I agree Soo that the very short cord holding up the final expulsion is
likely very rare. I can recall one situation at a homebirth where I was
supervising a very new midwife. First stage was uneventful. Second stage
was a bit longer than we might have anticipated, but this was a big baby
and a first homebirth (multip). The birth of the head was almost
"textbook" shoulder dystocia. And, we are now getting bradycardia.  I am
ready to move into "hip check" position to take over if the primary
midwife is not able. No cord says she. Ok, then what are you going to do
to get a shoulder. Well, she says, there is a shoulder just sitting
here. I shifted to have a better look and she was right, the anterior
shoulder was there, but the woman could not budge that baby. And around
the neck was the cord three times so tightly it almost looked and felt
like skin folds. She clamped and cut and the baby flew out. He did need
a little resuscitation but was crying lustily before the woman's partner
had even finished spelling out their name to the 911 dispatcher. We
cancelled the call.

Susan

***************************************************
Susan James
Directrice
Programme de formation des sages-femmes
Université Laurentienne
Sudbury, ON 

>>> [log in to unmask] 01/24/03 07:13AM >>>
I agree with your point re a short cord marlene, but the baby isnt
breathing till the lungs are expanded, is it? I must admit that my fear
here is that the cord is cut, and then there is a shoulder dystocia - at
that point, the only oxygenation the baby could get (from the cord
blood) is denied it.

I do see a need to cut the cord if it is very short and is holding up
the birth at the same time as the uterus is involuting and cutting off
placental blood supply, as the placenta shears - but I think this is a
very rare occurance. In fact, I wonder if the physiology of birth
mitigates against the instinct to cut the cord? Or am I completely off
the wall here?

all the best

soo

>>> [log in to unmask] 01/23/03 08:01pm >>>
This is  a very interesting discussion and it will be good to see if
there is any evidence.

It is not going to be easy to measure the outcomes and  produce hard
data on this subject.

 Having delivered several babies with very very  tight cords and
having been taught the same as the rest of you i did what i was
taught 'clamp and cut'. Thinking about this procedure leads me to
believe that there is something basic and instinctive about wanting
to release the choking pressure of a tight cord from the infants
neck.  No problem handling the loosely wrapped cord but the tight one
is very different.

The risk of having a short cord, wrapped round 3 times or so
(tightly) and leaving it in situ until the woman delivers the rest of
her baby could cause premature shearing of the placenta....risk
management issue. Ethically i don't think RCTs have any chance of
approval for the type of study required to give grade A evidence on
birthing women.


i think it is an area of great interest and it would be good to test
the natural instincts of midwives when faced with different types of
cord problems. However, i think this research could be conducted
using technology and video-taping midwives in simulation
activities........ You could collect reasonable evidence doing it
this way

Best of luck



Dr. Marlene Sinclair
Senior Lecturer in Midwifery
Course Director P/Grad Dip/MSc Advanced Nursing/Midwifery
University of Ulster at Jordanstown
Newtownabbey
BT37 0QB
e-mail [log in to unmask] 
Tel 02890 368118
Fax 02890 368208