Margi Coggins, CNM, MSN, IBCLCJudith Mercer, PhD, CNM, FACNM

DELAYED CORD C LAMPING Advantages for Infants

T

DELAYED CORD C LAMPING Advantages for Infants

pensate and appear well immediately after birth. Recent studies

that included long-term follow-up of infants with immediate

and delayed cord clamping have begun to reveal benefi ts over

time, especially in the area of iron acquisition.

PHYSIOLOGIC FOUNDATION FOR THE PRACTICE OF DELAYED CORD CLAMPINGBefore birth, approximately one-third of the fetal-placental

blood volume is in the placenta of a term infant (Wardrop &

Holland, 1995). The cardiac output (blood out of the heart in

one minute) to the lung before birth at term is only about 10

percent of the fetus’ blood volume (Rasanen, Wood, Weiner,

Ludomirski, & Huta, 1996). Immediately at birth, the cardiac

output to the lung must increase to 45 percent to achieve air

breathing and to wean from the placenta as the site of gas ex-

change. This process demands increased blood volume, espe-

cially for the lung. When the umbilical cord is clamped after

three minutes after birth, or after pulsations cease, and the baby

is positioned below the level of the placenta, a term infant will

receive approximately 20 to 35 mL/kg more blood than with

his article reviews the current theory used to explain

why delayed cord clamping offers an advantage to

infants, examines the recent evidence and provides clinical

recommendations for nursing practice for labor and delivery

nurses. Except for references to physiology and clinician at-

titudes, most citations are from randomized-controlled trials

(RCTs) and meta-analyses, the highest level of evidence avail-

able on a topic (U.S. Preventive Services Task Force, 1996).

BRIEF HISTORY OF CORD CLAMPINGIn 1801, Erasmus Darwin wrote the following in Zoonomia:

“Another thing very injurious to the child, is the tying and cut-

ting of the navel string too soon; which should always be left till

the child has not only repeatedly breathed but till all pulsation

in the cord ceases. As otherwise the child is much weaker than

it ought to be, a portion of the blood being left in the placenta,

which ought to have been in the child.”

The question of when to clamp and cut the umbilical cord

has been debated for many years. In the United States, delayed

cord clamping was the standard care between the 1930s and

1960s and was advocated by well-respected obstetricians (Bluff,

2005; Chaparro & Lutter, 2007). Over time, the practice of de-

layed cord clamping became viewed as dangerous or at least

inconvenient, without adequate scientifi c evidence applied to

the subject (Chaparro & Lutter).

In more recent times, the haste to “hand-off” even a vigor-

ous infant to the pediatric staff results in immediately clamping

and cutting the umbilical cord. This practice can lower the in-

fant’s blood volume as much as 30 percent and red cell volume

by as much as 50 percent (Yao, Moinian, & Lind, 1969). Even

with this decrease in blood volume, most healthy babies com-

TThe question of when to clamp and cut the umbilical cord has been debated for many years

immediate cord clamping (Yao et al., 1969). In a 3-kg term in-

fant, this amounts to 60 to 105 mL of whole blood and has a

positive effect on iron status. With delayed cord clamping, the

infant receives not only more blood volume, but also more red

blood cells and hematopoietic stem cells than when the cord

is cut immediately. In addition, circulation from the placenta

persists for a few minutes after birth and the infant continues

to get oxygen through the umbilical cord. When oxygen-rich

blood is allowed to course through the intact cord, the newly

born infant is afforded a protected time of adjustment to his

new world and his new way of breathing. A delay in clamp-

ing the cord facilitates a gentle physiologic transition that likely

benefi ts all neonates and may be critical to especially vulner-

able infants.

BENEFITS TO TERM INFANTSThe main benefi t of delayed cord clamping found in recent re-

search is the reduction of anemia of infancy. A 2004 systematic

review of term infants showed that delayed cord clamping, es-

pecially in anemic mothers, increased infants’ hemoglobin sta-

tus and reduced the risk of anemia at two to three months of

age (van Rheenen & Brabin, 2004). A meta-analysis of 15 con-

trolled trials (both randomized and nonrandomized) showed

improved hematocrit and ferritin for up to six months after

birth in term infants who had delayed cord clamping (Hutton

& Hassan, 2007).

Four recent RCTs found higher newborn hematocrit and

hemoglobin levels within the fi rst 24 hours after birth without

adverse outcomes in the infants who experienced delayed cord

clamping (Ceriana Cernadas et al., 2006; Chaparro, Neufeld,

Tena Alavez, Eguia-Liz Cedillo, & Dewey, 2006; Emhamed, van

Rheenen, & Brabin, 2004; Gupta & Ramji, 2002). Two of the

studies found signifi cantly fewer signs of anemia at three and

six months in infants with delayed cord clamping. Gupta and

Ramji, for example, found that infants with immediate cord

clamping were 7.7 times more likely to be anemic three months

after delivery.

In the United States, pediatric anemia has remained a prob-

lem affecting approximately 9 percent of toddlers and is found

in greater numbers among poor and minority children, those

with elevated blood lead levels and those who were born pre-

mature or small for gestational age (Looker, Dallman, Carroll,

Gunter, & Johnson, 1997). Even with the advantages of living in

a developed country, U.S. children with anemia suffer from per-

manently decreased cognitive and motor function (Grantham-

McGregor & Ani, 2001). In a longitudinal study of Costa Rican

children with and without anemia of infancy, Lozoff, Jimenez,

and Smith (2006) found more behavioral problems and lower

IQ scores at ages 15 to 19 years in the children who had anemia

of infancy, even when it had been successfully treated with iron.

Choosing to delay cord clamping is a simple intervention that

could improve the iron status of many American infants. Pre-

venting anemia and increasing iron stores in babies may help

prevent cognitive impairment that lingers well beyond infancy

(Yager & Hartfi eld, 2002).

BENEFITS TO PRETERM INFANTSPreterm infants appear to derive several benefi ts from delayed

cord clamping. Recall that for term infants about a third of

their fetal-placental blood volume is in the placenta. For pre-

term infants, about half of their fetal-placental blood volume

is in the placenta at any point in time (Wardrop & Holland,

1995). Immediate cord clamping leaves preterm infants with

only about half their total blood volume. They also have mul-

tiple blood draws during their neonatal intensive care unit

stays, exacerbating the hypovolemia of immediate cord clamp-

ing. The protocol for most studies on preterm babies calls for a

delay in cord clamping for only 30 to 45 seconds while holding

the baby in a warm towel either at the level of the placenta

or approximately 10 to 15 inches below the perineum (see 10

studies reviewed in Rabe, Reynolds, & Diaz-Rossello, 2008).

In that short amount of time, infants may experience an 8

percent to 24 percent increase in blood volume (Aladangady,

McHugh, Aitchison, Wardrop, & Holland, 2006; Narenda,

Beckett, & Kyle, 1998). This increase in blood volume trans-

lates to better respiratory function, less intraventricular he-

morrhage (IVH) and possibly less sepsis for preterm infants

(Rabe et al., 2008).

Better Hemodynamic ParametersA meta-analysis of 454 preterm infants (born before 36 com-

pleted weeks gestation) found that delayed cord clamping

improves hematocrit levels, reduces the need for blood trans-

134 © 2009, AWHONN http://nwh.awhonn.org

Margi Coggins, CNM, MSN, IBCLC, is a doctoral student at the Univer-sity of Rhode Island, Kingston, RI, and a nurse-midwife at Cambridge Hospital and Birth Center, Cambridge, MA. Judith Mercer, PhD, CNM, FACNM, is a clinical professor at the University of Rhode Island, Kingston, RI, an adjunct professor of pediatrics at Brown University, Providence, RI, and a research scientist at Women and Infants Hospital, Providence, RI. Address correspondence to zibida@rcn.com.

DOI: 10.1111/j.1751-486X.2009.01404.x

• Ample evidence suggests that delayed cord clamping can benefi t preterm and term infants.

• Incorporating delayed cord clamping into day-to-day practice may require a change of thinking on the part of many health care providers.

• Nurses in the obstetric and neonatal setting have a role to play in incorporating this into practice.

Bottom Line

April May 2009 Nursing for Women’s Health 135

fusions during hospital stay, improves blood pressure and in-

creases circulating blood volume (Rabe et al., 2008). In a study

of 37 “near term” preterm infants (34 to 36.6 weeks gestation),

babies had higher hemoglobin levels if their cords were cut

after three minutes (Ultee, van der Deure, Swart, Lasham, &

van Baar, 2008). Hemoglobin was consistently higher both at

one hour of life and at 10 weeks of life. Very preterm infants

whose cords were milked before cutting, an alternative to de-

layed cord clamping, also needed fewer transfusions (Hosono

et al., 2008).

Better Respiratory FunctionPreterm infants with delayed cord clamping required less sur-

factant and fewer days of oxygen and ventilator support (Kugel-

man et al., 2007). There was no difference in cord blood pH,

Apgar scores or body temperature upon admission between the

experimental and control groups in these studies, so resuscita-

tion was not compromised by the brief wait.

Tissue ProtectionDelayed cord clamping appears to protect very-low-birth-

weight (VLBW) infants from IVH. A recently published meta-

analysis reveals that IVH occurred more frequently in infants

with ICC (29 percent) compared with infants with delayed

cord clamping (16 percent) (Rabe et al., 2008). Delaying cord

clamping also improves cerebral oxygenation (Baenziger et al.,

2007). Mercer et al. (2006) demonstrated gender differences in

the development of late-onset sepsis. Male infants with delayed

cord clamping had signifi cantly lower numbers of late-onset

sepsis. Some studies have shown a tendency to less-necrotizing

enterocolitis with delayed cord clamping (Rabe et al.).

HYPOTHESES BEHIND BENEFITSBetter Blood VolumesBlood performs many functions for the transitioning infant. At

birth, blood rushes into the tiny capillaries in the lungs needed

to adequately open the alveoli and creates an osmotic gradient

suffi cient to pull fl uid from the lungs into the blood (Jaykka,

1958; Mercer, Skovgaard, & Erickson-Owens, 2008). This, in

turn, supplies all organs with oxygen, regulates blood pres-

sure and vascular resistance (Wallgren & Lind, 1967). Having

too little circulating volume and too few red blood cells could

cause ischemia in the most vulnerable tissues—brain, gut and

lung (Mercer & Skovgaard, 2002). Having too little blood vol-

ume can also lead to hypotension. Hypotension has been as-

sociated with poorer outcomes in premature infants, including

increased IVH and sepsis (Hall, Kronsberg, Barton, Kaiser, &

Anand, 2005). Mercer et al. (2006) found that VLBW infants

who developed sepsis generally had lower hematocrit levels at

birth. Receiving more blood volume at birth could possibly

reduce the incidence of illnesses associated with hypovolemia

and hypotension.

Stem CellsPreterm infants are known to have very high levels of hemat-

opoietic stem cells circulating in their blood (Haneline, Mar-

shall, & Clapp, 1996), higher than the already stem cell-rich

blood of term infants. Evidence suggests that hematopoietic

stem cells may migrate to and help repair damaged tissue and

can differentiate into such cells as nerve cells and cardiac cells,

depending on the need (Rojas et al., 2005). Meier et al. (2006)

performed a study in which 7-week-old rats’ carotid arteries

were severed on one side to cause ischemic injury in the brain.

Half of the rats were given human cord blood stem cells by in-

jection into their abdomens within 24 hours after the injury. At

21 days of age, these rats had normal walking behavior and no

cerebral palsy when compared with the rats that did not get the

stem cells. This demands further study to see if human perina-

tal hypoxic injuries may be prevented or repaired by stem cells.

Delayed cord clamping allows more placental-infant transfu-

sion of stem cells.

EVIDENCE SURROUNDING POTENTIAL RISKSDespite the benefi ts of delayed cord clamping as reviewed

above, practitioners sometimes feel uncomfortable waiting

to cut umbilical cords. They may cite increased risks of poly-

cythemia or jaundice, or remember reading something about

early cord clamping featured in active management of the third

stage of labor. Next, we examine the evidence regarding pos-

sible risks of delayed cord clamping.

PolycythemiaAlthough often cited as a cause for polycythemia, delayed

cord clamping has not been associated with symptomatic

polycythemia in any systematic review and meta-analysis of

premature infants or term infants (Hutton & Hassan, 2007;

McDonald & Middleton, 2008; Rabe et al., 2008). Initial hema-

tocrits and measurements of blood viscosity were often high-

er in delayed cord clamping infants, but no infants required

treatment (Hutton & Hassan; McDonald & Middleton). Sev-

eral authors have suggested taking no action in the absence of

symptoms, after seeing no ill effects in infants with hematocrits

of 65 percent to 70 percent (Chaparro & Lutter, 2007; Grajeda,

Perez-Escamilla, & Dewey, 1997; Ultee et al., 2008). Hutton and

Hassan found that asymptomatic polycythemia occurred in

both early and late clamping groups, suggesting that it could be

a normal fi nding for some infants. In addition, polycythemia

is often transient. Shohat, Merlob, and Reisner (1984) studied

50 term infants with cords clamped by 30 seconds; 20 percent

of infants had hematocrits over 65 percent at one hour of life,

but that number dropped to 2 percent at 12 to 18 hours. The

underlying causes for symptomatic polycythemia—maternal

gestational diabetes, hypertension and small for gestation in-

fants—are usually exclusionary criteria in cord-clamping stud-

ies (Hutton & Hassan; McDonald & Middleton; Rabe et al.).

136 Nursing for Women’s Health Volume 13 Issue 2

JaundiceLike polycythemia, jaundice is often attributed to delayed cord

clamping with little evidence of causality. Hutton and Hassan

(2007) found no signifi cant difference in serum bilirubin levels

in their systematic review and they found no increased risk of

jaundice in the fi rst 24 to 48 hours of life (eight trials, n=1,009

term infants). By contrast, in another systematic review of

1,762 infants from four trials, McDonald and Middleton

(2008) found an increased risk of need for phototherapy. How-

ever, this result was based mostly on fi ndings from McDonald’s

unpublished doctoral thesis completed in 1996 (n=961) when

the criteria for initiating phototherapy may have been differ-

ent. Also, if the pediatric staff were not blinded to the infants’

groups, bias may have been introduced. Because the study is

unpublished, this information is not known. In addition, the

need for phototherapy for jaundice should be determined by

levels of total bilirubin and hours of life of the newborn, rather

than visual determination by a clinician (American Academy of

Pediatrics, Subcommittee on Hyperbilirubinemia, 2004). Using

current guidelines instead of those at work in the 1990s may

have altered the fi ndings.

Postpartum HemorrhageAlthough initial guidelines had suggested that early cord

clamping be included in a protocol to reduce postpartum hem-

orrhage in mothers, current evidence suggests time of clamp-

ing does not alter maternal blood loss (Ceriana Cernadas et al.,

2006; Chaparro et al., 2006; McDonald & Middleton, 2008; van

Rheenen, de Moor, Eschbach, de Grooth, & Brabin, 2007). The

International Confederation of Midwives and the International

Federation of Gynaecology and Obstetrics (FIGO) have advo-

cated waiting until pulsations cease before cord clamping to

prevent newborn anemia since 2003 (FIGO, 2006). The Ameri-

can College of Obstetricians and Gynecologists (ACOG) does

not have an opinion paper on timing of cord clamping per se,

but does mention in a recent Committee Opinion that cord

blood banking collection should not interfere with the timing

of umbilical cord clamping (ACOG Committee on Obstetric

Practice, Committee on Genetics, 2008).

DELAYED CORD CLAMPING DURING COMPLICATED BIRTHSEven providers dedicated to delayed cord clamping could list

situations in which they would forgo delayed cord clamping.

But there is signifi cant evidence that many of those very situ-

ations may have better outcomes with delayed cord clamping,

including tight nuchal cords, infants needing help to breathe

and preterm infants.

Tight Nuchal CordIn the United States, the most familiar example of a hypovo-

lemic term baby is one born with a tight nuchal cord cut before

the shoulders deliver. As a result of hypovolemia, there are in-

creased risks to the newborn when the cord is clamped before

the shoulders are delivered, such as anemia, hypoxic ischemic

encephalopathy, cerebral palsy and possibly death (Mercer,

Skovgaard, Peareara-Eaves, & Bowman, 2005). Many deliv-

ery providers incorporate the somersault maneuver into their

practice and allow trapped blood to return to the stunned in-

fant before cutting the cord (see Figure 1) (Mercer et al., 2008).

Lowering the infant below the perineum after birth can help

to reperfuse the infant with the approximately 60 to 80 mL of

blood trapped in the cord and placenta (Mercer et al.). Making

a habit of not cutting the cord before the shoulders deliver can

also avoid the potentially devastating combination of a tight

nuchal cord coupled with shoulder dystocia (Flamm, 1999; Iffy

& Varadi, 1994).

Infants Requiring ResuscitationMidwives who deliver infants in birth centers and at home

most often leave the cord intact during resuscitation (Mercer,

Nelson, & Skovgaard, 2000). They do this so that the infant can

continue to receive oxygen via the umbilical cord while waiting

A delay in clamping the cord facilitates

a gentle physiologic transition that likely

benefi ts all neonates

April May 2009 Nursing for Women’s Health 137

Preterm InfantsFrom all the evidence reviewed, preterm babies benefi t the

most from delayed cord clamping. Preterm infants can be kept

warm, wrapped in a heated blanket, while waiting for 30 to 45

seconds and lowered 10 inches below the perineum. The sur-

gically delivered preterm infant is kept warm under a sterile

bowel bag while receiving positive pressure ventilation. If cir-

cumstances prevent delayed cord clamping, even milking the

cord quickly before clamping can increase hemoglobin and

blood pressure and reduce the need for transfusion in prema-

ture infants (Hosono et al., 2008). The placental-infant transfu-

sion the baby receives at birth provides many benefi ts (Rabe et

al., 2008).

IMPLICATIONS FOR NURSESEvidence supports delayed cord clamping at birth in both term

and preterm infants. If circumstances permit waiting until

pulsations cease before clamping (generally about three min-

utes), providers can be assured infants of any gestational age

have received the maximum possible placental transfusion. If

for respiration to be established. In the hospital, infants need-

ing resuscitation most often have immediate clamping to facili-

tate transfer to the warmer and a neonatal team. Incorporating

delayed cord clamping into resuscitation efforts is possible even

in the hospital (Hutchon, Bewley, & Nicholl, 2008). This in-

cludes using that fi rst 30 seconds to lower the infant below the

placenta to facilitate placental-infant transfusion as well as con-

ducting resuscitative efforts at the bedside with the cord intact.

The simplest solution is to bring the warmer to the bedside.

Conversely, the baby can be kept in the bed with the mother, on

or between her thighs on dry pads. A third option is to deliver

to the lowered foot of the bed (not “breaking the bed”) and

raising the entire birthing bed as needed. Resuscitative efforts,

following neonatal resuscitation program guidelines, can be

initiated in these locations while the infant continues to receive

oxygenated blood. This change in thinking in how resuscita-

tion is performed emphasizes the importance of blood and its

oxygen-carrying capacity and is supported by the fact most

stunned or slow-to-start babies revive with cord blood alone

(Wyllie & Niermeyer, 2008).

Figure 1 The Somersault Maneuver The head is delivered normally, but as the body is being born the delivery provider keeps the infant’s head close to the maternal symphysis pubis or thigh to minimize tension on the cord. The infant’s body is moved away from the perineum as it is born. The provider can then unwind the cord and allow the infant to reperfuse.

Reprinted from: Mercer, J. S., Skovgaard, R. L & Erickson-Owens, D. (2008). Fetal to neonatal transition: First, do no harm. In S. Downe (Ed.), Normal childbirth: Evidence and debate, 2nd ed. (pp. 149–174). Edinburgh: Elsevier. Figure reprinted with permission.

138 Nursing for Women’s Health Volume 13 Issue 2

Aladangady, N., McHugh, S., Aitchison, T. C., Wardrop, C. A., & Holland, B. M. (2006). Infants’ blood volume in a controlled trial of placental transfusion at preterm delivery. Pediatrics, 117(1), 93–98.

American Academy of Pediatrics, Subcommittee on Hyperbiliru-binemia. (2004). AAP Clinical Practice Guideline: Management of hyperbilirubinemia in the newborn infant 35 or more weeks gestation. Pediatrics, 114, 297–316.

Baenziger, O., Stolkin, F., Keel, M., von Siebenthal, K., Fauchere, J.-C., Das Kundu, S., et al. (2007). The infl uence of the timing of cord clamping on postnatal cerebral oxygenation in preterm neonates: A randomized, controlled trial. Pediatrics, 119(3), 455–459.

Bluff, L. (2005). Early versus delayed cord clamping. International Journal of Childbirth Education, 20(4), 16–21.

Ceriana Cernadas, J. M., Carroli, G., Pellegrini, L., Otano, L., Fer-reira, M., Ricci, C., et al. (2006). The effect of timing of cord clamping on neonatal venous hematocrit values and clinical out-come at term: A randomized, controlled trial. Pediatrics, 117(4), e779–e786.

Chaparro, C. M., & Lutter, C. (2007). Beyond survival: Integrated delivery care practices for long-term maternal and infant nutrition, health and development. Washington, DC: Pan American Health Organization.

Chaparro, C. M., Neufeld, L. M., Tena Alavez, G., Eguia-Liz Ce-dillo, R., & Dewey, K. G. (2006). Effect of timing of umbilical cord clamping on iron status in Mexican infants: A randomised controlled trial. Lancet, 367(9527), 1997–2004.

Emhamed, M. O., van Rheenen, P., & Brabin, B. J. (2004). The early effects of delayed cord clamping in term infants born to Libyan mothers. Tropical Doctor, 34(4), 218–222.

FIGO (2006). Prevention and treatment of post-partum haemor-rhage: New advances for low resources settings. Joint Statement In-ternational Confederation of Midwives (ICM) and International Federation of Gynaecology and Obstetrics (FIGO). Retrieved August 8, 2008, from http://www.fi go.org/docs/PPH Joint State-ment 2 English.pdf

Flamm, B. L. (1999). Tight nuchal cord and shoulder dystocia: A potentially catastrophic combination. Obstetrics & Gynecology, 94(5, Part 2), 853.

Grajeda, R., Perez-Escamilla, R., & Dewey, K. G. (1997). Delayed clamping of the umbilical cord improves hematologic status of Guatemalan infants at 2 mo of age. American Journal of Clinical Nutrition, 65(2), 425–431.

Grantham-McGregor, S., & Ani, C. (2001). A review of studies on the effect of iron defi ciency on cognitive development in children. Journal of Nutrition, 131(2S-2), 649S-666S; discussion 666S–668S.

Gupta, R., & Ramji, S. (2002). Effect of delayed cord clamping on iron stores in infants born to anemic mothers: A randomized controlled trial. Indian Pediatrics, 39(2), 130–135.

Hall, R. W., Kronsberg, S. S., Barton, B. A., Kaiser, J. R., & Anand, K. J. (2005). Morphine, hypotension, and adverse outcomes among preterm neonates: Who’s to blame? Secondary results from the NEOPAIN trial. Pediatrics, 115(5), 1351–1359.

Haneline, L. S., Marshall, K. P., & Clapp, D. W. (1996). The high-est concentration of primitive hematopoietic progenitor cells in

waiting is not possible, preterm infants benefi t from a delay

of at least 30 to 45 seconds, if held below the level of the pla-

centa, and/or cord milking. Because small for gestational age

term infants and term infants born to mothers with diabetes or

hypertension have all been excluded from delayed cord clamp-

ing studies, there is currently no evidence-based recommended

clamping time for these infants.

Incorporating delayed cord clamping into day-to-day prac-

tice will require a change in thinking for both nurses and ob-

stetrical providers. Nurses wanting to facilitate delayed cord

clamping can share these fi ndings with their provider col-

leagues. Discussions that share evidence and challenge com-

monly held beliefs will help nurses and others to examine

assumptions about delayed cord clamping. Brainstorming to

fi gure out the logistics before trying to change common prac-

tices can be helpful. If the questions of where to put infants

and how to keep them warm are addressed fi rst and rehearsed,

nurses and providers may be more willing to incorporate de-

layed cord clamping into their practice. Immediately placing

the newborn skin-to-skin on the maternal abdomen is a good

way to start to incorporate delayed cord clamping. When this

no longer seems “unusual,” more complex applications of de-

layed cord clamping such as using the somersault maneuver for

infants with tight nuchal cords might be more acceptable.

While preterm infants benefi t from delayed cord clamping,

nurses in that delivery setting will face challenges in changing

practice. Suggesting sterilized warm blankets and/or plastic

coverings at the time of delivery, with a prewarmed infant table

available can address concerns about potential heat loss during

a brief wait in cord clamping for these babies.

CONCLUSIONMost obstetric and neonatal providers and nurses are inter-

ested in evidence-based care, but implementing new behaviors

based on that evidence challenges even seasoned profession-

als. Obstetric or neonatal nurses are in a unique position to

facilitate change since they often set the physical stage for birth.

Many nurses train providers, formally or informally, and are

viewed as sources of new information. In addition, more and

more patients give nurses birth plans with requests for delayed

cord clamping. Nurses need to be able to intelligently discuss

this aspect of gentle birth with patients and providers. NWH

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