I’ve written before on this blog about the wonderful tether that keeps a baby close to his/her mother after birth. Here are some more ideas about preserving the sanctity of the umbilical cord and being respectful of the hours after birth.
The balancing of blood for the newborn takes some time.
Here are some of the thoughts and ideas I have gleaned over the years about leaving the umbilical cord intact until, at least, the placenta is birthed (extended delayed cord clamping) or not cutting it at all (lotus birth).
1. Leaving the cord to pulse does “no harm” and therefore should be encouraged. If you think
about what Nature intended, our ancestors way back before scissors and clamps were invented must have had to wait to deal with the cord/placenta at least until the placenta was birthed. They probably chewed it, ground it with rocks, or burned it through with hot sticks from the fire. Plastic umbilical cord clamps have little teeth that clamp onto the cord to quell bleeding (see photo), but they are a relatively recent invention so our very early ancestors probably chewed or traumatized the cord in some way. That could only have been done with the placenta out of the mother.
2. Leaving the cord alone slows down the “fire drill” energy that many birth attendants get into after the baby is born. Leaving off the busyness of midwifery for a half hour allows the mother and baby undisturbed bonding time without a “project” going on i.e. the cord cutting instructions, explanations, jokes, etc. Thus, the father, too, is undisturbed and able to enjoy this “high” time without focusing on a job at hand.
3. Preventing brain lesions in the newborn baby. Educator Joseph Chilton Pierce in his book “Magical Child” makes reference to studies that were done on primates who gave birth in captivity and had early cord clamping. Autopsies of the primates showed that early cord clamping produced unusual lesions in the brains of the animals.
These same lesions were also found in the brains of human infants when autopsied.
4. In Rh negative women, many people believe that it is the clamping of a pulsing cord that causes the blood of the baby to transfuse into the blood stream of the mother causing sensitization problems.
Robert S. Mendelsohn, M.D., in his book “How to Have a Healthy Child. . . In Spite of Your Doctor” blames the whole Rh negative problem on too quick clamping of the cord. Especially in Rh negative mothers, I urge midwives to wait until the placenta is out before thinking about cord clamping.
5. I think it is interesting that scientists are now discovering that umbilical cord blood is full of valuable T-cells which have cancer fighting properties. A whole industry has sprung up to have this precious blood extracted from the placenta, put in a cooler with dry ice, and taken to a special storage facility to be ready in case the child gets cancer at some time in the future. This is human insanity of the first order. That blood is designed by Nature to go into that child’s body at birth, not 30 yrs later! We need to acknowledge that there are things about the newborn circulation and blood composition that we just don’t know and we can bet that Mother Nature had things figured out pretty well for us to survive this long.
Something to think about: Maybe the supposed need for Vitamin K in the newborn comes out of early cord clamping? In my birth work (+1000 births) and practice of extended-delayed umbilical cord care, I have only given Vitamin K to one baby (on Day 8 after having a little blood on his diaper from the umbilicus every day < l tsp.--it was probably unnecessary). I have only had one Rh negative woman who showed fetal cells in her blood (she had had a bad fall 2
days prior to birth).
We have waited hours before cutting the cord and many couples never do cut it (they just carry baby, cord and placenta around together for days).
This is called Lotus Birthing and midwife Jeanine Parvati Baker popularized the
method. The nice thing is that it really limits the postpartum visitors list and keeps the new mother close to her bed!
If a baby needs resuscitation, it is important to leave the cord and do all work on Mom’s body. Cutting the back up oxygen supply doesn’t make any sense at all.
(The only time I cut a cord before the placenta comes out is if I have a mother in a water tub and I’m specifically worried about maternal blood loss. Then you want to get both out onto a dry surface quickly and sometimes it’s easier to
hand baby over to an adult while Mom is lifted separately. This would be a very rare occurrence).
Delayed cord clamping reduces the risk of feto-maternal transfusion, which is especially important for Rh negative mothers (Lapido, 1971; Rogers et al, 1998)
Added Jan 14, 2013 : Quote from British midwife, Mary Hall: “I have been a midwife for 32 years and have known at a deep level that putting a clamp on and cutting something (the umbilical cord) erect and pulsating vigorously was intrinsically wrong; it’s satisfying to see the evidence at last. Home births are physiological (that’s hard-core science, ahem), including cord management- -listen to the baby. There is only a very brief moment in time to make a decision that may impact on the infant for the next 70 years.”
Added May 22, 2017
From Gail Hart, Midwife, Oregon. “This one is good because it is matched pairs of moms, half clamped <10 seconds and half after the cord stopped pulsing. Many of the 'delayed clamping studies" are done on babies with only a 30 second to 60 second delay and some show little difference between early and late so this is a good study on physiological management.
Bloodwork was done on all babies AND on all mothers after birth and repeated on babies at 24 hours.
early clamping showed higher hemoglobin in the mom than late clamping (which probably explains much if not all of the supposed "benefits" of active third stage management?) early clamping hemoglobin was almost a point higher on average.
at 24 hour the mean infant hemoglobin averaged a point lower in early clamping 17.1 vr 18.5 and there was no difference in clinical jaundice or plethora.
two babies in the EARLY clamping group had bilirubin above 15 and eventually needed phototherapy and no babies did in the late-clamping group.
In the late clamping group 3 babies had hg numbers to signify 'polycythemia" but without any symptoms and with no need for treatment (and I can show data showing these are physiological levels in late-clamped babies).
Delaying cord clamping until the pulsations stop increases the red cell mass in term infants. It is a safe, simple and low cost delivery procedure”
PS i am going to try to track down details and see if i can find hemoglobin counts on moms at discharge or later. It intrigues me to think that early clamping simply moves the blood from the normal baby circulation and retains it in the mom. On the primary argument for ATSM is that ‘”it saves blood” and women have higher hgb after ACSM, but this may explain it. It does not ‘save blood” it is stealing it from the baby instead….
The early effects of delayed cord clamping in term… [Trop Doct. 2004] – PubMed – NCBI
PubMed comprises more than 21 million citations for biomedical literature from MEDLINE, life science journals, and online books. Citations may include links to full-text content from PubMed Central and publisher web sites. “ end of quote.
The Umbilical Cord
Early cord clamping deprives the baby of 54-160 mL of blood, which represents up to half of a baby’s total blood volume at birth. “Clamping the cord before the infant’s first breath results in blood being sacrificed from other organs to establish pulmonary perfusion [blood supply to the lungs]. Fatality may result if the child is already hypovolemic [low in blood volume]”.
– Morley, G. (1998, July). Cord closure: Can hasty clamping injure the newborn? OBG Mgmnt: 29-36.
Early clamping has been linked with an extra risk of anemia in infancy.
– Grajeda, R. et al. (1997).
Delayed clamping of the umbilical cord improves hematologic status of Guatemalan infants at 2 mo. of age.
– Am J Clin Nutr 65:425-431.
Premature babies who experienced delayed cord clamping–the delay was only 30 seconds–showed a reduced need for transfusion, less severe breathing problems, better oxygen levels, and indications of probable improved long-term outcomes compared with those whose cords were clamped immediately.
– Kinmond, S. et al. (1993). Umbilical cord clamping and preterm infants: A randomized trial. BMJ 306(6871): 172-175.
Some studies have shown an increased risk of polycythemia (more red blood cells in the blood) and jaundice when the cord is clamped later. Polycythemia may be beneficial in that more red cells mean more oxygen being delivered to the tissues. The risk that polycythemia will cause the blood to become too thick (hyperviscosity syndrome), which is often used as an argument against delayed cord clamping, seems to be negligible in healthy babies.
– Morley, ibid.
Some evidence shows that the practice of clamping the cord, which is not practiced by indigenous cultures, contributes both to postpartum hemorrhage and retained placenta by trapping extra blood (about 100 mL) within the placenta. This increases placental bulk, which the uterus cannot contract efficiently against and which is more difficult to expel.
– Walsh, S. (1968, May 11). Maternal effects of early and late clamping of the umbilical cord. The Lancet: 997.
Clamping the cord, especially at an early stage, may also cause the extra blood trapped within the placenta to be forced back through the placenta into the mother’s blood supply during the third stage contractions. This feto-maternal transfusion increases the chance of future blood group incompatibility problems, which occur when the current baby’s blood enters the mother’s bloodstream and causes an immune reaction that can be reactivated in a subsequent pregnancy, destroying the baby’s blood cells and causing anemia or even death.
– Doolittle, J. & Moritz, C. (1966). Obstet Gynecol 27:529 and Lapido, O. (1971, March 18). Management of the third state of labour with particular reference to reduction of feto-maternal transfusion. BMJ 721-3.
The above are excerpts from Sarah Buckley’s “A Natural Approach to the Third Stage of Labour,” Midwifery Today Issue 59
Links to info on delayed cord clamping.
An interesting article From Journal of Midwifery & Women’s Health
Evidence-Based Practices for the Fetal to Newborn Transition
Judith S. Mercer, CNM, DNSc; Debra A. Erickson-Owens, CNM, MS, ; Barbara Graves, CNM, MN, MPH; Mary Mumford Haley, CNM, MS Author Information
Many common care practices during labor, birth, and the immediate postpartum period impact the fetal to neonatal transition, including medication used during labor, suctioning protocols, strategies to prevent heat loss, umbilical cord clamping, and use of 100% oxygen for resuscitation. Many of the care practices used to assess and manage a newborn immediately after birth have not proven efficacious. No definitive outcomes have been obtained from studies on maternal analgesia effects on the newborn. Although immediate cord clamping is common practice, recent evidence from large randomized, controlled trials suggests that delayed cord clamping may protect the infant against anemia. Skin-to-skin care of the newborn after birth is recommended as the mainstay of newborn thermoregulation and care.
Routine suctioning of infants at birth was not been found to be beneficial.
Neither amnioinfusion, suctioning of meconium-stained babies after the birth of the head, nor intubation and suctioning of vigorous infants prevents meconium aspiration syndrome. The use of 100% oxygen at birth to resuscitate a newborn causes increased oxidative stress and does not appear to offer benefits over room air. This review of evidence on newborn care practices reveals that more often than not, less intervention is better. The recommendations support a gentle, physiologic birth and family-centered care of the newborn.
The transition from fetus to newborn is a normal physiologic and developmental process — one that has occurred since the beginning of the human race. Many hospital routines that are used to assess and manage newborns immediately after birth developed because of convenience, expediency, or habit, and have never been validated. Some practices are so ingrained that older traditional practices, such as providing skin-to-skin care or delaying cord clamping, must be considered “experimental” in current studies. However, recent research is beginning to identify some older practices that should not have been abandoned and some current practices that should be stopped. In order to achieve a gentle, physiologic birth and family-centered care of the newborn, practices that might interfere with maternal and newborn bonding need to be closely scrutinized. This article examines the evidence about practices related to the newborn transition, including the effects of various drugs used labor, umbilical cord clamping, thermoregulation, suctioning, and resuscitation of the newborn
There has been some great recent research and discussion on this
topic. What is absolutely great to see is that things which
progressive midwives have been advocating for years, now have
mainstream endorsement. eg cop this from the BMJ:
“The earliest time to assess whether ventilation is successful is
about 60 seconds after delivery.
All these steps can be done while the umbilical cord is intact. When
resuscitation is required the preferred position for the infant should
be between the mother’s legs, as bag-mask ventilation is not feasible
if the infant is placed on the mother’s abdomen. Immediate cord
clamping to enable resuscitation away from the mother could deprive
the infant of much needed extra blood volume, and the resulting
hypovolaemia might adversely affect tissue perfusion. Furthermore, as
long as the uterus is not contracting and the placenta has not been
detached, the infant may still receive oxygen via the intact
placental-fetal circulation. ”
Here’s more details of that BMJ article. They published a detailed
discussion on this topic in 2006. It’s intended specifically for
midwives and obstetricians, and discusses things like resus:
BMJ 2006;333:954-958 (4 November), doi:10.1136/bmj.39002.389236.BE
A practical approach to timing cord clamping in resource poor settings
Patrick F van Rheenen, consultant paediatrician1, Bernard J Brabin,
professor of tropical child health2
Here’s an extract:
Is delayed cord clamping associated with side effects that require treatment?
Four controlled trials and one randomised controlled trial, all from
industrialised countries,11-16 and two randomised controlled trials
from resource poor countries5 17 evaluated the incidence of
hyperbilirubinaemia and hyperviscosity in term neonates. Packed cell
volume was significantly higher after delayed cord clamping, but
infants showed no evidence of hyperviscosity syndrome and partial
exchange transfusion was never needed. Although peak bilirubin
concentrations tended to be higher after delayed cord clamping, the
phototherapy threshold was never exceeded and none required exchange
transfusion. Meta-analysis showed that delayed cord clamping in
healthy term infants caused no side effects requiring treatment (seven
trials, 583 infants, relative risk 0.20 (0.01 to 3.97)).
The BMJ also had an editorial endorsing ‘delayed’ cord clamping in
2007; I haven’t read the full article because the tight monkeys
stopped free access to their online journal, but if anyone can log in,
you can read it here:
BMJ 2007;335:312-313 (18 August), doi:10.1136/bmj.39282.440787.80
Late vs Early Clamping of the Umbilical Cord in Full-term Neonates
Systematic Review and Meta-analysis of Controlled Trials
Eileen K. Hutton, PhD; Eman S. Hassan, MBBCh
Here are some other refs which look good:
The JAMA meta-analysis of early versus late cord clamping in full-term
neonates, which you can read in full here:
They found that there was no increase in the incidence of clinical
jaundice or need for phototherapy with ‘late’ cord clamping, although
there was some increase in neonoatal polycythaemia. IN the
higher-quality studies this association did not reach statistical
significance. What they DID find was that late clamping was
associated with better iron status, as measured by serum ferritin
levels, to six months and beyond, and also with less anaemia in the
newborn periods. The babies who were breastfed and who experienced
‘late’ cord clamping had proportionately higher iron stores at six
months than the babies who were no longer breastfed.
Abstract copied below. See also NHS electronic library for health
discussion of the paper here:
ABSTRACT OF JAMA META _ ANALYSIS
Context With few exceptions, the umbilical cord of every newborn is
clamped and cut at birth, yet the optimal timing for this intervention
Objective To compare the potential benefits and harms of late vs
early cord clamping in term infants.
Data Sources Search of 6 electronic databases (on November 15, 2006,
starting from the beginning of each): the Cochrane Pregnancy and
Childbirth Group trials register, the Cochrane Neonatal Group trials
register, the Cochrane library, MEDLINE, EMBASE, and CINHAL; hand
search of secondary references in relevant studies; and contact of
investigators about relevant published research.
Study Selection Controlled trials comparing late vs early cord
clamping following birth in infants born at 37 or more weeks’
Data Extraction Two reviewers independently assessed eligibility and
quality of trials and extracted data for outcomes of interest: infant
hematologic status; iron status; and risk of adverse events such as
jaundice, polycythemia, and respiratory distress.
Data Synthesis The meta-analysis included 15 controlled trials (1912
newborns). Late cord clamping was delayed for at least 2 minutes (n =
1001 newborns), while early clamping in most trials (n = 911 newborns)
was performed immediately after birth. Benefits over ages 2 to 6
months associated with late cord clamping include improved hematologic
status measured as hematocrit (weighted mean difference [WMD], 3.70%;
95% confidence interval [CI], 2.00%-5.40%); iron status as measured by
ferritin concentration (WMD, 17.89; 95% CI, 16.58-19.21) and stored
iron (WMD, 19.90; 95% CI, 7.67-32.13); and a clinically important
reduction in the risk of anemia (relative risk (RR), 0.53; 95% CI,
0.40-0.70). Neonates with late clamping were at increased risk of
experiencing asymptomatic polycythemia (7 studies [403 neonates]: RR,
3.82; 95% CI, 1.11-13.21; 2 high-quality studies only [281 infants]:
RR, 3.91; 95% CI, 1.00-15.36).
Conclusions Delaying clamping of the umbilical cord in full-term
neonates for a minimum of 2 minutes following birth is beneficial to
the newborn, extending into infancy. Although there was an increase in
polycythemia among infants in whom cord clamping was delayed, this
condition appeared to be benign.
Author Affiliations: Department of Obstetrics and Gynecology, McMaster
University, Hamilton, Ontario (Dr Hutton); and The Child and Family
Research Institute (Dr Hutton), Western Regional Training Centre for
Health Services Research (Dr Hassan), and Department of Health Care
and Epidemiology (Dr Hassan), University of British Columbia,
> From: email@example.com
> Date: Fri, 28 Mar 2008 18:08:32 +0900
> Subject: [ozmidwifery] cord clamping.
> To: firstname.lastname@example.org
> More of the previous article I posted: An interesting article From
> Journal of Midwifery
> & Women’s Health
> Evidence-Based Practices for the Fetal to Newborn Transition Posted
> Van Rheenen and Brabin conducted a systematic review of two
> randomized controlled trials[34,36] that compared immediate versus
> delayed cord clamping in term infants to determine the effect on
> anemia status after 2 months of age. Their secondary objective was to
> assess the incidence of polycythemia and/or jaundice during the first
> week of life in infants who experienced delayed cord clamping. The
> authors found that delayed cord clamping, especially in anemic
> mothers, increased hemoglobin status and reduced the risk of anemia at
> 2 to 3 months of age (RR, 0.32; 95% CI, 0.02-0.52). Although infants
> with delayed clamping had higher hematocrit levels, no reports of
> symptomatic polycythemia or jaundice were found. The authors stated
> that delaying clamping may be especially beneficial in developing countries where anemia rates are high.
> The current literature refutes the idea that delayed cord clamping
> causes symptomatic polycythemia and indicates that immediate clamping
> of the cord may often lead to anemia of infancy.
> Clamping the Nuchal Cord Before Delivery of the Shoulders
> In addition to anemia, possible neurologic harm from clamping a nuchal
> cord before birth has been identified. A recent integrated review
> of the literature on nuchal cord management found reports showing
> increased risks to the newborn when the cord was clamped before the
> shoulders are delivered. Leaving the cord intact and using the
> somersault maneuver is recommended especially if shoulder dystocia is
> suspected. During the somersault maneuver, the infant’s head is kept
> near the perineum as the body
> delivers so that little traction is exerted on the cord (Figure
> 1). Resuscitation at the perineum allows the infant to regain the
> blood trapped in the placenta and can be accomplished using all the
> proper tenets of neonatal resuscitation.
> Click to zoom
> Figure 1. (click image to zoom)
> Somersault maneuver. The somersault maneuver involves holding the
> infant’s head flexed and guiding it upward or sideways toward the
> pubic bone or thigh, so the baby does a “somersault,” ending with the
> infant’s feet
> the mother’s knees and the head still at the perineum. 1, Once the
> nuchal cord is discovered, the anterior and posterior shoulders are
> slowly delivered under control without manipulating the cord. 2, As
> the shoulders are delivered, the head is flexed so that the face of
> the baby is pushed toward the maternal thigh. 3, The baby’s head is
> kept next to the perineum while the body is delivered and
> “somersaults” out. 4, The umbilical cord is then unwrapped, and the
> usual management ensues. Figure adapted with permission from Mercer et
> Cord Blood Harvesting
> Increasing blood volume by delayed clamping should result in the
> infant receiving a greater allotment of hematopoietic stem cells and
> red blood cells. Hematopoietic stem cells are pluripotent, meaning
> that they can develop into many different cell types. Evidence
> suggests that hematopoietic stem cells may migrate to and help repair
> damaged tissue during inflammation and can differentiate into such
> cells as glia, oligodendrocytes, and cardiomyocytes as needed. In
> a rat model of cerebral palsy, half the damaged rats were given human
> umbilical stem cells within 24 hours of the injury. The infusion of
> cord blood appeared to prevent development of the rodent version of
> cerebral palsy, which was clearly evident in the damaged rats who did
> not get human cord blood. Yet cord blood harvesting companies advertise cord blood as “medical waste”
> and encourage parents to collect it at birth. Although cord clamping
> not prescribed in the instructions for cord blood harvesting, the
> is that the earlier the cord is clamped, the larger the harvest will be.
> This practice of cord blood harvesting is not supported by the
> American Academy of Pediatrics unless there is a clear medical need
> within the family. Parents need to be fully informed by providers
> during pregnancy in order to make sound decisions about storing cord blood.
> In summary, the current literature supports a lack of harm for full
> term infants when cord clamping is delayed up to 10 minutes with the
> newborn placed on the maternal abdomen or held below the level of the
> perineum. In addition, the evidence is strong that delayed cord
> clamping offers
> infants protection from anemia. Based on the current evidence, the
> recommendation is to delay cord clamping to prevent anemia of infancy.
> we recommend that clinicians not cut a nuchal cord before delivery of
> the shoulders, but instead, use the somersault maneuver to deliver the
> resuscitate at the perineum as necessary.
New ACOG policy on cord blood collection for freezing. Bottom line—drs should give patients the info that they get a kick back of money from the co and they should be telling the pts that there isn’t a likelihood in hell that they’ll ever actually use that frozen blood for ANYTHING. Gloria Lemay
Early Cord Clamping Boosts Lead in At-Risk Infants
Tue Dec 11, 2007 6:52 pm (PST)
http://www.medscape .com/viewarticle /566984
Early Cord Clamping Boosts Lead in At-Risk Infants
By David Douglas
NEW YORK (Reuters Health) Dec 05 – In settings where lead exposure is high,
the practice of immediate umbilical cord clamping after delivery can give
rise to elevated blood lead levels in infancy, in part by decreasing iron
status, according to US and Mexican researchers.
“Clamping the umbilical cord in the first 10 to 15 seconds after birth,”
lead investigator Dr. Camila M. Chaparro told Reuters Health, “is frequently
practiced in many delivery settings — both in the developed and developing
world — and is a practice that was instituted with little scientific
evidence justifying it.”
In the November issue of the Journal of Pediatrics, Dr. Chaparro of the Pan
American Health Organization, Washington, DC and colleagues note that in
Mexico City, lead exposure is high and iron deficiency is also common.
To investigate whether infant iron status, modified by umbilical cord
clamping time and infant feeding mode, affected infant blood lead
concentration, the researchers randomized 266 prospective mothers in Mexico
City to 10-second or 2-minute umbilical cord clamping at the time of
Examination of data on maternal lead exposure at baseline and on infant
feeding showed that maternal blood lead concentration, infant ferritin, and
breast-feeding practices predicted infant blood lead concentration at 6
In infants with higher placental blood lead concentration and breast-fed
infants not receiving any iron-fortified formula or milk at 6 months, say
the researchers, “early clamping increased infant blood lead concentration. ”
The researchers suggest that the most plausible underlying mechanism is
upregulation of divalent metal transporter 1 in response to lowered iron
status, resulting in greater uptake of lead. Nevertheless, they point out
that for a variety of reasons, only 23% of the total effect on infant lead
status could be attributed to changes in iron status.
“Clamping the cord immediately not only decreases infant iron levels,”
concluded Dr. Chaparro, “but may increase infant blood lead levels. Both
iron deficiency and elevated blood lead levels are independently and
negatively associated with infant mental development, and waiting a few
minutes to clamp the cord at birth is one way to prevent the development of
J Pediatr 2007;151:506- 512.