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First there were these photos, uploaded to a social network. Suff Daddy, Hubert Daviz and Tobrock are chilling with a beer and a spliff in black and white. Sharp contrasts and very little light. R.Winterstyle. For the first time, these bedroom rockers look like pop stars or at least larger than life. My initial thought: we got to do something with these pics. For a year or two Robert had been taking his camera with him, when he was visiting his beatmaking friends at their studios, went digging or partying with them. Around the same time Hulk Hodn and Twit One turned in an album under the name Testiculo Y Uno. Special interest music with no rapping or singing that needed to be heard. Welcome to the club! Robert climbs the loft bed at the treehoue studio where Twit and Hodn have set up their gear. We press up 500 LPs and hold breath. Eight weeks later we have to do a repress. Have we just jumped on the Huss'n Hodn bandwagon or are people really diggin the music?
They do! 'Suff Draft' even tops the succes of volume 1 and after dropping Dexter's 'Jazz Files', we know that we are on the right track. We ignore the few haters who try to pin-point the Hi-Hat Club as a boom-bap revival and send Robert to Vienna where he dissects a sea bream with Brenk and Fid Mella. Bam, Oida! Next stop is Amsterdam where Full Crate and FS Green serve 'Eggs And Pancakes' so next-level and upfront that no app has been programmed yet. With DJ Adlib we are going back to CGN and a couple of MCs (Black Spade, Declaime, Frak Nitt, Planet Asia) on the back-seat... But the Hi-Hat Club is more than a series of records. It is our look out on today's beat generation. It's not a movement but an open stage that celebrates the art of beatmaking through photos, records, exhibitions and parties. Not bound to any borders, styles or labels. No more, no less.


text: The former View cohosts have put aside their differences in the name of charity to auction off a lunch date with the two of them to benefit the Figure Skating in Harlem "Skating WIth the Stars" Gala, of which Jones is co-chair. The lunch should be interesting: O'Donnell famously called Jones "delusional" in 2006 for telling fans she lost weight through exercise and diet alone. Jones -- who was replaced by O'Donnell on The View -- later admitted she had gastric bypass surgery.

subset: commoncrawl


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Dogwood Hills Academy
Canton, GA 30115
About This School
Dogwood Hills Academy Reviews
Dogwood Hills is AWESOME
Our son has attended Dogwood Hills Academy over a year, beginning at age 1. As a parent, sending your child to daycare is one of the most difficult decisions you can make and after quite a bit of research and touring, we chose DHA. In the beginning, safety, cleanliness and love were the top priorities as we began our search. Dogwood Hills gets 5 stars in all of these areas.
When you walk into Dogwood Hills the air is fresh and clean (which is unusual for a building FULL of kids.) The security system has always worked, there is always someone at the front to greet you and they are on a first name basis with all of the parents AND children. The equipment in and outside of the rooms is top notch. Everything looks and feels clean and secure and the staff is ALWAYS warm and friendly. As we walk the halls to class, teachers from other classes always stop to say hello, which adds to the atmosphere that makes DHA what it is.
As my son has progressed through the classrooms, we have found quite a bit of activity and learning. He comes home with artwork and activities and always has something new to share. The active calendar of DHA always keeps the children busy and engaged. The activities are ALWAYS fun and creative, adding to the overall experience.
While most children dread going to school and being left...my son LOVES going, playing with friends and ALWAYS has a smile on his face when he leaves. Most importantly, I feel comfortable leaving him, knowing that he will be safe and cared for while I'm working. Having this confidence in your childcare provider is CRITICAL. I would absolutely recommend DHA to anyone who asks me.
Great School!
I have 2 children in Dogwood Hills Academy and we love it here!! We are always greeted by a smiling staff member who is genuinely happy to see my children. I know both of my children are in great hands and would recommend this school to anyone looking.
Highly recommend!
My son went to Dogwood Hills starting in 2007 and continued through PreK in 2010. They gave him a solid foundation for elementary school. When we were ready for our second child to go to preschool we visited some other locations closer to home. That is when we realized the different experience Dogwood Hills offers. No complaints from my family and we have been using them for over 5 years.
Nurturing environment that promotes learning!
After a very negative experience elsewhere and the feeling that our child was never going to adjust to daycare, we decided to give Dogwood Hills a try.
Thank goodness we did! Not only is the ENTIRE staff nurturing and patient, they offer a well-organized and dynamic curriculum that keeps even the most "spirited" little ones busy and happy throughout the day. Our three-year-old is writing her name and starting to sound out words! Dogwood offers a warm environment where children feel safe and loved, making it easy for them to relax, make friends, have fun and LEARN!!! In addition, if you happen to have a more stubborn child (like ours) who is having a tough time adjusting to life at daycare, they are SO patient and really work with the parents to develop strategies to help the child make the transition comfortably.
Highly Recommend!
As a current educator, I am more than pleased with Dogwood Hills in every aspect. I have 3 children who currently attend and have attended since they were babies. Dogwood Hills has provided my children with a safe, nurturing, and educational environment. My 3 year olds have learned so much at DHA. They are being WELL prepared for Pre-K and Kindergarten. DHA is not just a daycare, it has been an educational foundation for my children.
great school!
I have two kids that attend dogwood hills academy and they both love it! I did a lot of research prior to sending my kids here and I could not imagine them anywhere else! They both love their teachers and we feel the teachers really care about our kids! They have definitely learned a lot and they have lots of fun too! Would def recomend this school!!
Great Pre-K program!
My daughter attends Dogwood Hills Academy and is in Pre-K. She absolutely LOVES going to school every morning! I am very impressed with the school, faculty and staff. My daughter is learning so much while have lots of fun!


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Productivity growth in 2006
March 06, 2007
Productivity, as measured by output per hour, increased 2.1 percent in the nonfarm business sector in 2006, reflecting increases of 3.9 percent in output and 1.7 percent in hours.
This was the smallest annual increase in productivity since 1997, when output per hour rose 1.6 percent in the nonfarm business sector.
Output per hour had grown at an above-average rate of 3.3 percent from 2000 to 2004. Between 1990 and 2000, productivity in nonfarm businesses rose 2.0 percent per year, on average.
These data are from the BLS Productivity and Costs program. Data are subject to revision. For more information, see the "Productivity and Costs, Preliminary Fourth Quarter and Annual Averages for 2006" (PDF) (TXT), news release USDL 07-0198.
Bureau of Labor Statistics, U.S. Department of Labor, The Economics Daily, Productivity growth in 2006 on the Internet at http://www.bls.gov/opub/ted/2007/feb/wk1/art04.htm (visited October 06, 2015).
Recent editions of Spotlight on Statistics
New estimates of personal taxes in Consumer Expenditure Survey
In 2013, the Consumer Expenditure Survey improved its personal tax data.
Trends in long-term unemployment
Long-term unemployment reached historically high levels following the recession of 2007–2009.
Housing: before, during, and after the Great Recession
looks at consumer expenditures on household items, employment in residential construction, prices for household items, and injuries in occupations involved in building and maintaining our homes.


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Velázquez: Obama Jobs Plan Would Recoup Lost Construction Jobs
If enacted, President Obama's jobs plan would create more than 27,000 jobs in New York City's hard-hit construction industry, through new infrastructure spending, according to a report prepared by Congresswoman Nydia Velázquez (D-Brooklyn, Queens and Manhattan).
Velázquez said nearly $3 billion could be made available for roads and bridges in New York City.
Tom Wright, executive director of the Regional Plan Association, a civic group, said two ongoing projects could really use the cash: the Second Avenue Subway and East Side Access, which would link the Long Island Rail Road (LIRR) to Grand Central Station.
"These are critical projects that we need to keep moving ahead," Wright said.
Other construction jobs deemed to be "shovel ready" include the extension of the number 7 train line and a new water filtration plant.
City Council Speaker Christine Quinn said the city's recently-approved capital budget contains plenty of projects which could be started quickly, if there were funding. "Certainly everything in year one is shovel-ready. Anything in year two is in essence shovel-ready, and things can quickly be made shovel-ready" she said.
The city lost 20,000 construction jobs between 2008 and 2010, so the Obama plan would more than make up for those losses, by Velázquez' calculation.
However, Velazquez acknowledged this kind of spending is not popular with her Republican colleagues in the House of Representatives.


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Abraham Lincoln and New Hampshire
After delivering his now famous antislavery address on February 27, 1860, at the Cooper Union in New York City, Lincoln became a national celebrity. He followed the address with a 12-day speaking tour of New England starting the next day. New Hampshire became the centerpiece of the tour, as the future president delivered speeches in Concord, Manchester, Dover, and Exeter. His speeches helped galvanize the growing state Republican Party behind his candidacy for president, and gave Lincoln an opportunity to visit his son, Robert, who was attending Phillips Exeter Academy. During the whirlwind visit, "Honest Abe" won new friends with his talents as a public speaker, storyteller, and political leader, and made a lasting impression on the people he met.
The exhibition, Abraham Lincoln and New Hampshire, on view at the Society from February 12 through December 31, 2009, shared some fascinating stories of New Hampshire people and events that intersected with the life of one of the nation's greatest presidents. These memorable stories were told through the Society's collection of Lincoln-related documents, photographs, and objects.One of the many items in the exhibition was a fragment of the coat Lincoln was wearing when he was assassinated on April 14, 1865. Dr. Ezra W. Abbott of Concord was one of six men who carried the wounded president from Ford's Theatre. He preserved a section of the sleeve from Lincoln's coat, cut away in search of the fatal bullet wound. Years later, Abbott recalled the event. "During the entire night I kept the record, and the only one, of the president's respiration and pulsation, noting them every half hour. At 3 a.m. I went to the office of the National Intelligencer and left a copy of my memoranda up to that time. I resumed my position at the foot of the sufferer's bed, and remained there until he breathed his last, at 7:22 a.m. Secretary of War Edwin M. Stanton immediately exclaimed, 'He now belongs to the ages.'"
Remarkably, this was not Abbott's first experience with presidential sorrow. He was also present at the death of Benjamin Pierce, the son of Franklin and Jane Pierce, who was killed in a train accident just days before his father's inauguration. Abbott's moving personal accounts of both tragedies were included in the exhibition.
A penknife Lincoln was carrying the night of his assassination was also on display. Charles Forbes, Lincoln's footman and messenger, who had accompanied the president to Ford's Theatre the night he was assassinated, was witness to the gruesome event. Shortly after Lincoln's death, when Mrs. Lincoln was packing to leave the White House, she gave Forbes some clothing and personal belongings of the martyred president. According to a sworn affidavit, on June 9, 1866, Forbes presented "the Pen Knife used by the late President of the U. States, Abraham Lincoln, and which he had in his possession the night of his assassination," to C. E. Creecy, a United States Treasury Department staff member. William E. Chandler of New Hampshire acquired the penknife from Creecy the same day. Chandler had been appointed Solicitor and Judge Advocate General of the Navy Department by Lincoln in early 1865. Later that year, he was appointed First Assistant Secretary of the Treasury. In 1880, long after returning to Concord, Chandler presented the penknife to the New Hampshire Historical Society.
Thanks to Our Sponsors
The exhibition Abraham Lincoln and New Hampshire was presented in cooperation with the state and national Abraham Lincoln Bicentennial Commissions, and was sponsored by Lincoln Financial Foundation and Rath, Young, and Pignatelli.
About Us
The New Hampshire Historical Society is not a state-funded agency. All of the Society's programs and services are made possible by dues and contributions from individuals, foundations, and businesses. You are invited to join today and enjoy the many benefits membership provides. Call the membership department at 603-856-0621 or use our convenient and secure online membership form.


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Something was wrong.
That's what my gut was telling me. For the last three summers, SCCSAV has gathered for a fortnight-long Haruhi marathon. Yet this year, it seemed there was no one to take up the mantle of organising it all. I bravely said "yeah whatever I'll do it", and here we are! Endless Summer 2013. Part Four.
For those who aren't familiar with Endless Summer, here's how it works. Over two weeks from August 17th we watch two episodes of The Melancholy of Haruhi Suzumiya per day, during which participants chat in a Skype call. Why the 17th? Because the infamous Endless Eight arc takes place over the same time period. We finish on the 31st with a viewing of the movie The Disappearance of Haruhi Suzumiya.
The episode order will be as in the original viewings, devised by Bitmap. The episode numbers listed below in brackets are the chronological order, as was used in the 2009 rebroadcast (and on the [Delicio.us] files). As the first series was broadcast out of order, we mix things up as an homage.
17th: The Adventures of Mikuru Asahina Episode 00 (25) / The Sigh of Haruhi Suzumiya I (20)
18th: The Melancholy of Haruhi Suzumiya I (1) / The Melancholy of Haruhi Suzumiya II (2)
19th: The Sigh of Haruhi Suzumiya II (21) / The Boredom of Haruhi Suzumiya (7)
20th: Endless Eight I (12) / Endless Eight II (13)
21st: Endless Eight III (14) / Endless Eight IV (15)
22nd: The Melancholy of Haruhi Suzumiya III (3) / The Sigh of Haruhi Suzumiya III (22)
23rd: Remote Island Syndrome (Part I) (10) / Mystérique Sign (9)
24th: The Sigh of Haruhi Suzumiya IV (23) / Remote Island Syndrome (Part II) (11)
25th: Someday in the Rain (28) / The Melancholy of Haruhi Suzumiya IV (4)
26th: The Day of Sagittarius (27) / The Sigh of Haruhi Suzumiya V (24)
27th: Endless Eight V (16) / Endless Eight VI (17)
28th: Endless Eight VII (18) / Endless Eight VIII (19)
29th: Bamboo Leaf Rhapsody (8) / Live Alive (26)
30th: The Melancholy of Haruhi Suzumiya V (5) / The Melancholy of Haruhi Suzumiya VI (6)
31st: The Disappearance of Haruhi Suzumiya (movie)
Notionally we begin at 8 PM US Eastern time (7 PM Central, 5 PM Pacific etc.), but we're never too strict with when we actually begin watching. You don't have to watch every day, so don't feel bad if you can't make it! If you want to participate, the best way to contact me is via Twitter @processr, via Skype at pro.cessr or by leaving a comment on this post. You'll need to let me know of your Skype username so I can add you into the group chat.
Each session should last between one and two hours, allowing generously for time spent chatting before and after episodes. The exception to this is Disappearance, as it's a whopping two-and-a-half hours long. If there's demand for it, we'll start earlier on the 31st to accommodate the runtime. That should be everything you need to know! These sessions are a great way to get acquainted with a great many anibloggers, and especially the people in SCCSAV – in fact it's how I got in with the crowd a couple of years ago. A fun time will be had by all!


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For US Lacrosse member discount information please call (877) 504-0739
"These headphones are awesome! Not only do they block out annoying coworkers, but you can hear so much more intricacy and depth in the music than you can with standard ear buds. You're getting the quality of those expensive headphones for less than half that price. If you need headphones, these are a great choice."
~You Can Tell Everybody!
Love my US Lacrosse® "Thunderbolt® Shorts. I bought these to bring with me on my Florida vacation. Went to the mall and outlet stores and couldn't find what I was looking for. My friend told me about this online store. I've always been a fan of Lacrosse, being on a team and all. So I went on and found the Thunderbolt shorts! I had people at the beach asking me where I bought my shorts from! Thank you ShopUSLacrosse!
~Tim G.


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Jessica Aron
Undergraduate Student, Psychology
Farquhar College of Arts & Sciences
A Dynamic Psychology Student
Jessica Aron is a psychology major in the Division of Social and Behavioral Sciences who exemplifies the diverse talents and focused determination of a Farquhar College of Arts and Sciences student. In fall 2006, NSU Performing Arts, housed in the college's Division of Humanities, was preparing its first full-length dance production, Groove. Despite not having performed since high school, Aron decided to audition. "I've danced since I was a little girl, in competitions and performances, but I took a break once I started college. Then I wanted a chance to dance again on stage. It's a great way to express yourself."
She succeeded in securing a part and soon began rehearsals in African, modern, hip-hop, step, and tap styles of dance. Aron appreciated the collaboration and shared enthusiasm that the performers and staff shared in working together toward a common goal.
Aron has kept busy with campus organizations when not studying or dancing. A member of Psi Chi, the U.S. National Honor Society in Psychology, she is also president of Social Action Social Awareness, which focuses on pressing local and global issues. This organization has helped with on-campus events such as Eating Disorders Awareness Week and Take Back the Night, among other social causes.
Aron also intends to pursue a doctorate in psychology. She feels that dance has been a helpful preparation for this because it taught her "about being with people and working through emotions. Dance has helped me put my feelings out there and work with people who are also working with their feelings."
NSU Performing Arts is gearing up for another powerful dance production in the winter semester of 2008 with Muscle to Bone: Moving the Power Within. The performance will take place in the Miniaci Performing Arts Center on February 1 and 2, 2008, at 7:30 p.m. If Aron could advise someone auditioning for next year's dance program, "I'd tell them they're making the right decision and to stick with it. The practices are long, and you can get frustrated, but enjoy it all you can. It'll be over before you know it." She also mentioned that some of the performers in Groove had never danced on stage before. "It shouldn't stop you from trying out. It takes discipline more than experience, and you have to be willing to take risks, put yourself out there."


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This resource is designed as a reference guide for teachers. We have listed the major themes and motifs within The Comedy of Errors and provided examples of scenes where you can study them.
Motifs:(Recurring elements and patterns of imagery in The Comedy of Errors which support the play's themes)
Download a printer-friendly verison of this page.Themes in The Comedy of Errors (PDF 64KB) »This document is designed as a resource for teachers which can be adapted to use with your students.
The search for identity and the need to feel whole.Some related scenes:
Alienation and the need to belong.Some related scenes:
Power and status in relationships and the fragility of these bonds when power is abused.Some related scenes:
Magic and witchcraft as alarming and alienating explanations of the confusions in the story. For example:
Money, gold, jewellery and othe material objects as the currency of relationships in the business culture which characterises Ephesus. For example:
Water, tears, oceans and seas as emblems of separation, loneliness and isolation.For example:
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Todo Sobre Mi Padre
In August 2010, Discovering Latin America successfully raised more than £4,500 for the building of a primary school in Costa Rica in association with sculptor Nicholas Arroyave-Portela and London's Contemporary Applied Arts gallery.
DLA was delighted to organise an exclusive fundraising auction and gala evening with Nicholas Arroyave-Portela as he presented his solo exhibition, 'Todo Sobre Mi Padre' at London's Contemporary Applied Arts gallery.
To mark this important personal exhibition, which referenced the artist's mixed Colombian background, Arroyave-Portela chose to support Discovering Latin America by donating three ceramic pots for auction to raise funds for the vital programmes of development we sponsor across Latin America.
About the exhibition
Arroyave-Portela's highly original and emotive work focuses on intimate relationships with people, memories, time and place. The pieces in 'Todo Sobre Mi Padre' loosely map the various migration routes the artist's father took through the course of his life while dealing with what it is that most drives our (often fractured) sense of identity as human beings.
For more on the exhibition, which has now passed, please see Contemporary Applied Arts' exhibition page
DLA auction and gala evening with the artist
In addition to the works being exhibited, the artist generously created three unique ceramic vessels exclusively for DLA to auction during the exhibition. Through this auction, we were able to raise a £4,800 donation towards the buildling of a primary school for the children of Ximiri in the Chirripó Indigenous Reserve in Costa Rica through Raleigh International.
The vessels were inspired by Uruguayan Artist Joaquin Torres Garcia (1874-1949), who created the Escuela Del Sur in Montevideo in 1935.
"Our north is the south. There shouldn't be a north for us, only the opposite of our south..... This rectification was necessary and as a result we now know where we are."
To celebrate the exhibition DLA also organized an exclusive gala evening with the artist at the gallery on 28 July. The evening featured a reception and panel discussion on the topic, As the Latin American Continent gears up to marking 200 years of Independence from Spain and Portugal, how has a sense of their national identities evolved into the present day?
Speakers included:
- Nicholas Arroyave-Portela, artist, discussing the evolution of his own sense of identity during the making of the work for the exhibition
- Professor Valerie Frasier from the University of Essex, Director of the Latin American Centre and Co-Director of the University of Essex Collection of Latin American Art (UECLAA), discussing the role played by art and architecture in forging the new nations of Latin America post-1810 and considering whether it is possible or desirable for art to continue to have any such role today
- Oscar Guardiola Rivera, author of What If Latin America Ruled the World?" a thought-provoking book demonstrating the ascending international importance the countries and cultures of Latin America are claiming by being unafraid to turn their back on commonly-held economic views which have lost their currency
To read more about the auction and evening, please visit out blog. Both the events were a great success and we would like to thank Nicholas, our speakers and CAA for their generous support!
More about the artist
Nicholas Arroyave-Portela was born in Oxford, England to Spanish and Colombian parents. As a fine-art ceramicist, his work has been featured in group and solo exhibitions across the UK, Europe, and USA, including a major solo traveling exhibition, 'Throwing Lines' in 2002-03. His work often addresses the issue of identity and expresses ideas about connectedness to the land of our birth or ancestors. He has been the recipient of several awards and grants, including the Young Achievers celebration at Buckingham Palace, an award at Talente, Munich, and first prize at Nache, Ceramic Contemporaries 2, at London's Victoria and Albert Museum.
For more visit www.nicholasarroyaveportela.com
This event has now passed. However if you would like to stay up to date on future events please contact us to be added to our mailing list. Thank you for your interest in Discovering Latin America.
Exhibition details
What: Nicholas Arroyave-Portela, 'Todo Sobre Mi Padre' solo exhibition
Where: Contemporary Applied Arts, 2 Percy Street, London W1T 1DD
When: 23 July 2010 - 21 August 2010


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Article ID: 926185 - View products that this article applies to.
On This Page
When you use the System Restore feature in Windows Vista, you receive the following message:Additionally, only the most recent backup files from Windows Vista Complete PC Backup are available. Earlier versions of the backup files are unavailable. You experience this problem if you are running Windows Vista, Windows 7, Windows Server 2008, or Windows Server 2008 R2 on a computer that is also configured to run an earlier Windows operating system.
Note This configuration is known as a "dual-boot configuration."
This problem occurs when you start the computer by using the earlier operating system, such as Microsoft Windows XP or Microsoft Windows Server 2003. In this situation, the earlier operating system deletes all the restore points that were created in Windows Vista. The earlier operating system also deletes all Complete PC Backup files except the most recent version of these backup files.
You can use either of the following methods to work around this problem.
Method 1To keep Windows XP from deleting restore points of the volume in Windows Vista, add the following registry entry under the
HKEY_LOCAL_MACHINE\SYSTEM\MountedDevices\Offlineregistry subkey in Windows XP:
Value name: \DosDevices\D:
Type: REG_DWORD
Value data: 1
Note If the
HKEY_LOCAL_MACHINE\SYSTEM\MountedDevices\Offlineregistry subkey does not exist, you must manually create this registry subkey. Create this registry entry when you have installed Windows Vista on the "D" partition in Windows XP.
Effects of this workaroundAfter you restart Windows XP, you cannot access the volume that is created in Windows Vista from Windows XP. However, you can still access the volume that is created in Windows XP from Windows Vista. You must use Windows XP drive or an additional drive such as a USB thumb drive for data exchange.
Limitations of this workaroundThis workaround only protects the volume in Windows Vista from being accessed or changed by Windows XP. If you have more volumes or if you want to add a volume from Windows XP to the system restore settings in Windows Vista, the system restore (Volume-Shadow-Data) on those volumes will be still overwritten. To avoid this problem, you must add those volumes to the
HKEY_LOCAL_MACHINE\SYSTEM\MountedDevices\Offlinesubkey. If you add the Windows XP volume to that subkey or if you delete this volume drive letter, you cannot then start Windows XP.
You can use this workaround only when the restore points for Windows XP and for Windows Vista are mutually exclusive. The restore points are mutual exclusive when no restore points are common across the volume in Windows XP or the volume in Windows Vista. For example, consider the following scenario:
In this scenario, the Windows Vista restore points are added on the E driver. Then, you must change the registry entry of the E driver under the
HKEY_LOCAL_MACHINE\SYSTEM\MountedDevices\Offline" registry subkey to 1.
Also, a common volume can be used for data exchange between Windows XP and Windows Vista. However, restore points must not be defined on this common volume.
Support Status of this workaroundAdding this key can have unwanted side-effects to your installation. For example, applications that put data on this drive before available may fail. If there is a reporting problem reported to Microsoft, you will be asked to delete this value
Method 2To work around this problem, use the Bitlocker feature on the volume in Windows Vista.
Bitlocker is a built-in security feature in Windows Vista. When Windows Vista starts, the Bitlocker feature should be enabled on the Windows Vista volume on which Windows Vista restore points are enabled. When Windows XP or Windows Server 2003 starts, the Windows Vista volume on which the Bitlocker feature is enabled is inaccessible. Therefore, the Windows Vista restore points are intact.
This workaround works for dual-boot configurations (Windows XP or Windows Server 2003 together with Windows Vista).This workaround requires no changes to Windows XP. Therefore, the volume in Windows Vista is still inaccessible when the system is started in Windows XP or in Windows Server 2003.
Note The Bitlocker feature is available for Windows Vista Enterprise Editions and for Windows Vista Ultimate Editions.
Microsoft has confirmed that this is a problem in the Microsoft products that are listed in the "Applies to" section.
For more information about how to configure a dual-boot environment in Windows Vista, visit the following Microsoft Web site:
Information for advanced usersConsider the following scenario. A shadow copy is created on a volume in Windows Vista or in Windows Server 2008. Then, you access the volume from an earlier Windows operating system. In this scenario, the shadow copy is deleted. You experience this problem if one or more of the following conditions are true:
Article ID: 926185 - Last Review: January 31, 2008 - Revision: 4.4
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Immigration law means hard choices for gay couples
DOMA court decision or immigration bill amendment could let citizens sponsor same-sex partners
Published On: Jun 16 2013 01:25:55 PM EDT
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Employee: John Martin
Employer: Cox Engineeing Co., Inc.
Insurer: United States Fire Insurance Co.
Board No.: 023558-05
(Judges Fabricant, Horan and Levine)
The case was heard by Administrative Judge Tirrell.
Peter T. Toland, Esq., for the employee
James P. McKenna, Esq., for the insurer at hearing
David M. O'Connor, Esq., and Joseph C. Abate, Esq., for the insurer on appeal
FABRICANT, J. The employee appeals from a decision in which the administrative judge awarded weekly incapacity benefits pursuant to §§ 34 and 35, but denied the employee's claim for benefit enhancement pursuant to § 51. [1] The employee also challenges the judge's retroactive modification of benefits. We agree that this retroactive modification violates Cubellis v. Mozzarella House, Inc., 9 Mass. Workers' Comp. Rep. 354 (1995)(order of discontinuance may go back no further than filing date of complaint). Accordingly, we reverse the decision in part. We also agree that the judge's analysis under § 51 was too narrowly focused on the employee's age. We therefore recommit the case for further findings.
The employee was a sheet metal worker at the time of his industrial accident on July 22, 2005. In order to attain journeyman status, the employee entered a union apprenticeship program in 2004. The program takes sheet metal workers through a number of progressive wage steps, until a $38.00 per hour journeyman status is achieved. The employee was fifty years old, and in his first year of that program, when he injured his knee. (Dec. 4-5, 11.)
Surgery performed after the accident left the employee with significant knee pain. As a result, the employee ultimately returned to light duty work as an electroplater for a different employer, at a lower wage. (Dec. 5-6.) The judge denied the employee's claim for an enhanced average weekly wage pursuant to § 51, concluding that the employee's age precluded its application. (Dec. 11.) The employee argues that § 51 does not limit the age at which the benefit enhancement mechanism afforded by the statute may apply. We agree.
The judge construed the statute's reference to age too narrowly by applying a literal interpretation to the broad language of Sliski's Case, 424 Mass. 126 (1997), limiting the scope of the statute only to "young employees." [2] However, there is no specific age limitation for the statute's application. Although we proffer no opinion on whether this case falls within the purview of § 51, we think the judge should determine its application by weighing all relevant factors, and not by disqualifying the employee based solely upon his age at the time of injury. Age is but one of several factors to be considered for the application of the statute, including the employee's reasonable expectation of wage increases due to skill acquisition, Sliski, supra at 135, completion of educational and vocational steps in that career pursuit, Hughes v. D&D Elec. Contr., Inc., 11 Mass. Workers' Comp. Rep. 314, 315 (1997), the connection between such skill acquisition and training and higher wages, Klimek v. Wilbraham Toyota Volkswagen, 17 Mass. Workers' Comp. Rep. 527, 530 (2003), and the time frame in which such wage increases would become effective. Starr's Case, 76 Mass. App. 119 (2010) (Memorandum and Order Pursuant to Rule 1:28), affirming our decision in Starr v. Maltby Co., Inc., 23 Mass. Workers' Comp. Rep. 39, 43 (2009). [3]
As noted above, the judge erred by modifying the employee's benefit entitlement from § 34 to § 35 retroactive to March 8, 2007. The filing date of the insurer's complaint, May 17, 2007, is the earliest date that any change in payments can commence. See Cubellis, supra. We therefore reverse the order of modification prior to May 17, 2007, and recommit the case for further findings consistent with this opinion.
So ordered.
Bernard W. Fabricant
Administrative Law Judge
Mark D. Horan
Administrative Law Judge
Frederick E. Levine
Administrative Law Judge
Filed: February 9, 2011
[1] General Laws c. 152, § 51, provides, in pertinent part:
Whenever an employee is injured under circumstances entitling him to compensation, if it be established that the injured employee was of such age and experience when injured that, under natural conditions, in the open labor market, his wage would be expected to increase, that fact may be considered in determining his weekly wage.
[2] Section 51 "protects young employees who are injured early in their careers by including expected wage increases in the determination of [their] average weekly wage." Sliski, supra at 127. Sliski was eighteen years old at the time of his injury. Id.
[3] Although the insurer addresses some of these factors on appeal, we are not in the position to review those arguments absent proper findings of fact made by the administrative judge. Cf. Bruenell v. Town of Framingham, 23 Mass. Workers' Comp. Rep. 133, 135-136 (2009)(judge's detailed findings on evidence presented in support of § 51 claim clearly erroneous as a matter of law; decision reversed).


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Rabbitohs re-sign Sam Burgess until 2016
THE South Sydney Rabbitohs have extended the contract of international forward Sam Burgess for three more seasons today, keeping him at the Club at least until the end of the 2016 season.
South Sydney to pay respect to defense forces in round 25
THE South Sydney Rabbitohs and ANZ Stadium are dedicating their final home game of the season to the brave men and women of the Australian Defence Force who are serving in Australia and on operations and peace keeping missions overseas, as they take on th
Bolton to remain a Cowboy
SCOTT Bolton will extend his NRL career with the North Queensland Toyota Cowboys to a seventh season after agreeing to a new one-year deal.
Off the Wall
PHIL Rothfield wrote in the Telegraph this week that the 16 NRL clubs were getting "restless" with the inaction from the ARLC.
VB NSW Cup Match Previews - Round 24
THANKS to NSWRL, we have previews for round 24 of the VB NSW Cup.
QLD Intrust Super Cup Previews - Round 21
PREVIEWS for Round 21 of the Intrust Super Cup, thanks to QRL.com.au
May issues 20,000 challenge to fans
NEW Jetstar Gold Coast Titans Chief Executive Officer David May today faced one of his fears by taking part in a rock climbing challenge in an effort to get the Gold Coast community right behind the club in its quest to make the finals.
Rabbitohs extend Reynolds contract until 2015
THE South Sydney Rabbitohs have extended the contract of South Sydney junior Adam Reynolds for two further seasons today, keeping him at the Club at least until the end of the 2015 season.
Sharks confirm player signings
IN adding further quality and depth to their 2013 roster, while at the same time retaining two important members of their current squad, the Sharks have confirmed three significant player signings.
2012 NRL Match Previews - Round 24
PAUL'S back to preview the big weekend of footy ahead, with Telstra Premiership Round 24 under the microscope.
NRL Injury and Suspension Summary - Round 24
ALL the latest injury and suspension news in one place heading into round twenty-four of the NRL!
Rabbitohs to play PNG Kumuls in Return to Redfern clash
THE South Sydney Rabbitohs have confirmed that their opponents in the 2013 Return to Redfern pre-season match will be the Papua New Guinea Kumuls on Saturday 9 February at the Australian Technology Park Performance Centre at Redfern Oval at 6pm.
QRL Intrust Super Cup Teams - Round 21
THE Intrust Super Cup is now entering it's final weeks, and here you can get all the teamlists for Round 21 thanks to the QRL.
NSWRL Bundaberg Red Cup Teams - Round 17
ALL the teams for Round 17 of the Bundy Red Cup as the competition enters it's final three weeks, all thanks to the NSWRL.
Toyota Cup Teams - Round 24
AS we do every week, here's the compilation of all 16 teamlists for Toyota Cup Under 20's ahead of Round 24 as the competition for finals spots heats up.


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I wish I had a river, I could skate away on
|It's coming on Christmas and I've done almost nothing. For some reason, this is making me terribly and stupidly anxious. At least something is making me anxious. And this anxiety is getting on my nerves, since I really have nothing to worry about.
It has been a bad brain week though. And I've had the usual niggle as to whether I can't write or paint because I'm just knackered or because I am lacking motivation, or at least in the wrong frame of mind. This is the great problem with fatigue and anything creative; if it was just sums, I could either make myself do them or I couldn't, whether I wanted to or not. Whereas people in perfect physical and mental health have creative blocks.
I suppose there are clues. Fatigue causes muddles and mistakes. Fatigue begins lots of sentences which, you know. um...
Trouble is, as soon as I ask myself whether my frame of mind is part of the problem, I begin to feel guilty and miserable. And being rather miserable, I have even more reason to suspect that it isn't just fatigue. Which makes me feel more guilty and miserable. And anxious. That and the Christmas thing. I was going to make cards and I realise that my cards are going to be crap, consisting of a great deal of glitter and not much else. If I actually finish them. Oh who cares? Do you care?
It took me all of today to write this. And that pisses me off.
Also, I realise that I was doing great last week, but feel like I haven't done one productive thing in months. And that pisses me off. My ingratitude! I am by far the most irritating person I have ever met.
Labels: Events, General Nonsense, Handiwork, Headspace, Novel Writing


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A wide range of indicators on agriculture, development, economy, education, energy, environment, finance, government, health, innovation and technology, jobs and society.
An appropriate set of compact city policies, such as environmental friendly urban regeneration, policies to offset the side effects of compact development, strong management of transport demands, and governance enforcement, can accelerate Korean cities' sustainable development.
Building on the successes of its fast-developing ICT sector, Korea is using digital technology to stimulate a creative approach to learning that gives students access to education materials wherever and whenever they want.
Korea has been at the forefront of green growth initiatives. The National Strategy for Green Growth (2009-2050) and the Five-Year Plan (2009-2013) of Korea provide a comprehensive policy framework for green growth in both the short and long term.
The major functions of the OECD/Korea Policy Centre are to research international standards and policies on international taxation, competition, public governance, and social policy sectors in OECD member economies and to disseminate research outcomes to public officials and experts in the Asian region.
This document sets out when Korea joined the OECD, what its permanent delegation does, and the benefits of OECD membership.


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The Developer Days agenda is final, the Developer Days agenda is final
If you haven't had a chance yet to look at the Java Mobile & Embedded Developer Days agenda do so. This is really a revolutionary conference in the Java Mobile & Embedded space.
Crammed into 36 consecutive hours you'll find 25 sessions, 21 lightning talks, and 4 30 minute poster sessions. And if that isn't enough you can stay up part of the night at the brainstorming and bar/camp sessions.
Yeah, but it's a Sun conference! Wrong, it's a Mobile & Embedded Community conference that was developed by developers for developers. One of the things that Terrence and I did was make sure that the selection committee was made up of a lot of outsiders so this conference has a lot of outside voices, industry leaders, and forward thinking companies presenting. Of those 25 sessions only 12 are from Sun. In the conference you'll hear from Sun, Nokia, IBM, and Intel and you'll hear from a truly international cast speakers from Brazil, Sweden, Ireland, Italy, the Czech Republic, Russia, and the United States.
And the content, oh my, the content. It's like being a kid in a candy store when it comes to width and breadth of the topics. Java FX/Mobile, JavaME Security, Near Field Communication, Sun SPOTs, Pervasive Computing, SVG, new JXTA for JavaME, phoneME VM architecture, JavaDB and tear off databases, mobile augmented reality, blu-ray, interactive set top boxes and many more.
So print out the agenda now that it's 99.9% complete and stick it under your boss' nose and say "I'm going" and get him to cough up the measly $175 to register. That right I said $175 for two days. Let me put it to you this way that's $7 per technical session and I'm throwing in the 21 lightning talks and 4 poster sessions for free. ;) Ok I admit that's a little bit cheesy but still you aren't going to find this value anywhere else.
So come on. Go to the conference site and hit the register button and sign up. You know you want be there. You know you should be there. Java Mobile & Embedded Developer Days is calling.
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Jon Yount
Fiona Apple's Eccentricities, Roald Dahl's Genius, and the Age of Twitter Diplomacy: Today's TNR Reader
June 19, 2012
Editor's Note: We'll be running the article recommendations of our friends at TNR Reader each afternoon on The Plank, just in time to print out or save for your commute home. Enjoy! How strange is Fiona Apple? One magazine writer's quest to find out. NY Mag| 29 min (7,349 words) Sentenced to life in prison, Jon Yount became a gifted jailhouse lawyer and a crusader for prisoner rights.


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The essence of optimism is that it takes no account of the present, but it is a source of inspiration, of vitality and hope where others have resigned; it enables a man to hold his head high, to claim the future for himself and not to abandon it to his enemy.Dietrich Bonhoeffer
Man seeks, in his manhood, not orders, not laws and peremptory dogmas, but counsel from one who is earnest in goodness and faithful in friendship, making man free.Dietrich Bonhoeffer
Jesus' call to bear the cross places all who follow him in the community of the forgiveness of sins. Forgiving sins is the Christ-suffering required of his disciples. It is required of all Christians.Dietrich Bonhoeffer
"If any want to become my followers," Jesus says. Following him is not something that is self-evident, even among the disciples. No one can be forced, no one can be expected to follow him. ... "If any want to follow me, they must deny themselves and take up their cross."Dietrich Bonhoeffer
It is the characteristic excellence of the strong man that he can bring momentous issues to the fore and make a decision about them. The weak are always forced to decide between alternatives they have not chosen themselves.Dietrich Bonhoeffer
The Cross is not the terrible end of a pious happy life. Instead, it stands at the beginning of community with Jesus Christ. Whenever Christ calls us, his call leads us to death.Dietrich Bonhoeffer
To understand reality is not the same as to know about outward events. It is to perceive the essential nature of things. The best-informed man is not necessarily the wisest. Indeed there is a danger that precisely in the multiplicity of his knowledge he will lose sight of what is essential. But on the other hand, knowledge of an apparently trivial detail quite often makes it possible to see into the depth of things. And so the wise man will seek to acquire the best possible knowledge about events, but always without becoming dependent upon this knowledge. To recognize the.Dietrich Bonhoeffer
The activity will prove to be "peculiar" by leading the active person into Christ's own passion. This activity itself is perpetual suffering and enduring. In it, Christ is suffered by his disciple. If this is not the case, it is not the activity Jesus intended. In this way, the "extraordinary" is the fulfilling of the law, the keeping of the commandments.Dietrich Bonhoeffer
Distant or near, in joy or in sorrow, each in the other sees his true helper to brotherly freedom.Dietrich Bonhoeffer
There remains an experience of incomparable value. We have for once learned to see the great events of world history from below, from the perspective of the outcasts, the suspects, the maltreated in short, from the perspective of those who suffer. Mere waiting and looking on is not Christian behavior. Christians are called to compassion and to action.Dietrich Bonhoeffer
Who stands fast? Only the man whose final standard is not his reason, his principles, his conscience, his freedom, or his virtue, but who is ready to sacrifice all this when he is called to obedient and responsible action in faith and in exclusive allegiance to God the responsible man, who tries to make his whole life an answer to the question and call of God. Where are these responsible people?Dietrich Bonhoeffer


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Today is the day to voice your opinion and vote for what you believe in, of course, but this whole election thing got me thinking that I personally would much rather be voting for dogs. So I decided to suggest some potential...Read more
Tag Archives: Airedale Terrier
By Linda Hubbard Gulker Willows resident Bobbie Fakkema admits to being competitive, a trait that serves her well in both her vocation as caterer/event planner and avocation owning Airedale champion show dogs. She was first introduced to terriers in 1970 when she...Read more


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March 10, 2014
Star News
Woman heavily fined for cocaine
A woman who was told to compose herself and talk to the presiding magistrate in the Corporate Area Resident Magistrate's Court last Thursday, begged for leniency after she pleaded guilty to several cocaine-related charges.
She is Gloria Blake, 49, who was fined $200,000 or six months for possession of, $250,000 or six months for dealing in, and $350,000 or six months for taking steps to import point six ounces of cocaine.
In addition, she was also sentenced to serve 12 months for conspiracy.
Senior Resident Magistrate Judith Pusey said if the fines are not paid, then the sentences are to run concurrently to 18 months in prison.
"Compose yourself and talk to me," RM Pusey said to Blake, who started crying when she heard the judge's orders.
"I am asking you to be lenient with me," the accused woman told the court.
Allegations are that the accused arrived at the Norman Manley International Airport on a flight from Curaçao and during routine security checks she was searched and interviewed.
It is reported that several cylindrical parcels containing cocaine were removed from her vaginal cavity.
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Redouble efforts to wipe out leprosy, Vatican urges
Catholic World News - January 29, 2010
Leprosy remains a scourge, particularly in the southern hemisphere, and world leaders should join in efforts to eradicate the disease, the Pontifical Council for Health Care said in a statement published for the 57th World Day of Leprosy. The Vatican statement, signed by Archbishop Zygmunt Zimowski, the president of the pontifical council, pointed to the 210,000 new cases of leprosy diagnosed in 2009, with India accounting for the greatest number of cases. The statement said that the search for a cure should continue "without overlooking educational and awareness-raising campaigns capable of helping those affected, and their families, to emerge from isolation and obtain the necessary treatment."
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text: Classic car prices in UK for last 20 yrs? Jan 28, 2011 20:50:31 GMT Quote Select PostDeselect PostLink to PostMemberGive GiftBack to Top Post by denis23 on Jan 28, 2011 20:50:31 GMT What is exactly my question is - I am looking for classic car market trends for last 20 years, but cant find nothing perhaps. From some odd sources I know, that there was market bubble which exploded in the early nineties, but what did prices since that time? And is there different cars values changed different way? For example, "hot GT-s" like Interceptor or E-type? What P5B prices did for last decades?


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On Friday, David and I drove up to the Plateau des Glières, the famous hiding location of the French Resistance fighters during WWII. There's a Resistance Monument, a few restaurants, and several hiking trails on the plateau. David had heard about Chez Constance and their delicious meals of beignets, so we decided to head there for lunch.
Mappy.com's directions lead us to believe it would take 44 minutes to drive there. It took us nearly an hour an a half because there are absolutely no signs for the plateau, except right next to the road that leads up the mountain. We drove through La Clusaz, Grand Bornand, St. Jean de Sixt and Thones (all of which are cute Alpine towns, btw) before we finally found the right road in Petit Bornand. That was actually the easy part.
The road that leads up the mountain is a tiny, although paved, path that only allows for one car at a time. Several of the curves had no guard rails, so I can only imagine how many cars have slid over the edge during the winter. We almost gave up and turned around twice because we didn't think we were on the right road. Finally, nearly an hour after we were supposed to arrive, we made it to the plateau.


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(based on 1 review)
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More swag than ever before
By Ricky Bobby
from Portland OR & Juneau AK
About Me Classic, Lots Of Muscle, Practical, Small Layer Of Blubber
Best Uses
Comments about Casual Industrees Stevens NDub Crewneck Sweatshirt:
great item, for a great price. Id buy it over and over if I wasnt broke.
Service and delivery comments:
arrived on time, right before I needed it.Thx Evo
Bottom Line Yes, I would recommend this to a friend
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I would like to reply to the U.S. Air Force Colonel who said science has all the answers and there is "no God." I know that you are a very intelligent man; you could not be an Air Force Colonel and not be smart. But before you destine everyone to hell, I would like to express the opinion of a person that would like everyone to believe God. Please notice I did not say believe in God. Satan believes in God and trembles. The God you would like everyone not to believe in said, "Let there be light," and everything was made. And, believe it or not, there wasn't a scientist around to give Him advice. Science can only theorize what they find.
Sir, I would like you to look outside yourself and "believe God." It is going to take faith. It is looking outside yourself and believing there is a marvelous God who loves you. He loved you so much that He sent his son, Jesus Christ, to come down to the earth and die for the sins of the world — past, present, and future sins. I would like for you, sir, to have a relationship with God, not "get religion. There are two forces in the world — good, which is God, and evil, which is the other being who is trying to destroy all that he can that is of God.
Unfortunately, our country is turning away from God and we are becoming a nation whose God is money. I pray we will return to God.
Jack R. Darling
Apache Junction


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Jason Longbrake told the Jackson Citizen Patriot that he was in a tree stand while hunting Sunday when a screech owl apparently attacked. The 30-year-old from Jackson said he felt something slam into his head and moments later spotted the owl nearby.
Longbrake said he kept hunting for a few hours at the tree stand in Hillsdale County, located south of Jackson. After realizing that his eye was bloodied he sought medical treatment. He hasn't lost any vision and the redness is expected to disappear.
Gary Siegrist, a naturalist at the Dahlem Environmental Education Center, said the owl may have attacked in a "territorial dispute."


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Umbilical Cord FAQ
By Lindsey Wimmer, MSN, CPNP, CPLC
Umbilical cord accidents continue to be the number one topic I hear about in emails and phone calls from pregnant or grieving families. The reasons for this are many. I do not claim to be an expert on umbilical cord issues, and the topic has been poorly researched. However, I struggle with the 'facts' that are often used without telling the whole truth. Here is my understanding of the most common questions or comments I hear regarding cord accidents.
The Whole Truth
It is true that a significant number of babies are born with cords around their necks and the majority of them do not show any signs of distress. This does NOT mean, however, that cords cannot cause problems! To tell someone that cords can't be problematic because they aren't ALWAYS problematic is misleading.
Not EVERY person who smokes tobacco will die of lung cancer. Does this mean smoking doesn't cause lung cancer? Of course not. Does it mean we don't need to tell people who smoke of the dangers? Of course not.
If your baby was born with an umbilical cord issue and your baby is happy and healthy, PLEASE count your blessings and consider yourself fortunate to have landed on that side of the statistics. We are not all so lucky. Most of all, please don't say my baby's cause of death isn't significant or worth worrying about just because it didn't happen to your baby.
Should I worry about the 'nuchal' cord?
When we hear about cord issues, most people think about or are talking about nuchal cords. This is when the umbilical cord is wrapped around the baby's neck. That placement alone is not necessarily the problem. It is a problem if it is wrapped tightly. However – not for the reason most people think. A tightly wrapped nuchal cord is not a concern because of the baby's neck (before birth, the baby does not get oxygen through the trachea into the lungs). It is a concern because of the compression that is put on the cord itself. The umbilical cord IS how the baby gets oxygen before birth. So – a nuchal cord that is tight enough to restrict blood flow through the cord between the placenta and the baby puts the baby's oxygen supply at risk. However – the same is true for any position of the baby and umbilical cord that compresses the cord and reduces blood flow. This can occur around a limb, around the baby's body, as a knot in the umbilical cord, with multiple nuchal cords or wraps, as a poor insertion point into the placenta, between the baby's body and mom's, and so forth. Nuchal cords get the most attention, but that is just one type of potential cord issue.
My doctor says cord accidents don't cause problems and then my doctor said my baby was stillborn due to a cord accident.
I am the first to admit that the research into umbilical cord issues and how to manage them is lacking. Much more is needed. But the problem is compounded by the medical community not even being able to agree if this is a legitimate cause of death. The part that is most frustrating to me is that many providers use both of the above statements when it fits the situation.
According to the Stillbirth Collaborative Research Network (SCRN) studies, 11% of all stillbirths were determined to be caused by umbilical cord issues. By their own description, this is probably a low number because they had very strict conditions for coming to this conclusion and required definitive pathologic evidence of such.
It can be extremely distressful and frustrating to parents to hear during the pregnancy that umbilical cords don't cause problems and then after the pregnancy that the cause of their baby's death was an umbilical cord accident. We can't have it both ways. This gives the appearance that providers either don't know about the issue or they are taking the "easy" way out. (Meaning it's easier to reassure parents and play the odds during the pregnancy.) It's also easier after a stillbirth to provide an "answer" that is easy for families to understand and accept. The belief that "nothing can be done about umbilical cord issues" doesn't help because it allows providers to use the line that "these things just happen".
If cord accidents DO happen, then why are we told they don't? If they DON'T happen, then why are we told they do?
Why should I say anything about a cord issue?
Many families find out accidentally or after the fact that their baby had an umbilical cord issue. Most providers I talk to tell me that they will not tell families about the issue. If they do tell them or the family finds out, the provider will minimize their level of concern. Why?
Most providers say they 'reassure' their patients that cords don't cause problems because they don't want the mothers to worry and they can't do anything about it anyway.
First – your job is not to keep me thinking that everything in pregnancy is bubblegum and unicorns. Your job is to assess me and my baby and provide your professional recommendations about how to protect us both from harm.
Second – why aren't you the ones asking for studies to be done that would help you have treatment options?? Our medical community should be leading the charge in demanding we learn more. The advancements we have made in the last few decades in almost every area of medicine are incredible. Why isn't stillbirth (and cord accidents in particular) one of them? The lacks of research and treatment options directly affect you, your patients, and how you practice.
Third – If you don't know what to do about a condition or don't feel like there are good options, tell us that! We have the right to know what is going on with our bodies and our babies. Let us be a part of that conversation. Other areas of medicine don't get away with this.
Cords don't get tight with labor or cause the baby to be in distress
Umbilical cords can become taught during labor depending on many forces including the length and position of the umbilical cord and the position of the baby. All the ways a cord can be compressed or compromised during the pregnancy can happen during delivery as well. Any change in physiologic status can cause fetal distress – including hypoxia secondary to cord compression. Not every baby who experiences distress during labor has a cord issue, but many do. There are other causes of distress as well, but that does not mean cords aren't one of them.
I personally had the experience of watching my baby demonstrate this effect. While on a fetal heart monitor and having an ultrasound completed, we were able to see my baby's position compress the umbilical cord. Within about 8-10 seconds, my baby's heart rate started to decelerate. When she moved and the cord compression was relieved, her heart rate returned to normal. Once her heart rate began to decelerate and she was not able to relieve the compression enough for her to recover, she was immediately delivered. Because of this experience, I believe 100% that cord compression can be a cause of fetal distress.
Cesarean section is the only cure for a nuchal cord.
A newer question I have been asked is if a C-section is required to save a baby when a nuchal cord is identified. I'm going to discuss this in terms of all cord issues (not just nuchal for the reasons mentioned above). A C-section does not necessarily prevent cord issues, and it is certainly not the only way to reduce or manage cord complications. There are situations where a provider feels this gives the mom and baby the best chance of positive outcomes. I am in support of any decision made with the family for those reasons. I also believe vaginal deliveries are possible when cord issues are present. In this case, knowledge about the issue, close fetal monitoring, and access to emergency care can help provide reassurance and warning about emerging symptoms.
There are many, many complex factors that must be evaluated when making the decision to have any surgical procedure. I am not a fan of surgery whenever possible, but I also firmly believe that surgery is not the worst thing that can happen to someone. This is simply another treatment modality that can be evaluated and considered. Sometimes we must choose the lesser of evils.
Umbilical cord accidents don't happen very often.
This is a statement made only by one who has never been affected.
And I would like to know what your definition is of the word "often".
Stillbirth in general occurs 26,000 times every year in the United States. If we use the SCRN numbers of 11% of stillbirths being caused by umbilical cord accidents, that would indicate that 2,860 babies will be stillborn this year due to umbilical cord accidents. That is more than the number of SIDS deaths per year. That is significant.
And these are the prenatal deaths. What about the babies with umbilical cord accidents that only survive minutes or days? What about the babies who develop cerebral palsy or other conditions as a result of the hypoxia suffered during an umbilical cord accident?
Which leads me back to where we began – we need more research to understand, manage, and prevent this cause of poor pregnancy outcomes.
The Problem with Umbilical Cords…
Going through my email today, I had three notes from three different parents sharing their stories of umbilical cord issues.
The first was a father wanting advice for helping his wife after she had recently delivered their stillborn child at 41 weeks. The cause was determined to be a cord accident.
The second was a woman asking for prayers for a friend's newborn child. During delivery, the umbilical cord was compressed and the child suffered hypoxia (lack of oxygen). The baby is currently in the NICU undergoing body cooling in an attempt to reduce the swelling in his brain.
The third was a woman who recently delivered a baby in Japan. Ultrasounds were a routine part of every prenatal visit during the third trimester. At the 36 week visit, they noticed the baby had several umbilical cord wraps around the neck and arm. Her OB showed her the concern, they did some extra tests to identify if the baby was in any distress, and then a cesarean section was scheduled at 38 weeks of gestation to avoid the baby having complications from the umbilical cord issues during a vaginal delivery. She said it hadn't occurred to her that her pregnancy might have been managed differently in the US.
A few major problems stand out to me with these stories.
Families are told every day that umbilical cord issues don't cause problems. Yet, this is also the most common answer families are given when they ask why their child was stillborn. This hypocritical approach is not acceptable. If cord issues truly cause birth injuries and death, then that needs to be recognized, accepted, communicated, and addressed. If they don't, we need to stop attributing such a large number of poor outcomes to this cause. It is true that many babies are born healthy despite umbilical cord issues, but this is not the same as saying the cord issues aren't a cause for concern.
Providers will often say cord problems are not concerning, but what they actually mean is that they don't think they should alter the plan or don't know what to do differently – so they simply offer false reassurance. In the event of a poor outcome, a cord issue might really be the cause, but "cord accident" may also be the easy answer because it is accepted as something that "nothing" could be done about.
The woman from Japan proves that cord issues can be addressed. It is impossible for us to guess if she would have had a poor outcome if they had chosen a different approach, but she and her providers chose not to gamble with her child's health/life and took a route that they believed offered the least amount of risk. This does not seem that radical to me. I had similar thoughts and questions during my subsequent pregnancies. My children all experienced different types of complications that were only identified because I was considered 'high-risk' (and that was only because of my previous stillbirth). Each of these complications were managed and monitored closely. They were delivered when the risks and benefits of their issues and prematurity flipped so that they had a greater likelihood of survival outside my womb than in it. And they are all 3 happy, healthy beautiful children today. Again – no way to know what the outcome would have been otherwise. I'm eternally grateful for their health, I'm scared when I think about what other outcomes were possible, and I can't help but wonder if their oldest brother would have survived if he had received the same level of care.
Likewise, we have no way of knowing if recognition of the cord issue could have prevented the stillbirth of the child in the first email. But these are what-ifs that this family (and many of us) will live with for the rest of their lives. The providers may be left with the same questions, How many babies MIGHT we be able to save or improve the outcome for if we identify potential problems before the mom or baby is symptomatic?
In the email from Japan, the cord issue was identified because she had a level of care that is not routine in the US and the provider was willing/able to offer a management plan that is not readily accepted in the US. Americans have insurance companies wanting to reduce the number of tests and procedures, lawyers wanting to eliminate provider liability, and special interest groups pushing their agendas into the medical decision making process of families, providers, and hospitals. The baby in the NICU is a perfect example that everyone involved might have benefitted from knowing in advance about a potential cord issue and management beyond watching and waiting. The stress, costs, and potential long-term effects for this child/family make some extra tests and a possible c-section seem pretty minor. The family who experienced a stillbirth didn't know what cord issues could do or that they might be preventable until after their child had died. The family in Japan was shown the potential issue and allowed to have a discussion with the provider about any risks and benefits of various options. Together, they developed a plan that they felt comfortable would reduce the risk as much as possible. Again, this seems rather simple to me.
I routinely hear stories of heath care professionals opting not to look for or to tell families (if they did look) about potential umbilical cord issues. Their rationale is this – "Why scare the family when I can't do anything about it?" This is unbelievable. The family has a right to know regardless of the options. Most people are understanding and realistic about what medicine is able to provide. This would not be the first time that families are given information about a diagnosis that doesn't have easy options.
But the next, obvious question is – why can't we do anything?
I understand that we may not be able to unwrap a nuchal cord or undo a knot in the cord. But we can manage the pregnancy differently from that point forward. We do it every day with many other issues. Why not this one? When we see sensational stories on the news about significant anatomical abnormalities that are corrected in utero, it seems unreal that we throw our hands up when it comes to issues like cord and placenta issues.
Medicine is not black and white.
What works for one person may not be the best solution for another.
- I am frustrated by recommendations and policies that assume all situations to be identical.
- I am frustrated by providers choosing to keep their heads buried in the sand instead of looking for warning signs or risk factors because it makes their job easier or reduces their liability or because the odds are in their favor.
- I am frustrated by health care professionals not involving families in health care decisions after an honest discussion of all information available.
- I am frustrated by insurance companies or other parties influencing medical decision making more than the physicians and the families directly impacted.
- I am frustrated by providers, organizations, and policies that ignore the fact that obstetrics is monitoring the health of TWO patients.
To me – these are some of the real problems with umbilical cords…and too many other causes of miscarriage, stillbirth, birth injury, and neonatal death.
We need more providers who are willing to do what makes sense
for their patients with their patients.
We need more families to communicate their desires.
We need more awareness of these issues so that every baby, mom, and family
get the absolute best that medicine can provide.
"What's the truth about cord accidents?"
I was asked this question earlier this week. And it's a very good question. There are so many conflicting thoughts, ideas, and beliefs regarding the role of the umbilical cord in stillbirth. So why is there so much confusion? And, what is the truth?
The truth is that umbilical cord accidents CAN cause stillbirth. There are numerous studies that have shown this to be the case. The percentage of stillbirths caused by cord accident is not as clear. Depending on the study, it can range from 5-30% of all stillbirths. The Stillbirth Collaborative Research Network (SCRN) of the NICHD recently published well-respected results from their comprehensive, 5-site study. In this paper, 11% of the stillbirths studied were attributed to cord issues. This is a significant number, but it is also likely to be a conservative number because they required physical evidence of a cord accident to be present during autopsy for this diagnosis.
There are many types of umbilical cord issues that can cause problems. The more common issues include true knots, velamentous or marginal insertions, hyper or hypo coiling, lack of Wharton's jelly, 2-vessel cords, and compression. Characteristics like long cords, short cords, nuchal cords, or body loops may not directly cause interruption in the blood flow, but they present a situation where compression may be more likely.
Why do so many people insist that cords (especially nuchal cords) don't cause problems? I think it's because most OBs and midwives have seen hundreds of healthy babies that are born with nuchal cords (the cords wrapped around the baby's neck). This leads many people to believe that it's not a big deal. The problem is that it CAN be a big deal for some babies. Just because it isn't a problem for ALL babies, doesn't mean it isn't a problem. I know people who smoke and don't have lung cancer. That doesn't mean that smoking is safe. The second issue with this is that nuchal cords are just one type of cord issue that could be problematic.
Why are cord accidents difficult to diagnose? There may be physical evidence of cord compression or other type of cord accident present after birth. However, this is not always the case. Plus, many stillbirths are not evaluated by someone trained in placenta and cord pathology to identify this evidence. In fact specially trained placental pathologists are few and far between.
Another significant problem in diagnosis is that we lose possible evidence with delivery. It is almost impossible to know (or even guess) where the cord and all other structures were when a problem occurred if we only look at the baby and cord AFTER they have been delivered. I think all stillbirths should have a comprehensive ultrasound at the time of diagnosis to evaluate the umbilical cord, baby's position, placental location, and amount of amniotic fluid. This is information that is impossible to determine if we don't look at the "scene of the crime" before it has been disrupted by the birth process.
With all of these issues, why are so many parents told that an umbilical cord accident was the cause of their child's death? This is a very good question. Anecdotally, I hear much more than 11% of stillbirths being attributed to cord accidents. Personally, I think this may be true in many of these cases. I also think it feels like an 'easy' answer to give parents. It is relatively simple to understand (as opposed to genetic alleles and complex medical conditions) and doesn't appear to require a lot of explanation or proof for most families. Plus, the term 'accident' gives the impression that is wasn't anybody's fault or that it was a freak occurrence – wrong place at the wrong time type of scenario. I've heard people say the word accident makes it less likely the parents will blame their providers, and also that it brings a sense of closure if it's "just one of those things". Regardless, it should not be a default diagnosis because it's easy. If that's really the best educated guess of the provider, then this should be explained to the family.
I am also very irritated by the connotation that nothing can be done about issues called accidents. In many cases, there are signs or symptoms that are not identified or addressed. What these symptoms are and how they should be managed is not something I'll get into here – but we need to start having frank discussions with expectant families and loss families about symptoms they have/had and if they could be signals of a baby in distress.
If it's so simple, why is there so much confusion about cord accidents?? I think this is the result of the above issues in combination. During pregnancy, parents are told umbilical cords don't cause problems. But if a loss occurs, many of these same parents are told that a cord accident is the likely cause of their child's death. We can't have it both ways.
How do we clear up the confusion? In my opinion, several things should happen.
- First, we need to STOP telling expectant parents that cord issues aren't a cause for concern.
- Second, we should be encouraging families to have the baby (or at least the umbilical cord and placenta) evaluated after a stillbirth to attempt to identify the cause of death without guessing.
- Third, we need more information about how to identify these cord issues and how to manage them – this needs more research.
Until we have more research, we should be looking for signs of distress in pregnancies, and we should be looking at umbilical cord characteristics during any and all ultrasounds. If cord issues or distress are identified, the parents deserve to be told and it needs to be addressed immediately. Our OBs and midwives deserve more research and education to guide them in prevention of stillbirth from cord accidents.
With the highly sophisticated medical technology available today, I firmly believe this is a cause of stillbirth that is highly preventable! We need to work together to make it happen!
Help us learn more about umbilical cord accidents and all stillbirths – PLEASE participate in the STARS Study and encourage others to do the same. We need women who have EVER had a stillbirth after 28 weeks gestation, women who have had a baby in the last 3 weeks, and women who are currently pregnant (28 weeks or more).
Click on the logo on the left or go here to participate: http://starlegacyfoundation.org/stars1/
We can be part of the solution!
The STARS Study is underway!
The STARS Study is underway!! We at the Star Legacy Foundation are incredibly excited to share this news with you!
One year ago at the Stillbirth Summit, a group of researchers, organizations, and stillbirth families began discussions about designing a research study. This group worked diligently over the last several months to create an online survey for this purpose. STARS (Study of Trends and Associated Risks for Stillbirth) was born and it is now open!
We have had great responses, a lot of interest, and also several questions. In case you have the same thoughts, here are the top 10 Frequently Asked Questions about the STARS Study.
1. What is the purpose of this study? – This study was designed to replicate portions of the Auckland Stillbirth Study to learn more about its findings. The other researchers at the Stillbirth Summit and stillbirth organizations provided input for additional questions to learn as much as we can.
2. What will be done with the data collected? – The researchers involved will use the information relative to their individual work. Their teams will analyze the information to determine if any conclusions can be made. If so, it may support their current/other research studies or it may spark a new concept for researchers to evaluate.
3. Who are the researchers? – The STARS Study team members are:
* Jane Warland, RN, RM, PhD, University of South Australia; Adelaide, South Australia
* Louise O'Brien, PhD, MS; University of Michigan; Ann Arbor, MI
* Jason Collins, MD, MCR; Pregnancy Institute; New Roads, LA
* Alex E P Heazell, MBChB, PhD; University of Manchester; Manchester, UK
* Jennifer L Huberty, PhD; University of Nebraska Medical Center; Omaha, NE
* Jamie A McGregor, MD, CM; University of Southern California; Los Angeles, CA
* Edwin A Mitchell, MBBS, FRSNZ, FRACP, DSc; University of Auckland; Auckland, New Zealand
* Mana Parast, MD, PhD; University of California San Diego; San Diego, CA
* Tomasina Stacey, RM, PhD; University of Auckland; Auckland, New Zealand
* Lindsey J Wimmer, MSN, CPNP; St. Catherine University; St. Paul, MN
The STARS Study Coordinators are:
* Shauna Libsack, Star Legacy Foundation
* Sherokee Ilse, Babies Remembered
* Marti Perhach, Group B Strep International
* Candy McVicar, Missing GRACE Foundation
4. Is this study IRB approved? – This study was reviewed by the IRB at the University of Michigan and determined to be exempt. All IRB regulations regarding exempt studies have been met. IRB #HUM63655 If you're wondering what an IRB is – an Institutional Review Board is a required function at any organization that conducts research with people. The primary responsibility of the IRB is to be sure that research involving people is conducted with full informed disclosure and consent and is conducted ethically.
5. Who can participate? – We need women from the following three groups to complete the survey:
* Women who are currently at least 28 weeks pregnant or who have given birth to a live-born baby in the last 3 weeks
* Women who have had a stillbirth after 28 weeks gestation in the last 3 weeks
* Women who have ever had a stillbirth after 28 weeks of gestation
Click here to participate in the study!
6. I live outside the US or did when my child was born. Can I participate? – Absolutely! This is an international survey. The more women who participate from around the world and around the US, the better our results will be.
7. Why are only stillbirths after 28 weeks being considered? – The study was designed to replicate portions of the Auckland Stillbirth Study. In this study, they evaluated late stillbirths (after 28 weeks). To make our results relevant to their findings, we needed to have similar criteria. In addition, this is an international study and there is not a clear definition between various countries about what gestation is considered a stillbirth. It does not change the importance of what can be learned from all types of pregnancy loss, but research rules require strict boundaries on some items. Please know – that all babies are important to us and we have visions of additional research that would include earlier pregnancy & infant loss.
8. What about me? My stillbirth occurred before 28 weeks? – We appreciate your interest and willingness to help! We recognize the significance of earlier pregnancy losses and intend to have additional studies in the future that will be focused on those babies. I hope you'll be willing to participate when we have more projects available!
9. How can I help? – The best way to help with this study is to participate if you qualify, and to share the information with anyone else you know who may be interested, willing, and able to participate. The more women who complete the survey, the more we will learn. The faster we are able to get women to complete the survey, the sooner we will have information to share!
10. How can I learn about the findings? – The researchers will be writing papers regarding their analyses. We will definitely share any and all official findings on our website and on our facebook page. If you would like to receive an email when these findings are published, send an email to: firstname.lastname@example.com.
If you have other questions regarding this study, please contact me at email@example.com .
THANK YOU for your help and support!
Copyright 2012 © Star Legacy Foundation
Thinking outside the box……
Last October, Star Legacy Foundation hosted the Stillbirth Summit 2011. After thinking about this type of an event for a while, we decided to pull the trigger and make it happen!
There are so many fantastic people working on stillbirth prevention around the world. Looking through some of those efforts, we discovered some similarities and overlapping concepts that were very exciting. Our minds wandered to 'what if' we could get these brilliant minds in the same room to share their findings. The biggest winner of that type of event would be the babies!
The focus was on stillbirth topics that are emerging ideas and 'outside the box' thinkers. We needed people who are open-minded and looking at all aspects of this considerable problem. We got just that – and so much more!! Fortunately, we had a great response from these researchers who were all very willing to participate.
The topics included infection, hypotension, thrombophilias, sleep, placenta, cord, and fetal movement. Researchers included Dr. Harvey Kliman, Dr. Uma Reddy, Dr. Mana Parast, Dr. Moraji Peesay, Dr. Louise O'Brien, Dr. Jane Warland, Dr. Alex Heazell, Dr. Ed Mitchell, Dr. Tomasina Stacey, Dr. James McGregor, and Dr. Jason Collins. The discussion was lively and very educational. Even better, at the end of the presentations, everyone worked together to discuss ways to work together and identify new projects needed.
One of the outcomes discussed was the publication of the presentations from the Summit. Dr. Mitchell and Dr. Heazell took a leadership role and each researcher wrote a summary of their presentation. The combination of these efforts was a summary of the Proceedings of the Stillbirth Summit 2011. We are thrilled to announce that this article was just published!
It is so important to have these topics and this information in the medical literature to help the cause of stillbirth prevention. Please take a moment to read the article, share it with your friends, and share it with your health care providers. Every little bit learned is one step closer to being able to prevent many, many stillbirths.
I am extremely grateful for the researchers who participated so eagerly and the many, many volunteers who helped make this event a reality. We are looking forward to the next Stillbirth Summit – in 2014! But for now, we take a moment to savor this accomplishment and say thank you to the researchers for sharing their findings with the world.
Click here to read the Proceedings of the Stillbirth Summit 2011
as published in
About the author:
Lindsey Wimmer, a Pediatric Nurse Practitioner, is Mom to four children; Garrett, stillborn in 2004, Grant, Bennett and Austyn. Lindsey is an adjunct instructor of pediatrics at the St. Catherine University in St. Paul, MN and also teaches pediatric and obstetrical nursing at Hennepin Technical College in Eden Prairie, MN. Lindsey and her husband Trent founded the Star Legacy Foundation shortly after Garrett's birth when realizing that the numbers of stillbirths in the US were staggering and that very little was being done to determine the causes or find prevention initiatives. Visit the Star Legacy Foundation to learn more.
A picture is worth a thousand words…and possibly your baby's life too.
by Lindsey Wimmer, MSN, CPNP
I LOVE pictures of my kids. I mark the major milestone dates with pictures, I try to get pictures of the little faces I don't want to forget, and I send pictures to family members assuming they want them as much as I do! Those pictures tell us so much about them. We can see their personalities, we watch them grow, we remember specific accidents or events, we evaluate genetics by figuring out who they look like, and so much more. There are probably MANY reasons for this obsession (another blog topic in itself!) – but the bottom line is that I LOVE every picture I have of my kids.
That includes the ultrasound pictures I have of our son Garrett who was stillborn at 38 weeks. Sadly, the last pictures I have of him while his heart was beating are from the 20 week ultrasound. That is the only time in any of my kids lives that I have gone almost 5 months without taking their picture. Yet that is the standard of care during pregnancy. It seems crazy to me that we know so much is changing inside the uterus the last half of the pregnancy, yet we don't utilize modern technology to watch and make sure mom and baby are healthy and growing as they should.
I believe at least one third-trimester (32 weeks to delivery) ultrasound should be a new standard for prenatal care. Some physicians and midwives have started this, but most have not.
First, ultrasound has been proven to be safe and is non-invasive. There is essentially no physical risk to the mom or the baby. What can we learn from a third trimester ultrasound?
1. How baby is growing and estimate current size
2. How much amniotic fluid is present
3. Where the placenta is, how large it is, and how mature it is
4. Where the umbilical cord is, how long it is, how twisted it is, if there are loops or knots in the cord
5. How the umbilical cord is inserted into the placenta
6. Blood flow through the placenta and umbilical cord to the baby
7. Signs of inflammation
8. Position of baby
Obstetricians know the end of pregnancy is critical – that's why they start increasing the frequency of prenatal visits. Yet, most of these visits include very little exam of the baby. They will listen to the baby's heartbeat and measure mom's belly. The heart beating for 15 seconds is hardly an accurate determinant of health. Measuring mom's belly with a tape measure does very little to tell us about what's going on inside the uterus. That measurement can be affected by the size of the baby, the size of the mother, the position of the baby, the amount of amniotic fluid, and the size of the placenta. Once a baby is born, the pediatricians begin seeing that child on a regular basis. First at birth, then at 4-5 days, then at 2 weeks, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, and 24 months. Not until a child is 2 years old does their growth and development slow down enough that physicians feel comfortable letting them go more than 3 months between examinations. We shouldn't let a baby grow and develop that much before birth without watching more closely.
The major concern I hear is the cost. I understand that this would add to the cost of prenatal care, but I believe the potential benefit is greater. In most health care facilities, this ultrasound would cost the patient between $100 and $300 if their insurance did not cover it at all. To some this is not a problem, and to others it is. But I believe that physicians should offer it and let the patients decide if this is a cost they can incur. We recommend vaccines, mammograms, blood tests, medicines, and more even though we know many patients won't be able to afford them. We leave the final decision to the patient.
The other argument from health care professionals is that they can't do anything about the umbilical cord or the other factors they could see. But I disagree. Pregnancies that have been deemed "high-risk" have these extras tests on a regular basis to monitor the situation. The United States is actually very good at reducing prenatal and infant deaths among this population. It's the "low-risk" pregnancies that have a higher death rate. Why?? Because the qualifications for high-risk are mostly characteristics of the mother. Many high-risk babies are in danger because they have a low-risk mother. The only way to find a high-risk baby is to LOOK at the baby with a third trimester ultrasound. If a concern is found, the pregnancy can then utilize high-risk pregnancy protocols and be monitored more aggressively.
If you are pregnant, ask your health care provider about a third trimester ultrasound. Anytime you are concerned about the health of your baby, particularly any fluid leaking, weight loss, excessive weight gain, change in baby's movements or behavior, pain, bleeding, fever, or past your due date – ask for an ultrasound and non-stress test for a full evaluation of your baby. If you have concerns or symptoms, most insurance companies will cover the cost of these additional tests. Don't let cost be a roadblock if you or your baby are experiencing concerning symptoms. Those extra pictures of your baby are not only precious keepsakes, but they might help save your baby's life. That's a powerful picture.
P.S. We are taking an informal, unscientific survey of moms to see how often women are having a third trimester ultrasound. If you have had a baby (alive or stillborn), click here to take our survey.
About the author:
Lindsey Wimmer, a Pediatric Nurse Practitioner, is Mom to four children; Garrett who was stillborn in 2004, Grant, Bennett and Austyn. Lindsey and her husband Trent founded the Star Legacy Foundation shortly after Garrett's birth when realizing that the numbers of stillbirths in the US were staggering and that very little was being done to determine the causes or find prevention initiatives. Visit the Star Legacy Foundation to learn more.
Cord Accidents – Myth or Reality???
The Star Legacy Foundation is frequently contacted by couples that have been told their child was stillborn due to an umbilical cord accident. Yet, many obstetricians will also say that babies are born all the time with a nucal cord (cord around the neck) and dismiss that as a cause of a stillbirth. Cord issues aren't just limited to nucal cords – simple compression, cord wraps around other body parts, torsion (twisting to the point of coiling back upon itself like a telephone cord does when twisted too many times), and true knots are also known to cause stillbirth.
Many of the same callers ask us what we know about Dr. Jason Collins and his work involving cord accidents. Dr. Collins, an obstetrician, has dedicated his career to stillbirth research and umbilical cord accidents specifically. The following is a brief summary of a presentation he recently gave at the Stillbirth Summit (October 4-6, 2011 in Minneapolis, MN, USA) which is a very high level overview of his research and conclusions.
The presence of umbilical cord issues have been well documented in published literature since the 1700s. Yet, this remains an area of obstetrics that is greatly understudied and ignored. The umbilical cord, the insertion site, the placenta, and the baby should be evaluated and characterized with every pregnancy. With advancing imaging technology, it is becoming even easier to identify areas of concern on ultrasound as early as 10 weeks of gestation.
Umbilical cord torsion occurs when the number of twists exceeds the ability of the cord to withstand the force generated. The cord compression generated causes fetal hypoxia (lack of oxygen). On placental exam, chorioangiosis (cellular changes) can be identified as a result of ischemia (restriction) due to cord compression. The length of the cord determines the amount of twisting that is harmful. The human umbilical cord will tolerate one twist per 5cm of cord length. Twists exceeding this ratio are associated with torsion and fetal death. The length of the umbilical cord and the number of twists present should be identified and documented at every delivery. Identification of torsion prenatally allows for altered management of the pregnancy with a better chance of a positive outcome.
There are two types of nuchal cords: type A and type B. Type A is a wrap that can possibly be undone with movement or delivery of the baby. Type B is a hitch that is impossible for the baby to release. If a type B loop around the neck, ankle, or other body part is pushed off the body, a true knot is formed.
With umbilical cord issues, the factor that determines the risk is the amount of slack available. For this to be determined, the cord location, cord structure, placenta, placental position, cord length, insertion site, and position of the baby must all be evaluated and considered. Short cords have been associated with an increased risk of neurologic insults and long cords have been associated with an increased risk of fetal death.
Work at the Pregnancy Institute has indicated that hyperactivity, hypoactivity, and hiccups may be clinical indicators of fetal distress. Women presenting with these symptoms should be evaluated for sources of cord compression. Fetal heart rate can provide information on this compression as well. Frequent decelerations, W signs, lambda signs, and spikes should be taken as indicators of fetal distress and managed accordingly. The exact amount of time that it takes for fetal chemistry to return to normal after cord compression has not been studied, but we estimate that more than three compressions in ten minutes would create increasing blood chemistry concerns and should be dealt with immediately.
Interviews at the Pregnancy Institute have also revealed that a vast number of fetal deaths occur during maternal sleep between the hours of midnight and 6am. Maternal low blood pressure may play a significant role in this finding as a reduction in blood pressure may alter the fetal response to underlying cord issues. Melatonin is produced during sleep and is known to affect the uterus. During these overnight hours, the melatonin produced stresses the uterus and the baby is challenged. Babies with cord compression may not tolerate this stressor.
Finally, work at the Pregnancy Institute has identified that umbilical cord accidents are not random or rare. Women who have had umbilical cord issues with previous pregnancies, have as much as a ten-fold increased risk of umbilical cord issues in future pregnancies. These women need additional monitoring for these concerns.
Management of umbilical cord issues is possible with proper diagnosis and fetal monitoring.
It is true that not all cord issues lead to stillbirth. However, it is also true that cord issues are a significant risk factor and cause many stillbirths. The evaluation of the umbilical cord and placenta should be included in a new standard of care for obstetrics in the 21st century.
About the author:
Lindsey Wimmer, a Pediatric Nurse Practitioner, is Mom to four children; Garrett who was stillborn in 2004, Grant, Bennett and Austyn. Lindsey and her husband Trent founded the Star Legacy Foundation shortly after Garrett's birth when realizing that the numbers of stillbirths in the US were staggering and that very little was being done to determine the causes or find prevention initiatives. Visit the Star Legacy Foundation to learn more.
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