Is there a reason why you have to cut the cord? why not leave it intact? Surely leaving the baby to an oxygen source if it has poor apgars would be the best course of action. In some hospitals they actually have special resuscitation tables that allow the baby to be resuscitated whilst cord attached as evidence has suggested this to be the best for baby. And in speaking to midwives where they don't have these 'special' tables they say there is no reason baby cannot be resuscitated while cord attached. Not judging just curious why poor apgars would make you sever a cord that is supplying an excellent supply of blood and oxygen, especially onside ring there is a lot of evidence and studies to support this now. Maybe paramedic education needs to be updated on this, actually I think in some hospital setting this needs to be updated also.
Hey Eenee, our practises are all evidence based and in terms of obstetric guidelines, we follow the recommendations of the RWH (in Vic). Our training is to cut the clamp and cut the cord after the baby is delivered. There was a thread a while ago which addressed the reasons a baby couldn't be resuscitated (in a pre hospital setting) with the cord still attached, but I don't even remember what the thread was originally about! A lot of it is based around OH&S; we often worked in very cramped conditions and if we did need to commence a full resuscitation on a neonate, our goal would be to do so in a clear area with room for not only up to 4 paramedics, but all of our equipment. Effective CPR requires a firm surface such as a floor or, in the case of a small child we often use a dining room table with clear access all sides. A resuscitation between mums legs on a bed or in a cramped bathroom etc. poses avoidable risks to both the operator (the paramedics) and the mum. It is very unlikely that a neonate would be in a rhythm which would be suitable for defibrillation, but if perchance the baby did require defib, this should never be delayed and could not be performed whilst attached to mum by the cord. Most parents (myself included!) would be distressed to see their newborn child receiving CPR and the logistics of performing a resus between mum's flailing legs, most likely with her reaching for her precious baby (I would be!) are impossible. We do often continue resus en route to hospital - if there are any signs of life, in children and certain other cardiac arrest situations - and obviously it would not be possible to transfer a baby to the ambulance with CPR in progress if he or she were still attached to mum by the cord.

In the case of a newly born healthy baby, I am very happy to delay clamping the cord. Heck, if your cord is long enough for you to safely hold your baby and walk to the stretcher, if bub is doing well and there are no signs of a PPH, I'm happy to not clamp the cord at all and record that this was the request of the mother! Our current guidelines state that clamping the cord provides stimulus for the neonate to breathe (remember, evidence based on the advice of the RWH!), but I would try tactile stimulation and happily use some oxygen or light respiratory support in the first instance before clamping the cord. This would take about a minute and most babies respond well to tactile stimulation (vigorous rubbing with a towel for example, we don't turn them upside down and spank bums!). If that first minute APGAR is poor, it is a good indication that bub is may require further support and it would be at this point that I am considering the logistics of a full resus - which hopefully won't be required.

The tables sound magnificent, and there must be good evidence surrounding the practice of leaving the cord intact in order for hospitals to use them. That evidence has not yet filtered through to Ambulance practice and will only occur on the recommendation of RWH. Do you know if they are used in Australian hospitals? Unfortunately, the fact that the environment we work in in pre hospital care is so uncontrolled that 'best practice' sometimes must be replaced by 'best possible practice' and for all the reason discussed above, a full resus with cord attached would not be possible in a pre hospital setting.

Each time a new recommendation is made by the RWH, our training is updated. Once the new guideline is passed, it can take around 12 months to get us all through the training program. The most recent change to our obstetric guidelines was breech delivery, which was altered around twelve months ago. We now perform a cesarian for all breech deliveries... No. No, we don't. (It's humour there... don't hang me for it!) Anyway, the point is, our training is updated when there is evidence our practice should change, but it does take time, both to approve the changes and to facilitate the training.

On a personal level, I'm all for delayed cord clamping and would be pleased to have this introduced into paramedic practice in the case of a neonate not requiring full resuscitation and where the mother was agreeable. Quite honestly, many paramedics have very little experience with childbirth or babies - young people who haven't had kids of their own, older blokes who stayed well away from the business end when their own children were born - and I think that there would be a lot of paramedics who simply wouldn't consider delaying clamping of the cord. Hmm.. maybe there is a professional challenge in this for me!