Delayed Cord Clamping Part Two: Working with Your Provider

Now that we've taken a look at the evidence supporting delayed cord clamping, let's have a chat about incorporating it into the birth wishes and having a discussion with the care provider, if need be.  Despite the World Health Organization's strong recommendation for delayed cord clamping at all births ("Delayed Clamping"), many care providers in the greater Philadelphia appear to continue to be quick with the snipping.  As we often discuss in birth classes, policies and practices quite frequently get handed down to students without much question about their basis (Gaskin).  Unfortunately, many policies are also enforced despite a lack evidence supporting their use (Trochim).  Still other practices remain in place because of the desire to keep things moving along in a process that often requires a lot of "just waiting."  The lack of delayed cord clamping can fall into all of these categories.  

As their is greater awareness about the importance of stem cells, we've begun questioning the practice of immediate cord clamping even more.  Is it more important for babies to have these stem cells at birth or more important to save them for a potential sibling down the road?  This has brought up other questions related to the benefits of the baby receiving much of his own blood back into his body at the moments following birth.  The benefits have been discussed in the prior post so let's assume now that a couple is trying to exert their legal right to evidence-based care in relation to delayed clamping ("The Rights").  

It's always helpful to approach a provider about their common practices, whether it be cord clamping, episiotomies, manual rotation of the baby's shoulders at birth, etc. before labor.  Despite this being another legal right for a laboring woman, most interventions are not discussed with a couple before birth, unless an out-of-hospital birth class is being taken.  Yet, even then, as educators, we are often limited by time and scope in discussing every possible intervention in depth.  Anyway, I digress.  Back to the point, a conversation during pregnancy can do wonders in terms of helping a couple to assess if they've chosen the right provider for them, if they feel they have a trusting relationship with their doctor or midwife, and what their provider's common practices really are.  However, as Sheila Kitzinger states, "...you may have to develop new social skills to create a satisfactory dialogue with those who care for you." (The Complete Book of Pregnancy and Childbirth).  Understanding that the answer not only lies in response but in the body language, the willingness to discuss, and the answer to the question "Why?"

Stating your request clearly and concisely (Kitzinger), while fully clothed and seated in an upright position, is key to an open dialogue.  If your request is met with reluctance or hesitation, you can simply restate your wishes.  It's also never a bad idea to ask a provider for the research they are using to back their practice.  I have, unfortunately, had several clients who did just that and were told by their provider that they did not have the research.  Waiting until labor to voice requests can put a woman in a very vulnerable position, making it more difficult for her to voice her needs clearly and assertively.

After a discussion with your provider, it's always a great idea to ask about the way that other providers in the practice carry out the same routine.  This will help in knowing what to be prepared for in the moment, should a different provider be present during the labor, and also helpful in getting an overall feel for the practice.  If your provider has okay'd a request that you've made, it may be helpful to ask them to make note of that in your chart or to have them initial it on a list of your birth priorities.  

In the moment, while mom is pushing her baby out or, in the case of a cesarean, while the baby is emerging, partners can take an active role in continuing to advocate for what had been requested.  Reminding a provider that delayed clamping is a priority for you can help ensure that things are done the way you'd prefer.  A doula or other birth support person can also remind the partner at this point to advocate for the birth wishes.  

With clients, I've been in situations where they've requested delayed clamping only to have the doctor or midwife wait 30 seconds before clamping the cord.  (On the flip side,I've also been in situations where the provider has asked the client if they were ready for the cord to be clamped before doing anything, which I've found to be very respectful.)  One thing that I've found helpful in ensuring that the cord is allowed to finish pulsating is when client's have requested that the cord not be clamped or cut until the placenta is birthed.  This provides a bit more insurance that the baby will receive as much blood back into his body as possible.  

In a hospital, if there is a concern about the baby's well-being, the baby will be taken to the warmer for the pediatrician or neonatologist to evaluate.  In a home birth, the vast majority of the time, the baby is able to be assessed while still on mom, allowing the cord to provide a back-up of blood and nutrients to the baby.  Unfortunately, in the hospital scenario, cord clamping does happen immediately so that the baby can be checked out.  However, in your average healthy birth, the baby is able to be fully assessed while on mom, cord intact.  A move is slowly made towards a family-centered cesarean yet the hospitals in our area still have a ways to go.  Unfortunately, at this point, I don't know of any obstetrician who will allow for delayed cord clamping outside of 15 to 30 seconds, during a cesarean section.  

The client is the catalyst for change and it's important that we all remember this.  The more informed, the more actively participating, and the more knowledgeable a client is, the more opportunity they have to ask questions and request evidence-based care.  As much of a fan of the written birth wishes as I am, nothing can replace a face-to-face conversation between a client and their provider.  Having a birth in which you are as in control of the process of decision making as possible, quite often makes for a very positive experience.  Your birth, your baby, your body.  

Sources
"The Rights of Childbearing Women." Childbirth Connection. Childbirth Connection. 2006. Web. 14. Oct. 2014.

"Delayed Clamping of the Umbilical Cord to Reduce Infant Anaemia."  WHO.  n.p. 2014. Web. 5 Oct. 2014.

Gaskin, Ina May. Birth Matters: A Midwife's Manifesto. New York: Seven Stories Press, 2011. Print.

Kitzinger, Sheila. The Complete Book of Pregnancy and Childbirth. London: Dorling Kindersley Limited, 2003. Print.

Trochim, William, Ph.D., Cathleen Kane, M.P.A., Mark J. Graham, Ph.D., and Harold A. Pincus, M.D. "Evaluating Translational Research: A Process Marker Model." CTS Journal 4.3 (2011): 153-162. Web. 14 Oct. 2014