decreased movement. Do talk with your doctor about how to do kick counts and make sure to do them at the same time of the day when baby is awake so that your decreased movement isn't just baby sleeping. It is normal for baby to move less as you get further along because there's not as much room in the uterus as before. Decreased movement at 36 weeks vs 30 weeks can be normal, but it is worth getting checked out. Some moms have said that their baby had a flurry of kicking activity when they were anemic before passing away. It's also normal for baby to be kicking a lot if mom has had sweets or something cold to eat/drink. Movement is no guarantee of how baby is doing, but sometimes it's all there is to go on. 


The survival rate of babies born at 35 weeks is over 99%. The rate of infant death for those born 34-36 weeks was 7.1 out of 1000, that is 0.0071%, which means that 99.9929% of babies born between 34 and 36 weeks survive. At 32-33 weeks, the mortality rate was 16.2 per 1000, so 0.016%, but 99.98% survived. (55) The rate of loss from an IUT is 1.8%. For IUTs performed after 2001, the survival rate is 97%. This is why doctors induce and treat after birth instead of continuing to transfuse and reach a higher gestation. (56)


It may be helpful to wait to have the delivery discussion in detail until you are approaching the 35 week mark. A lot can change between where you are now, and later. When the time comes, print off articles that show that induction is the regular course for women with isoimmunization. The ACOG Practice Bulletin 192 may be one of them. It is helpful to highlight the articles and let the doctor read them so that you can have a discussion about the timing of delivery. There are a variety of methods used for induction. Ask your doctor for additional resources, what the procedures are, and any other questions you may have.



Delayed Cord Clamping

Delayed cord clamping is a practice where the umbilical cord is not immediately clamped or cut after birth. The delay time can range from a few minutes up to half an hour. Generally the cord will be limp, pale, and no longer pulsing when clamped. Up to 1/3 of the baby's blood is in the placenta at the time of birth. Delayed clamping allows the baby to get his extra blood back from the placenta. Keep in mind though that with the blood comes the antibodies too.


Our MFM recommended it. Our ISO case was not severe, and there was greater benefit to our baby getting the extra blood than the risk from the extra antibodies. He did have a drop in his hemoglobin levels (3 whole points), but because he had his extra blood, it was not low enough to need a transfusion. Some MFM recommend against it. In severe cases of ISO, your antibodies will do more harm than the good the extra blood will do. In this case, it is preferable to give the baby a transfusion with clean donor blood than to give him blood with more antibodies. A study done in 2016 showed that infants who received delayed cord clamping were less likely to need an exchange transfusion. They also went longer before needing their first transfusion after birth. "This study highlights a significant benefit of DCC in anemia secondary to red blood cell alloimmunization with a resulting decreased postnatal exchange transfusion needs, an improvement in the hemoglobin level at birth and longer delay between birth and first transfusion with no severe hyperbilirubinemia." (57)


Talk with your doctor and decide what is best for you and your baby. Regardless of if you choose to do delayed cord clamping or not, it is very important that cord blood be drawn to be tested for hemoglobin, bilirubin, and the direct coombs test.


Vaginal Birth

Even if you have ISO, you can still have a vaginal birth. For us, it meant there was an entire team of people in the delivery room (9+), including a midwife, obstetrician, neonatologist, some people from the special care nursery, lab tech, and several nurses. Talk with your doctor and see what they recommend, and who they recommend be present. Blood needs to be drawn at birth, so have someone, such as your support person, make certain that it is done. Since it is not commonly done everywhere, it can be easy for delivery personnel to forget to do the immediate draw.

Cesarean Birth

Cesarean sections, C-sections for short, can happen at any time for ISO babies. Talk with your doctor about a contingency plan for if you need a C-section, who will be present, what will happen with the baby, will you get to hold him/her, etc. Delayed cord clamping is also possible with a C-section. Keep in mind that a C-section is still major surgery and you will probably feel out of sorts for a few days. It's a good idea to have some extra help with moving, caring for the baby (and other children), housework, etc.

Special Care/NICU

Regardless of how you deliver your baby, an infant born to an isoimmunized mother shows clinical signs based on the severity of the disease. The typical diagnostic findings are jaundice, pallor, enlarged liver and/or spleen (hepatosplenomegaly), and fetal hydrops in severe cases. The jaundice typically manifests at birth or in the first 24 hours after birth with rapidly rising unconjugated bilirubin level. Occasionally, conjugated hyperbilirubinemia is present because of placental or hepatic dysfunction in those infants with severe hemolytic disease. (5)

For this reason, you should talk to your doctor about delivering in, or near, a hospital with a NICU or special care team equipped to take care of the baby. One of the worst things is to be stuck at one hospital while your baby is sent to another hospital (possibly hours away), without you. We have 2 hospitals in my town, one with a NICU, and one without. I chose to deliver at the one without the NICU, but I was informed beforehand that if my baby needed a transfusion or special care, the baby would be transferred, but I may not be (depending on how busy the hospital was).


These are pictures and descriptions of what care for an isoimmunized pregnancy and a baby with hemolytic disease of the newborn looks like. The photos might seem scary at first, but remember, knowledge is power. It's much better to have an idea of what things might look like, than to be shocked when your medical team first does something. It should also be reassuring the number of babies who have gone through this before and are now perfectly healthy, normal children. All of the babies below were in the NICU. Not all babies born with iso are sent to the NICU. For the babies who did not have HDN as severely, see photos on the Birth page.
  • Born at 31 weeks after a failed IUT.
    Born at 31 weeks after a failed IUT.
  • Born at 31 weeks after a failed IUT. This baby is swollen from hydrops.
    Born at 31 weeks after a failed IUT. This baby is swollen from hydrops.
  • This baby is swollen from hydrops.
    This baby is swollen from hydrops.
  • This baby was born at 28 weeks 6 days.
    This baby was born at 28 weeks 6 days.