Why??

[~TT40~]

the really fast birth, mainly really fast 2nd stage (pushing) can cause them to become contused (have a blue bruised face) because of the changes in pressure, which makes them greater risk of being jaundice (high bili levels) and heamorrage, but that would happen anyway, i wouldnt think delayed (or not) cord clamping would make a difference. would it? maybe it does, Im not sure.

[jellybean88]

That's interesting came out in 3 pushes (5min) and was very jaundiced that's why I've been hesitant on delayed clamping I thought if there more jaundiced they would get taken after a couple days for phototherapy

[Traveller]

so far the evidence has shown a slight, but not statistically significant, increase in jaundice in babies with delayed cord clamping. However after babies have delayed cord clamping they are less likely to become anaemic by 6 months of age and this is generally considered to be more of an advantage than the slight risk of jaundice. Basically if a child is going to become extremely jaundiced then this is likely to be the case regardless of how quickly the cord is clamped. And because I'm still in uni mode here's the reference: Cook, E 2007, 'Delayed cord clamping or immediate cord clamping?: a literature review', British Journal Of Midwifery, 15, 9, p. 562, CINAHL with Full Text, EBSCOhost, viewed 11 November 2012.

[willow5]

By removing their oxygen source prematurely. If baby is flat it is even more important that they remain attached to their cord and life source.

I would agree with this too. I'm not a medico though. To me it sounds like common sense.

[nickle730]

A pulsating cord is NOT an indication that a neo nate is receiving adequate oxygen to prevent ischaemia (tissue death due to insufficient supply of oxygen) of brain tissue. Current resuscitation guidelines (which are determined by the Australian Resuscitation Council) state that an untrained person delivering first aid should assume that the non breathing patient is also pulseless. The reason for this is that most panicked bystanders can't find a pulse in a crisis or imagine that they find one which is not actually present. If bub is not breathing, you should assume he also does not have a pulse - so that inadequate supply of oxygen being delivered through the cord will not be being delivered to any vital organs if the heart is not pumping. If bub still has a pulse but is receiving an inadequate oxygen supply, not only will he sustain ischaemic damage to his vital organs, his heart will stop if an adequate supply of oxygen is not established - either with effective EAR or the onset of spontaneous respiration.

If bub is not breathing spontaneously and respiration does not commence with tactile stimulation or clamping of the cord, CPR must be performed. The first APGAR is recorded at 1 minute and resuscitation should commence at this point in a non breathing neo nate who has not responded to attempts to stimulate spontaneous respiration.

We're not talking here about a lovely planned homebirth with an experienced MW in attendance or a nice controlled hospital delivery with MW's, Ob's and NICU around the corner - this particular thread is discussing an unexpected and unplanned delivery in an uncontrolled and unprepared environment. Whilst you may prefer delayed cord clamping (I delayed the clamping of my own children), if you are sitting on the floor of your toilet with a floppy, blue, non breathing baby between your legs a minute or two after delivery... delaying clamping will be the least of your concerns.

If your baby delivers unexpectedly at home and breathes spontaneously - leave the cord alone. If your baby is flat and non breathing, do not assume that the cord will continue to provide adequate oxygenation after delivery.

[Eenee]

None of my babies even had one slight bit of jaundice and we didn't cut the cord until ages after and well after placenta was passed.

[jellybean88]

These were all baby's crying straight away and feeding straight away which is good

[e_p]

If a delivers unexpectedly at home and breathes spontaneously - leave the cord alone. If your baby is flat and non breathing, do not assume that the cord will continue to provide adequate oxygenation after delivery.

I didn't think anyone here suggested they would assume that? While the cord remains intact, the baby can still receive *some* oxygen while attempts are made to assist a flat baby to commence breathing. I know a midwife who trains paramedics in emergency childbirth and she instructs them to leave the cord intact for that very reason.

[HotI]

If bub is not breathing spontaneously and respiration does not commence with tactile stimulation or clamping of the cord, CPR must be performed. The first APGAR is recorded at 1 minute and resuscitation should commence at this point in a non breathing neo nate who has not responded to attempts to stimulate spontaneous respiration.

i appreciate the info you have provided, but why not commence cpr while the cord remains attached and the baby is still potentially receiving oxygenated blood from the cord?

[PumpkinZulu]

I guess what confuses me is why cut the cord at all in that situation? There is still *some* oxygen being passed through, it's not like it's doing any harm, is it? Why can't you just do (as HotI said) all CPR efforts etc with an attached cord?

[Traveller]

I guess what confuses me is why cut the cord at all in that situation? There is still *some* oxygen being passed through, it's not like it's doing any harm, is it? Why can't you just do (as HotI said) all CPR efforts etc with an attached cord?

The main issue is that it is very hard to perform CPR on an infant whilst it is attached to the mother as you need a flat surface and space to do that. So in an emergency situation the cord will most likely be but to allow access to the infant if someone is available (other than the mother) to commence CPR. If the mother is home by herself then CPR can be commenced between her legs if she is focussed enough to do it. However an OB in (I think) the UK has designed a resuscitation table that can be moved to a close proximity to the mother to allow CPR without clamping and cutting the cord but these devices are few and far between.

[willow5]

I guess as well the emergency operator could be assuming that the person making the call isn't trained in CPR, or isn't calm and focussed enough to perform it properly so maybe clamping the cord is a more straight forward option to possibly stimulate breathing.

I know that in all the shows I've seen(not that I've seen them all ) even when the baby birthed unexpectedly is screaming and is clearly heard by the operator they have still instructed to clamp the cord. This is surely unnecessary, and some simple re-training or change of process, policy procedure etc wouldn't be hard to do. I really think it's just overlooked and still old school like most OBs.

[nickle730]

HotI, it's just not practical. If you disregard the stimulation to the respiratory drive associated with cutting the cord and assume that the baby will require active resuscitation (ie. CPR) you can't adequately perform CPR on a baby which is still attached to mum. Usually, if a baby is delivered unexpectedly at home, the delivery takes place either in the toilet or on the bed. There is simply not enough room to get a paramedic (usually two, and if a baby is being resus'd you'll soon have a crowd of them) plus mum into the cramped room. Position, both of the operator and the patient, is paramount when performing CPR in order to position the airway correctly and to avoid injury to the paramedic. CPR needs to be performed on a firm surface in order to achieve the correct depth of chest compression - a bed does not provide enough resistance. Add to all of this that mum will most likely be panicked at this point and the last thing you need is flailing legs and grabbing hands. If possible, I will always place a baby or a small child on a table at waist height (dining room table is perfect) when performing CPR in order to provide clear access to the patient for myself and my colleagues and to avoid further injury to my already-screwed back.

As far as the physiology of performing CPR with the cord still attached, I wonder (but I don't know) how much of the circulating blood volume would be lost to the cord with each compression as opposed to being delivered to bub's vital organs. There's no point pumping blood back up the cord towards mum. I don't know if any research has been conducted which could answer that.

eutra_phalia, it is very reasonable to leave the cord intact to the point of the 1 minute APGAR (and longer if the APGAR indicates a robust baby), but a poor APGAR indicating active resuscitation is required necessitates that the cord is clamped and cut. I guess there is a 'grey area' where a paramedic may feel that the baby requires respiratory support only (ie. has an adequate pulse but is non breathing or ventilating inadequately) where he or she may leave the cord intact for an additional minute or so in the hopes that bub will pick up whilst they assist ventilation. If the baby is being effectively ventilated, there is no clinical need for whatever oxygen which might still be delivered through the cord - oxygen is being delivered via manual ventilation of the lungs and oxygen saturation (how much oxygen is in the patient's blood) will be measured to determine whether supplemental oxygen (as opposed to room air) is required. Usually, if the baby is flat at the 1 minute APGAR, one paramedic will begin ventilating/CPR whilst the other clamps and cuts the cord. The baby will then be moved to a position of better access for the reasons I have stated above.

[PumpkinZulu]

The main issue is that it is very hard to perform CPR on an infant whilst it is attached to the mother as you need a flat surface and space to do that. So in an emergency situation the cord will most likely be but to allow access to the infant if someone is available (other than the mother) to commence CPR. If the mother is home by herself then CPR can be commenced between her legs if she is focussed enough to do it. However an OB in (I think) the UK has designed a resuscitation table that can be moved to a close proximity to the mother to allow CPR without clamping and cutting the cord but these devices are few and far between.

Ahhhh okay. See I was assuming placenta was already out (silly assumption, didn't think, DD's came quickly so I applied that to every situation, oops!)

[e_p]

nickle - thanks for clarifying - I appreciate the info lots for me to think about and look into further

[HotI]

argh, i lost a big reply i have been working on

for now,

Neonatal Resuscitation with Intact Umbilical Cord
by Angie Evans

© 2012 Midwifery Today, Inc. All rights reserved.

[Editor’s note: This is an excerpt of an article which appears in Midwifery Today Issue 102, Summer 2012.]

Abstract: This paper investigates neonatal resuscitation with the umbilical cord intact. Research confirms numerous immediate and long-term benefits to leaving the cord intact while performing neonatal resuscitation in both term and preterm neonates, while doing no harm. Current neonatal resuscitation guidelines from around the world are discussed with respect to the cord. Methods for incorporating an intact cord into standard resuscitation procedures are explored.

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In many birth places, including birth centres, hospitals and home, neonatal resuscitation equipment is set up out of the way of the birth area. In hospitals, assessment and resuscitation of newborns almost always occurs on a large table across the room and far from mother. Obviously this requires severing the umbilical cord. In addition to the physiological advantages of leaving the cord intact, keeping the baby close to mother reduces maternal stress—and surely infant fear as well (Strange 2009)—and helps facilitate bonding (Wright 2011). Term and preterm neonates are safer and healthier when neonatal resuscitation includes delayed cord-clamping. Clamping, whether the cord is cut or not, immediately halts placental transfusion. Clients who ask for delayed cord-cutting could be counseled to request delayed clamping.

During pregnancy, the umbilical cord provides oxygen and transfers blood between the placenta and the baby. Nature has perfectly designed a placental transfusion to carry the blood through the cord and into the newborn baby. If the cord is intact, then oxygenation continues after birth until the newborn lungs have transitioned to air; a process that takes 30 to 90 seconds in a full-term infant. If a newborn isn’t breathing independently, the placenta is nature’s neonatal life-support system. Newborns are not simply tiny adults; the newborn heart can beat for 20 minutes or longer despite anoxia and the brain can tolerate lack of oxygen for this duration of time (Resuscitation Council [UK] 2001; Frye 2004; World Health Organization 1999). Newborns cope well with hypoxia but struggle with hypovolemia. At the moment of birth, 30 to 50% of the baby’s blood volume is in the placenta, and immediate clamping deprives the baby of that blood. Adults are in perilous danger of hypovolemic shock and receive blood transfusions at 15 to 30% blood loss.

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References:
•Frye, A. 2004. Holistic Midwifery; Care during Labor and Birth, Vol. II. Portland: Labrys Press.
•Resuscitation Council (UK). 2001. Resuscitation at birth, the newborn life support provider course manual, 2nd ed. London: Resuscitation Council (UK).
•Strange, K. 2009. “NRP for midwives certification class.” Seattle, WA.
•World Health Organization (WHO). 1999. Basic Newborn Resuscitation Practical Guide, Revision. Geneva: World Health Organization Safe Motherhood Unit.
•Wright, A. 2011. “BASICS: Bedside Assessment, Stabilisation and Initial Cardiorespiratory Support.” Liverpool Women’s NHS Foundation Trust.