Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

Super Comment! Re: The Deal with Delayed Cord Cutting May 19, 2009

Many of you might not realize that I personally read every comment that is posted to my blog.  Why you ask?  Because I love reading what the people following my blog have to say!  I love when people engage in great discussions that have been stimulated by something I have written.  I love when women post comments seeking advice, information, or camaraderie and other readers respond!  And I love reading about other women’s birth experiences that they share via this forum.  Often, a reader will post a question to me under the comments section, a question so great that I take hours or days to research and write a response.  And I am such an information/research junkie that if I don’t know the answer, I’ve got to find out!!  Other times a reader will post a comment with some really great information or resources to share with other readers.  Unfortunately, many of these “super comments” often go unnoticed by readers who only read the posts and not each “comments” section.  So I have been inspired to create a new category for my blog entitled “Super Comments” to pay homage to all of the great super comments and questions that my readers post!

 

Today’s Super Comment is in response to May 17th’s post entitled The Deal with Delayed Cord Cutting or “Hey! Doctor! Leave that Cord Alone!”

 

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Dear Nursing Birth,

 

I have a student nurse question. In nursing school we were taught that clamping/cutting the cord stimulates respirations. This comes from our textbook, Maternity, Newborn, and Women’s Health Nursing by Susan Orshan, specifically this quote “…clamping of the umbilical cord affects chemoreceptors sensitive to changes in arterial oxygen and carbon dioxide content, contributing to the onset of respirations.” This sentiment was echoed by our faculty to the tone of *this is why cords are clamped and cut immediately after the birth*.

I guess my question is this: Is the above quote enough to justify swift cord-clamping? Or not?
Thanks so much for this post. I’m enjoying the research you’ve done!

 

Sincerely,

BCB

 

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Dear BCB,

 

That is a really great question!  What you (and I) both learned in nursing school is right on one hand, but wrong on another.  Let me explain a bit further.  I would like to first address the statement you found in your textbook.

 

Your textbook reads “…clamping of the umbilical cord affects chemoreceptors sensitive to changes in arterial oxygen and carbon dioxide content, contributing to the onset of respirations.”  This is true in the fact that clamping the umbilical does stimulate the baby to breathe…BUT the act of clamping the umbilical cord is NOT necessary for the baby to take his first breath!  Clamping of the umbilical cord in a way actually forces the baby to take his first breath!  In the textbook Respiratory Physiology author John B. West writes:

 

“The emergency of a baby into the outside world is perhaps the most cataclysmic event of his or her life.  The baby is suddenly bombarded with a variety of external stimuli.  In addition, the process of birth interferes with placental gas exchange, with resulting hypoxemia and hypercapnia.  Finally, the sensitivity of the chemoreceptors apparently increases dramatically at birth, although the mechanism is unknown.  As a consequence of all these changes, the baby makes the first gasp.  

 

The fetal lung is not collapsed but is inflated with liquid to about 40% of total lung capacity.  This fluid is continuously secreted by alveolar cells during fetal life and has a low pH.  Some of it is squeezed out as the infant moves through the birth canal, but the remainder has an important role in the subsequent inflation of the lung.  As air enters the lung, large surface tension forces have to be overcome.  Because the larger the radius of curvature, the lower the pressures, this pre-inflation reduces the pressures required.”  (page 152, chapter 9)

 

Also (and this is a bit technical so bear with me!) an excerpt from the article “Cord Closure: Can Hasty Clamping Injure the Newborn?” by George M. Morley, MB published in OBG Management in July 1998 tell us:

 

“Very early clamping results in less than physiologic blood volume. The normal, term child routinely survives, but clamping the cord of a compromised child before ventilation is riskier. Initial aeration of the lungs causes reflex dilatation of pulmonary arterioles and a massive increase in pulmonary blood flow. Placental transfusion normally supplies this volume. Clamping the cord before the infant’s first breath results in blood being sacrificed from other organs to establish pulmonary perfusion. Fatality may result if the child is already hypovolemic.”  (Thanks to gentlebirth.org for the reference!)

 

And to answer your second question…

 

Homebirth midwife from Mountain View, CA and author of the website http://www.gentlebirth.org/ Ronnie Falcao, LM MS writes in a post entitled “Some comments about ‘Anatomy of A Fetus: Circulation and Breathing’” :

 

“It is not air hunger that causes the newborn to take a first breath, and it is certainly not necessary for the cord to be cut in order for the baby to start breathing.  …I am quite certain that nature didn’t assume that a birth attendant would be standing nearby, scissors in hand.  In reality, babies start to breathe right away even if the cord is left untouched.  It is not air hunger that stimulates a baby to take its first breath.  It is likely the stimulation that comes from the shock of cold air and the sudden exposure to light and noise.  Even dim lights and low noises seem very startling to a baby who’s only used to life in the womb.

 

Both Williams Obstetrics  and Varney’s Nurse-Midwifery concur: ‘The phenomenon that occurs to stimulate the neonate to take the first breath is still unknown.  It is believed to be a combination of biochemical changes and a number of physical stimuli to which the neonate is subjected, such as cold, gravity, pain, light and noise, which cause excitation of the respiratory center.’

 

Beyond the question of what stimulates the baby to take a first breath, we can look further at the triggers for the changes in the foramen ovale and ductus arteriosus. The delicate process of rerouting the circulatory system depends on the intricate interplay of blood gas levels that occurs naturally as there is a gradual shift from reliance on umbilical cord oxygen to reliance on air breathed into the lungs.  Sudden severing of the umbilical cord is an unnecessary and dangerous meddling with this process. Some people refer to this as premature amputation of the placenta because the baby is still using oxygen carried through the cord from the placenta.”

 

As an L&D nurse, I have witnessed births where the birth attendant practiced early cord clamping and some where the birth attendant practiced delayed cord clamping.  And guess what!?  These normal, healthy, uncompromised babies took their first breath and started to cry whether the cord was clamped early or late!  (When I first personally witnessed a few of the delayed cord clamped babies breathing just fine I started to wonder if the impression that I was given in nursing school (i.e. that babies needed their cord to be clamped to take their first breath) was really totally true.  Both experience and research have shown me otherwise!  Pretty cool huh! 

 

 

Thanks for your great question!

 

Best,

NursingBirth

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23 Responses to “Super Comment! Re: The Deal with Delayed Cord Cutting”

  1. Stephanie Says:

    I was wondering if you have any “favorite” books for a woman who wants to have a better birth experience the next time around. It’s not that I had a bad experience but I want to do a few things differently the next time. Primarily not using an epidural because I was poked 4 times and ended up with months of spinal headaches/nausea/vomiting/back pain which lead to nursing issues which lead to PPD and so on. My labor/delivery was pretty quick for an induced, first time mom so I am hoping that will again be true for the next baby. Any websites I should check out? Any advice you can give me? Thank-you!

  2. briome Says:

    Cool! I love you blog (and my ICAN people read it too!)

  3. maresi Says:

    My daughter flew out screaming after 2 pushes – we still waited to cut the cord for about 5 minutes. Even if we hadn’t have wanted to (which we did), we basically had to since there was no tray in the room with clamps, no doctor around and only one nurse was there! (Needless to say, it was a speedy delivery – I was glad just to be on a bed and not in a wheelchair when she came out.)

    • nursingbirth Says:

      maresi, that is a great story!! It reminds me of a quote I read in the book Silent Birth by Cohen & Estner. Now that I am looking for it of course, I can’t find it. But it goes something like this…

      If you were trapped in your car in a storm with no one around to help you, no husband, no partner, no doctor, no midwife, etc…you would still give birth to your baby and you and your baby would be okay. Women do not need anyone to deliver them. They deliver their own babies!”

      Im sure it was an INTENSE experience to say the least but WOW how awesome!!!

  4. vbacwarrior Says:

    When my son was born he was a whitish/greyish color and wasn’t breathing. His 1 min apgar was a 2, actually. Instead of clamping/cutting his cord right away, the doctor held my baby between my legs on the bed and firmly rubbed his back for a minute or two (with cord intact). Only after my son began breathing a bit did the doctor clamp and cut the cord. (His 5 min apgar was a 9, btw).

    • nursingbirth Says:

      vbacwarrior, GREAT story!! It is a perfect example of how a calm, experienced, knowledgable, evidenced based practicing birth attendant who has experience with normal birth would handle your particular situation!! Its not just about an immediate breath. Think about these two situations:

      baby comes out not breathing, great muscle tone, heart rate >100, had reactive fetal heart tones/strip before delivery

      baby comes out not breathing, floppy as a rag doll, heart rate <100, really crappy fetal heart tones/strip

      They are not the same and should not be treated the same!! Most people think they are the same but they are not! Thanks again for the story!

  5. BCB Says:

    Thank you for your answer — I think I understand better now. Cord clamping is not necessary for the initiation of respiration, but it is a factor in the process. I found it very interesting that the Cochrane reviews that you linked to did not find any association between delayed cord clamping and respiration difficulties.
    I truly appreciate your discussion on this topic of delayed cord clamping for healthy new borns. So many important points have been brought up. In the future, I feel I will be able to advocate for women who include this in their birth plan. Also, I enjoyed gentlebirth.com. I will be spending a few hours there.
    Nursing school is so wonderful, but they teach and reinforce what is conventional. I can sympathize with that, though, I mean, how hard would it be for all our faculty and administrators to be on top of all the research in all the different areas of practice and then try to teach this to us students? Very difficult, I think. Nursing blogs really help me realize how important it is for me to continue reading, learning and researching to improve my future nursing practice.

    So a big THANK YOU to you Nursing Birth, and Reality Rounds, and At Your Cervix, and Rebirth Nurse for being really great nursing mentors from across the internets. And an even bigger THANK YOU to all the mothers who write share your stories — you teach us through your experiences.

    • nursingbirth Says:

      BCB, you are making me all verklempt!! You are very welcome. And thanks to YOU for being an nursing student who is so motivated to continue reading, learning and researching. You are going to be a GREAT nurse! You write “Nursing school is so wonderful, but they teach and reinforce what is conventional. ” Boy are you right on sister!

  6. Emily Jones Says:

    vbacwarrior – I am a big fan of delayed cord clamping, especially with borderline babies. Since the cord is the baby’s primary source of oxygen and blood, it only makes sense to keep that line open as long as possible.

    nursingbirth – as just a little anecdotal evidence, I had three hospital births with immediate clamping/cutting, and my last was an unassisted home birth in which we waited 2 1/2 – 3 hours before tying off and cutting the cord. My first three all had jaundice, and their cords took 2+ weeks to fall off. My home birth baby never had jaundice, and her cord fell off in 4 days. (Which is a pet theory of mine, that the longer you wait the cut the cord, the sooner the stump falls off.) Oh, and she came around to breathing just fine on her own. 🙂

  7. Birth_Lactation Says:

    This was good reading! It provoked a question in my mind. At a C/S, the cord is clamped faster in many cases than at a vaginal birth because there is another person to do it or place the clamp….I wonder if there has been research on that factor with regards to the higher incidence of TTNB (transient tachypnea) in C/S versus vaginal births….
    Hey–they used to think the baby had to be held upside down and spanked to cry!
    Thanks, mel

    • nursingbirth Says:

      Birth_Lactation, That is a great question. Obviously (and I know you know this too) studies have shown that C/S babies have greater incidence of respiratory distress and admit to the NICU than vaginal babies. Research I have read has found it is part related to iatrogenic prematurity and not being “squeezed” out of the vagina. I too wonder if perhaps immediate cord clamping plays a role as well!! i’ll have to look into that!! Great question!

      LOL on the spanking btw!

  8. Veronica Says:

    I think I was lucky to give birth in a hopsital that routinely practises delayed cord cutting and skin to skin contact for at least the first hour. My son established his breathing (and screaming) before he was completely born. My midwife said it’s not something they normally see. Then again, he was in a hurry to come out, 90 minutes from start to finish.

    • nursingbirth Says:

      Wow!! Rock on Veronica!! It is so nice to hear there are hospitals out there that practice delayed cord clamping. You know, women should not have to demand this very important step in childbirth!!

  9. Kathy Says:

    NursingBirth,

    Thank you for highlighting this comment and bringing attention to all comments. I’ve just subscribed to the comments in my Google Reader, so I can listen in on these comment-conversations that I would otherwise miss. Since I read my blogs in Google Reader, I rarely read any comments, unless I happen to comment as well, so I’m glad you brought attention to this important topic.

  10. […] in that very post you are referring to (Super Comment! Re: The Deal with Delayed Cord Cutting)  I referenced two research articles from the Cochrane Collaboration (considered the gold standard […]

  11. Jenn Says:

    Something I can point out about breathing that I think many people are unaware of is that breathing is not stimulated by lack of oxygen in the blood, but rather a build up of carbon dioxide.

    Given that…if you are in an environment that has a large amount of oxygen and low amount of carbon dioxide, you will actually have your carbon dioxide level decrease to the point that you will not breath “automatically,” so if you happen to be unconscious…you will suffocate DESPITE being in a high oxygen environment!

    I’ve also seen a couple of babies breath before being completely born…again showing that the cord does not need to be clamped for breathing to start. I’ve always wondered though…why is it that in a shoulder dystocia case the baby will not breathe? The head is delivered….

    • nursingbirth Says:

      Jenn, Kathy is almost right. Its not the body compression that we are worried about, its the cord. In the case of shoulder dystocia the umbilical cord is being compressed between the fetal body and the maternal pelvis (aka the cord is getting pinched between the baby and the pubic bones). That is why prompt identification and effective evidenced based management of shoulder dystocia is so important when it (rarely) does happen. great question!

  12. Kathy Says:

    “I’ve always wondered though…why is it that in a shoulder dystocia case the baby will not breathe? The head is delivered…”

    My understanding is that even though the head is out, the body is being compressed in the birth canal, so the chest cannot expand. If I’m wrong, I’m sure somebody will correct me. 🙂

  13. Jane Kamper Says:

    I am wondering if there is a particular way that the cord clamping can be delayed in C-section delivery. I am going in for a c-section(first child wth severe shoulder distocia, so they scheduled me for c/s), and I want to delay the cord cutting. Is this a realistic request? Or is it difficult for them to do?

  14. yoursurprise-bellatio-5 Says:

    Hello! I’m at work browsing your blog from my new iphone 4! Just wanted to say I love reading your blog and look forward to all your posts! Carry on the superb work!


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