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

 

The Deal with Delayed Cord Cutting or “Hey! Doctor! Leave that Cord Alone!” May 17, 2009

Recently I have received a few emails/comments asking me about the pros/cons of delayed cord cutting.  Delayed cord clamping/cutting is the process of waiting until the umbilical cord stops pulsating (approximately 5 minutes) and/or waiting until the placenta is delivered (approximately 30 minutes) before the cord is cut after the baby is born.  In today’s hospitals, obstetricians typically wait no longer than 30 seconds after the shoulders are delivered before they clamp the cord.  Why such a short time?  Author Tina Cassidy in her book Birth: The Surprising History of How We Are Born sheds some light on the subject:

 

“Throughout history, the immediate postpartum period has been as much a victim of fashion and misconception as has labor and birth.  And standard practice still varies among countries, hospitals, doctors, and midwives. 

 

The first act that usually occurs after the slippery baby emerges is the cutting of the umbilical cord.  …The act also forces the newborn to breathe air through its lungs for the first time.  Perhaps because of the symbolism of that moment, cord cutting has been a magnet for drama, ceremony, and superstition.

 

In most hospitals today, cutting the cord is such an uneventful routine that it can pass unnoticed by the overwhelmed mother.  Doctors generally wait about thirty seconds a time period long enough, they believe, for the baby to receive all the blood it needs from the placenta.  …They then apply two clamps, break out the scissors, and often ask the father if he wants to cut between the ligatures.  Doing all of this quickly also allows for the baby to be suctioned, weighed, and swaddled, before it gets cold.  

 

Some childbirth experts argue that, rather than being guided by a clock, it’s best to wait until the cord stops pulsing before cutting, allowing the baby to receive all the blood it was meant to receive from the placenta.  They say it helps the mother as well, because the placenta shrinks as it pumps out extra blood, making it easier to deliver.”

 

Penny Simkin, author of the book The Birth Partner, also writes about this subject:

 

“The cord is often cut immediately, but a recent scientific analysis has found benefit to waiting for at least two minutes or until it stops pulsating—in five minutes or so.  Less likelihood of anemia for as much as six months exists in babies whose cords are cut late.  Until the cord is clamped or stops pulsating, blood passes back and forth between the baby and the placenta.  It goes from placenta to baby when ever the uterus contracts, squeezing blood from the placenta through the umbilical cord to the baby.  Between these contractions, with each beat of the baby’s heart, blood is pumped from the baby through the umbilical cord and back to the placenta.  This transfer stops when the cord is clamped or stops pulsating, which occurs when the blood vessels close down.  The best way to make sure that the baby has the right amount may be to place the baby on the mother’s belly and wait for the cord to stop pulsating.  Exceptions to this are when the baby needs immediate medical attention, when the cord is tightly wrapped around the baby’s neck, preventing delivery, and when you have decided on cord blood removal and storage.”

 

So what can we take from these quotes?  I believe we can take the following two things:

 

#1  Immediate cord cutting is very convenient for today’s hospital staff and birth attendants.  It allows for the birth attendant to begin inspection of the mother’s perineum and stitching up of any episiotomy or tear that may have occurred (or was cut) during delivery.  It also provides an opportunity to use a sponge stick to provide traction on the placenta (a.k.a. slight tugging) to “assist” the placenta in detaching (Note: The majority of obstetricians do this as it is part of “active management of the third stage” which is predominately and widely taught in medical schools and residency programs across the U.S.)  When the cord is cut soon after delivery, it also allows for the nurses/pediatrician to take the baby away from the mother (either in or outside of the room) and weigh it, tag it, footprint it, give it medications like vitamin K shot and erythromycin eye ointment, and swaddle it. (Note: If you think that sounds assembly line-ish, your right!  These practices are based on a desire for modern maternity hospital wards to increase their efficiency!)  Typically mothers are told “Oh this won’t take very long!  You’ll have the next 18 years to spend with your baby!  It’s too hard to hold the baby and get stitched up anyways!  We’ll give her right back…promise.”  I would like to add that it is my personal philosophy that any practice that is done solely or mainly for obstetrical convenience and not for the safety or wellbeing of the mother or baby is a practice that should be re-thought or abandoned!

 

#2  The placenta does not stop working when the baby is born.  In addition, blood continues to flow from the baby to the placenta and back again making the claim that the baby will get “too much blood” a physiological fallacy especially if the baby is placed on the mother’s abdomen skin-to-skin above the level of the placenta which assures that blood will continue to flow, but not to excess.  (Unless, of course, the cord is milked, and by that I mean the practitioner puts the cord between his thumb and forefinger and pushes all the blood in the cord into the baby and then clamps it, a practice which is both outdated and harmful in the fact that it will most surely lead to neonatal jaundice.  This old-school practice of “milking” the cord is probably where delayed cord clamping inaccurately got its bad reputation!) 

 

In my quest for more knowledge on this topic I stumbled upon a YouTube video entitled Better Birth VA – We Can Be Much Kinder” produced by L. Janel Martin. 

 

 

This video was created in part for the Birth Matters Virginia Video ContestIt is a fascinating video that interviews a variety of midwives/obstetricians including:

 

 

This list of birth attendants, both obstetricians and midwives, are practitioners who are in support of delayed cord cutting.  More research into their backgrounds and practice revealed to me that they all believe in, work within, and support a midwifery model of maternity care, a woman-centered model that has been proven to reduce the incidence of birth injury, trauma, and cesarean section and promote empowering, positive birth experiences for childbearing families. 

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Let’s take a moment to learn a little bit more about the research that SUPPORTS delayed cord clamping/cutting:

 

  • Delayed Umbilical Cord Clamping Boosts Iron In Infants (2006): A report of a study conducted by UC Davis nutrition professor Kathryn Dewey that revealed a two-minute delay in cord clamping at birth significantly increases a child’s iron status at 6 months of age.  This study documented for the first time that the beneficial effects of delayed cord clamping last beyond the age of 3 months.

 

  • Early versus delayed umbilical cord clamping in preterm infants (2004): A Cochrane review (considered the “gold standard” of research and evidenced based practice) of studies on babies born prematurely which revealed that delaying cord clamping for greater than 30 to 120 seconds, rather than early clamping as is the current obstetrical practice, seems to be associated with less need for transfusion, less intraventricular haemorrhage, and helped the babies adjust to their new surroundings better.

 

  • Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes (2008): A Cochrane review that showed no significant difference in postpartum hemorrhage rates when early and late cord clamping were compared. The review also reported growing evidence that delayed cord clamping confers improved iron status in infants up to six months after birth, with a possible additional risk of jaundice that requires phototherapy.  (It is important to note however that the act of placing the baby on the mother’s abdomen skin-to-skin above the level of the placenta assures that blood will continue to flow, but not to excess.)

 

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So let’s break it down shall we?!

 

The PROS of Delayed Cord Clamping/Cutting

(This list was written by Marie Berwald, a certified HypnoBirthing practitioner and Yoga instructor from Canada, for a post entitled “Late vs Early Clamping of the Umbilical Cord in Newborn Babies” on her blog Birth Bliss.  Marie supports each one of these points with research so please check her blog out!)

 

1) The blood in the placenta rightfully belongs to the baby, and babies not receiving this blood have the deal with the equivalent of a major blood loss or hemorrhage at birth.  It is estimated that early clamping deprives the baby of 54 to 160 ml of blood, which represents up to half of a baby’s total blood volume at birth.

 

2) There is a significant amount of iron in the cord blood which the baby needs for optimal health and for the prevention of anemia.

 

3) Babies benefit from the increased oxygen available to them from the cord-blood when the taking these first few breathes.  The earlier the cord is clamped, the more likely the incidents of respiratory distress.

 

4) The blood that babies receives through the cord after birth acts as a source of nourishment that protects infants against the breakdown of body protein.

 

5) As an added bonus, delayed cord clamping keeps babies in their mother’s arms, the ideal place to regulate their temperature and initiate bonding and breastfeeding.

 

The CONS of Delayed Cord Clamping/Cutting

 

1)     May increase the baby’s risk for jaundice, a condition that many newborns develop related to the baby’s immature liver that cannot process bilirubin, a yellow byproduct of the breakdown of old red blood cells.

 

It seemed to me that the PROS of delayed cord clamping outweigh the CONS however I feel that it is important to explore the subject of newborn jaundice more…that is, Is it something that parents should be worried about?  Is it serious enough to trump all of the research supported benefits of delayed cord clamping? 

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The answer to my question came from one of the obstetricians featured in the YouTube video featured above, Dr. Sarah J. Buckley.  In an article entitled, Leaving well alone: A natural approach to the third stage of labour  Dr. Buckley writes,

 

“Early clamping has been widely adopted in Western obstetrics as part of the package known as active management of the third stage. This comprises the use of an oxytocic agent- a drug that, like oxytocin, causes the uterus to contract strongly- given usually by injection into the mothers thigh as the baby is born, as well as early cord clamping, and ‘controlled cord traction’- that is, pulling on the cord to deliver the placenta as quickly as possible.

 

While the aim of active management is to reduce the risk of haemorrhage for the mother, ‘its widespread acceptance was not preceded by studies evaluating the effects of depriving neonates [newborn babies] of a significant volume of blood.’

 

Some studies have shown an increased risk of polycythemia (more red blood cells in the blood) and jaundice when the cord is clamped later. Polycythemia may be beneficial, in that more red cells means more oxygen being delivered to the tissues. The risk that polycythemia will cause the blood to become too thick (hyperviscosity syndrome), which is often used as an argument against delayed cord clamping, seems to be negligible in healthy babies.

 

Jaundice is almost certain when a baby gets his or her full quota of blood, and is caused by the breakdown of the normal excess of blood to produce bilirubin, the pigment that causes the yellow appearance of a jaundiced baby. There is, however, no evidence of adverse effects from this mild jaundice.  In fact, jaundice, which is present in almost all human infants to some extent, and which is often prolonged by breastfeeding, may be beneficial because of its powerful anti-oxidant properties.

 

Early cord clamping carries the further disadvantage of depriving the baby of the oxygen-rich placental blood that Mother Nature provides to tide the baby over until breathing is well established. In situations of extreme distress- for example, if the baby takes several minutes to breathe-this reservoir of oxygenated blood can be life saving, but, ironically, standard practice is to cut the cord immediately if resuscitation is needed.”

 

I encourage you to read the full text of Dr. Buckley’s article on her website as she not only talks more about the benefits of delayed cord clamping, but she also supports all of her arguments with research.

 

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Are you interested in delaying cord clamping during the birth of your baby?  If you are, know that the research supports you!  If your birth attendant states that she/he does not usually practice delayed cord clamping/cutting but doesn’t automatically shoot the idea down, as her/him if she would be willing to learn more about it.  On the other hand be weary of any birth attendant that discourages this practice, tries to talk you out of it, or outright refuses to participate.  This could be a red flag that she/he will not be wiling to support any other desires in your birth plan.  A regular visitor to my blog recently wrote me this email:

 

Dear NursingBirth,

 

I belong to an online birth club and a fellow mom wrote this post the other day:

 

“I met with my obstetrician yesterday for my 32 week appointment and brought my birth plan with me.  She looked over it and proceeded to tell me all these issues with it…  I want to have a natural/med-free childbirth and mentioned if the labor wasn’t progressing I would like to try nipple stimulation or breaking my water first. She told me no, this it is bad for the baby, and that pitocin is less bad for the baby.  I want to let the baby’s cord finish pulsating before cutting it… she said absolutely not, because it increases the risk for jaundice. Then at the end of the appointment she walked out and I over heard her talking to a nurse about all the issues with my birth plan and how I must have just copied and pasted stuff from the internet.  Maybe I’m being overly sensitive, but it just seemed a little harsh and awkward.  What would you guys do?”

 

Everyone has been writing back to her that she needs to consider finding another doctor but she seems reluctant because she is already 32 weeks along and has had this doctor for her entire pregnancy.  What do you think?

 

Sincerely, 

Concerned Friend

 

My thoughts….this is a RED FLAG to walk right out of that doctor’s office and never look back.  This doctor CLEARLY does NOT practice evidenced based medicine.  Is switching birth attendants during the last few weeks of pregnancy a hassle and nuisance that a mother should not have to go through on top of all the other stresses she is probably experiencing?….ABSOLUTELY!  But is it absolutely imperative that she still switch practices even though it sucks big time….YOU BET IT IS!  I hope that any mother that finds herself in a similar situation truly understands the risk of staying with a birth attendant that does not support her birth plan just because she don’t want to a) hurt anyone’s feelings, b) think she can still have the birth you want without her/his support, c) go through the hassle of finding a new attendant (trust me, I know it is a huge hassle). 

 

The bottom line for me is this:

 

IT’S YOUR BIRTH!!  YOU ARE ONLY GOING TO BE GIVING BIRTH TO THAT CHILD/CHILDREN ONCE IN YOUR WHOLE LIFE!!  YOU, NOT YOUR BIRTH ATTENDANT, ARE THE PERSON THAT IS GOING TO HAVE TO LIVE WITH THE CONSEQUENCES OF A BIRTH THAT IS CONTROLLED BY SOMEONE ELSE!!  YOU HAVE THE RIGHT TO HAVE THE POSTIVE, EMPOWERING, SAFE, AND HEALTHY BIRTH THAT YOU DESIRE!!

 

For help writing a birth plan please check out: