The actual process of labor and delivery hasn’t changed since the inception of time. But how we in healthcare react and intervene has been scaled back quite a bit during the last century. As recently as the 1970s, a woman could expect to go to the hospital in labor, leave her companion in the waiting room, have her pubic area shaved, then receive an enema prior to delivery. Once the baby was born, the mother would only get to see and hold her baby during feeding times – otherwise the baby was whisked back to the nursery. Finally, she would be discharged from the hospital 3-5 days later if an uncomplicated vaginal delivery took place.
We’ve learned that this isn’t the best scenario to create a strong family bond, nor to create a positive birthing experience in the healthcare setting. The shaving, the enemas, and limiting the amount of time a mother can hold and bond with her baby have all but been eliminated. Presently, skin-to-skin care, breastfeeding, and unlimited time for mother and partner to bond with baby are the norm. However, there are still a few current obstetrical trends we in EMS need to stay up to date with.
Umbilical cord clamping, milking
Understanding the mindset of umbilical cord clamping requires going back to the 1930s – when laboring moms would be given nitrous oxide (aka, laughing gas), along with scopolamine, ketamine or opiates to alleviate their pain [11]. When the baby was born, it was under the influence, so to speak. Thus, began the practice of clamping the cord immediately to prevent any further medication infusion to a newborn.
Over time, this procedure became routine post-delivery even if the mother hadn’t received any medication – remaining in place long after nitrous oxide was discontinued. It should be mentioned that nitrous oxide administration during labor and delivery is making a comeback in other countries, but the dosage and duration of administration is very different than when it was common practice in the 30s [9,10].
Fast forward to 2015 when several studies suggested that umbilical cord milking is beneficial to premature babies born at less than 37 weeks gestation [1-3]. This paradigm shift then pushed the investigation into delaying cord clamping instead of, or in addition to, milking the cord.
In 2020, the American College of Obstetricians and Gynecologists (ACOG) released a statement recommending that cord clamping be delayed by at least 30-60 seconds in term and preterm births [4]. Other agencies, such as the American College of Nurse-Midwives, recommends delaying cord clamping for 2-5 minutes after birth [5].
Making delayed clamping our current practice has shown multiple benefits, including improved transitional circulation, an increase in red blood cell volume, decrease in fetal anemia, and a lower incidence of necrotizing enterocolitis and intraventricular hemorrhage. Additionally, until the cord is clamped, or stops pulsating on its own, the baby is still receiving oxygenated blood. Delaying cord clamping by even one minute infuses the newborn with an additional 80 mL of blood. A three-minute delay has been shown to provide a newborn with approximately 100 mL of blood. The initial breaths taken by the newborn facilitate placental transfusion.
Suctioning the newborn
The second big change we’ve seen in the world of obstetrics is the practice of suctioning a newborn. We were taught to suction when the newborn’s head was delivered and then after the entire body was delivered. Additionally, we were encouraged to continue to suction whenever the newborn sounded “wet.” In 2014, the Journal of Family Practice suggested we stop suctioning newborns, as studies found that that intervention created no benefit and was likely to cause bradycardia and apnea 6,7]. The alternative would be to wipe the newborn’s nose and mouth with a towel [6]. Most of those studies referred to children born in the presence of meconium. However, the medical teams noticed most meconium babies did very well with no aggressive suctioning required.
Eventually, this non-practice was extended to newborns without meconium present. The reasoning was that during the birthing process, as a mother is either squatting or lying on her back, the newborn is brought up and out of the vagina facing the mother’s chest. Amniotic fluid is forced out the newborn’s mouth as its chest is compressed during passage through the vaginal canal. Once the newborn is paced on the mother’s chest face down, drainage out of the mouth is additionally facilitated by positioning and gravity. This, combined with drying and stimulation, encourages the newborn to swallow what remains in their mouth. Typically, within a minute, the newborn will then draw in a first breath.
Both changes in childbirth and immediate newborn care came with some speculation and resistance, as any paradigm shift does. But if you think about how women delivered babies thousands of years ago, we are simply doing what seems to be inevitable in healthcare as being accepted as the best practice; go back to the basics.
This article was originally posted March 08, 2023. It has been updated.
References
- “Umbilical Cord Milking Versus Delayed Cord Clamping in Preterm Infants” Pediatrics July 2015, Volume 136, Issue 1.
- “Umbilical Cord ‘milking’ improves blood flow in preterm infants”. National Institutes of Health and Eunice Kennedy Shriver National Institute of Child Health and Human Development. June 29, 2015.
- NeonatalResearch.org “Delayed Cord Clamping or cord milking for the very preterm newborn….or both?” May 18, 2015.
- Delayed Umbilical Cord Clamping After Birth. Committee Opinion White Paper. Number 814 December 2020.
- “Don’t cut that umbilical cord too soon: A brief pause after birth could benefit most newborns by delivering them a surge of oxygen-rich blood.” Neergaard, Lauran
- “Suctioning neonates at birth: Time to change our approach” Journal of Family Practice August 2014 63(8): 461-462
- Neonatal Resuscitation: Updated Guidelines from the American Heart Association American Family Physician 2021; 104(4): 425-428
- “To Suction or Not to Suction” Neonatal Resuscitation Program Instructor Update.
- “Laughing gas helpful for labor pain, safe for baby, but ultimately most women switched to an epidural, study shows.”
- “Nitrous Oxide During Labor” American Pregnancy Association. Retrieved January 4, 2023.
- Nitrous oxide’s revival in childbirth. Contemporary OB/GYN Journal Volume 64, No. 05 May 10, 2018.
