I have only encountered it once in my career (over 1300 births plus lots of prenatal class parents, 35 years in the birth biz). The baby with polycythemia I worked with was very ill with it, she was hospitalized on Day 2 of life and had some blood removed which improved her condition right away. She remained in hospital for about 7 days. She had Down syndrome and polycythemia can be part of the presentation with Down. A very good friend who is also a doula has a daughter with Down Syndrome and her story is almost exactly the same as the baby girl in my practice i.e. polycythemia after a gentle homebirth which was treated well in hospital. Both these baby girls were discharged from hospital much faster than the medical professionals involved expected.
I am a believer in leaving the birth of the placenta for a full 30 minutes (or longer). If the placenta births before 30 minutes, it is rare, and it means that the mother pushed it out without any advice from me. In my work, the cord is clamped and cut only after the placenta is out. With the one exception of the girl with Down Syndrome, I do not see cases of polycythemia, jaundice or any of the other dire predictions that the medical profession warns about with leaving the cord to pulse until it stops naturally. Fear of polycythemia is no justification for continuing on with amputating the placenta prematurely. Waiting only two or three minutes to clamp the cord is still an assault on the baby.
Remember, scissors, hemostats and cord clamps have only been invented for a short time in human history. Before that, people waited till the placenta came out naturally before doing anything about the umbilical cord. When the baby is adjusting to life with the cord intact, the blood goes back and forth through the two arteries and one vein in the cord. . . it isn’t just going in to the baby from the placenta, it’s coming out, too, in correct balance for that baby’s anatomy. The placenta was trusted to sustain the well being of the baby in every way for nine months, I am certain that it’s okay to let it keep performing that function for another 30 minutes.
(This is a comment from Facebook that I made in response to a query about cord clamping. The women who birth at home are not induced, not medicated and receive no routine injection of pitocin after the birth. They are healthy women with full term babies, for the most part.) Gloria Lemay
LOTUS BIRTH: Birth with an intact umbilical cord.
Baby and placenta are kept together until the cord falls off naturally.
Lotus birth is another grass roots movement. Woman to woman the word is passed. . . it makes sense and a heartstring is touched. . . .the father is enlisted for support and, one family after another, declines the use of scissors at birth. This movement causes the knowledgeable professionals to stop and then flounder for answers. As the things they hold to be sacred are questioned and thrown out, everything they know to be true is also called into question. This is a good thing and enriches those who can admit that things are not always as they seem.
When your clients are planning a lotus birth, think ahead to what some of the pitfalls might be.
1. The relatives might be upset. Many couples who plan lotus birth see the days with the placenta (usually 4 to 6 days) as private family time and make a rule that they will not have guests until the placenta is separated. This relieves the new mother of performance anxiety as she gets to know her new baby. It gives the baby a quiet transition period to intensively bond with his/her parents. One couple I know did not let anyone know their baby had been born until the placenta had separated naturally.
2.What if it smells terrible? Ground rosemary sprinkled all over the surfaces gives the placenta a pleasant smell like turkey stuffing. Some women put lavender and rosemary essential oil on the placenta first to prevent smell. Some put salt on both sides. There will be a smell. It is not terrible. A cake rack or a Chinese wooden steamer can be helpful to place the placenta on to allow air to circulate. Blue Chux (incontinent) pads are helpful to prevent bedclothes from being stained with blood. The placenta is organ meat that is fresher than any meat you have ever purchased. It will naturally begin to smell after a few days of being in the air.
3.What if I decide not to do it once I’ve started? Not a problem. The cord can be cut at any time and usually is atrophied (dried and shrunk) enough that it needs no clamp after 24 hours. It is common for new parents to go through periods where they think Lotus birth is just too much trouble. Often the mother wants to give up and cut the cord and the father will talk her into persisting a while longer; then, the father can be fed up and the mother will encourage him to keep going. It becomes a quiet meditation to wait vigilantly for the cord to fall and in our fast-moving society it is a real contest to slow down for the baby. Parents report that the days spent with the placenta attached taught them a great deal about cooperative parenting and patience.
4. What are the annoying aspects of Lotus birth? It can seem like a nuisance to have to move the placenta every time you move the baby. Having a piece of raw meat in your family bed is a little peculiar, too, and can be messy. Once the cord dries after 24 hours, it has the consistency of rawhide which makes it seem like your baby has a wire coat hanger protruding from his/her belly. None of these problems is insurmountable if the parents can be relaxed, stay close to bed and view Lotus Birth as a rites of passage.
5. How do I do this with a 3 year old jumping around on the bed? This is actually one of the biggest challenges and is a reason that Lotus Birth most often happens with first births. Protecting the newborn from the exuberance of a 3 year old is not easy at the best of times. Prior to the birth, the parents should put some thought into creating a “nest” for the new baby and mom for the Lotus time. The father and older child can build a “play space” of some kind with new library books and music for nap times. Enlisting friends and family to take the older child for some active outdoor fun each day will also help the new parents maintain the sanctity of the Lotus time for the baby.
The role of the Attendant in a Lotus birth
Educating your clients about the possibility of a Lotus birth is easily done with a handout. For many families, Lotus birth is not a preference but knowing that there is no problem leaving the cord intact indefinitely reassures them that it’s all right to slow down the cutting of the cord after the birth. When physicians justify early clamping and cutting of the umbilical cord with erroneous statements like “the baby may become jaundiced”, the parents can point to Lotus birth as proof that patience with cord clamping is perfectly healthy.
If your clients decide to have a Lotus birth, your encouragement and support can mean a lot to them. Talking through the logistics prior to the birth and making a plan for what equipment will be needed is helpful. Remind the mother to keep the house warm so that she can be naked (except for panties/pad) and the baby can just wear a diaper. Lots of skin-to-skin contact in the first few days of life gets the breastfeeding relationship off to a good start. A supportive attendant can remind parents that the Lotus process has its highs and lows and that many people find deep meaning in giving this patient beginning to their child.
Caroline and Paul’s Lotus Birth
Caroline is the daughter of a family physician and Paul works in the film industry. They were planning a home water birth for their first baby and had heard about Lotus Birth and wanted to give it a try. The birth process was long but Caroline coped well and gave birth around suppertime in the water. Paul was so captivated with the birth that he did a poor job of filming it! The midwives helped the family to take lots of photos of parents and baby and placenta all resting in bed together. It was a glorious feeling for everyone —a birth that flowed easily and needed no scissors, clamps or cutting of any kind.
When the midwife returned to the home the next afternoon, the bloom was off the rose. The father looked rather anxious and wanted to know “How much longer are we going to have to have that THING on the baby?” The mother and baby were sleeping peacefully together so the midwife had some time to spend talking to the father as they cleared up dishes in the kitchen. She let the father know that his impatience to have things “tidied up” after the birth was normal. She also pointed out that very few times in his life would be as profound as the first days of his son’s life. She encouraged him to really listen to the messages that his son, his wife and the placenta might be telling him. The father decided to relax again and let the placenta stay attached.
A few days later, he was lying beside his son on the bed and, as he watched him, he saw the cord slowly detach from the baby’s belly. Right then, he felt a “release” from his own belly and something freed up in his core that had been blocked. He began sobbing with joy. When he planted the placenta under a tree in front of the house, he felt a deep sense that his transition into fatherhood had taken place, not in an instant, but in a slow leisurely process of learning and letting go.
I’m a little afraid to even mention this in case it disappears. Shhhhhh. . . don’t tell anyone but there’s a doctor talking about leaving the baby’s precious backup oxygen supply (the umbilical cord) alone to do its physiological job. He’s calling it “delayed cord clamping” which is a ridiculous description but, as long as babies get to enjoy some cord time, I’m not going to quibble about semantics. Perhaps we’ll see an end to this kind of violation of a newborn baby who is trying desperately to protect herself from the bulb syringe and the clamps/scissors that are stopping her oxygen supply.
You can read all about his research and insights at Academic ObGyn
I’m going to paste in here the comment by Gail Hart, midwife from Portland, Oregon because she has an interesting view of the history and physiology involved in leaving the cord to pulse.
December 6, 2009 at 9:29 am
Gail Hart comment
“The large body of research over 5 decades shows benefits from delayed clamping of the umbilical cord, but there are conflicting reports of potential rise in rates of jaundice. I believe the conflict in these reports is a result of the variations in conduct of third stage. The practice of delayed cord-clamping does not mix well with oxytocics given as part of “active third stage management”.
Under normal physiologic conditions, the uterus remains in quiet tone for a few minutes while the baby receives the “correct” amount of blood remaining in the placental circulation.
If oxytocics are given with delivery, the early uterine contractions may result in an over-infusion of blood to the baby, polycythemia, and elevated risk of jaundice. In my region, the understanding of the association of increased risk of jaundice with the practice of “pitocin with the shoulders” was the major reason for the abandonment of this routine in the 1980s.I think a wise policy is to allow normal third-stage umbilical transfusion by clamping after the cord goes flat under most circumstances. But when pitocin is used then the cord should be clamped within 30 seconds.
Midwives and doctors who follow this policy report rare incidences of neonatal jaundice, and extremely rare need for phototherapy.
Regarding ‘what to do with the baby while waiting”… Let MOM deal with the baby!
In almost all cases, the cord is long enough to allow the baby to be held on mom’s abdomen (and in her arms). There is no need to keep the baby at the level of the introitus: in fact, this is not physiological. It is normal instinctive behavior for mothers to want to hold their babies at birth; in evolutionary terms, this means mothers hold babies while the cord is still intact!
The maternal abdomen may be considered to be close enough to the level of the placenta that gravity is not likely to impact either under-infusion or over-infusion, unless the woman has given birth while standing (and this is unusual in our culture)
(On a personal note: I’ve been a midwife for almost 40 years and can attest that babies do extremely well with a policy of delayed cord-clamping! I think they transition to extra-uterine life more easily, and breathe more quickly and deeply with a lower incidence of “gunky lungs” or TTN (transient tachypnea of the newborn). Also, their intact cord allows them an additional life-line in the rare instance when they require assistance.
Immediate cord-clamping is a very new development in human history. The routine evolved as a method to reduce the neonatal load of maternal medication when births were conducted under general anesthetic.
Those days are LONG past, but this old routine still remains!
We’re having a heck of a time getting rid of the silly thing!
see: JAMA. 2007 Mar 21;297(11):1241-52.
Late vs. early clamping of the umbilical cord in full-term neonates: systematic review and meta-analysis of controlled trials.
Hutton EK, Hassan ES.
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 who cord clamping was delayed, this condition appeared to be benign.
(note nearly a 1000 babies in late-clamping study)
also check out PMID: 16567393
PMID: 18624002 — describes additional benefit of increased alveoli perfusion and recommends a minimum of 3 minutes delay
end of Gail’s comment.
Update Dec 2014: If you’d like to see some photos of how the cord reduces naturally when left alone, see this blogpost by Morag Hastings, a birth photographer and doula. http://www.appleblossomfamilies.com/blog/2014/12/delayed-cord-clamping-vancouver-doula-and-birth-photographer/
Question: My patient is in early labour. She was 3 cm dilated with a posterior cervix, ruptured membranes and well applied head. At her next assessment, five hours later, there was no change. Cervix is still very posterior and can only be walked up to midway. Generally, I would just let things plug along, but after 24 hours, the hospital protocol where I work is to administer IV antibiotics. I really want to avoid that. Baby is in an anterior position.
Answer: It’s difficult to avoid antibiotics at this point, when you’ve done at least two pelvic exams. You’ve now pushed her up to a 25% risk of acquiring an ascending infection.
(illustration from “Heart and Hands” by Elizabeth Davis)
The only way to sit on your hands and let her birth naturally is to not do any pelvic exams. In Europe, the rule is “the baby should be born within 24 hours of the first pelvic exam” with PROM. That gives you weeks, if you don’t examine. Listening to fetal heart tones daily and taking the maternal temperature every four hours while the woman is awake is the appropriate course of action when the membranes release. Many midwives will leave a fetoscope at the house for the parents to listen to the baby’s heart rate for reassurance. Iatrogenic infections are a serious problem in obstetrics. There was a time when no vaginal exams were done in hospitals at all because of the danger. If a cervix had to be examined, it was done with a rectal exam to keep fingers out of the vagina. Just because we now have a wide variety of antibiotics is no reason to expose women and babies to this danger. Gloria
Question: I have some questions about how to collect the umbilical cord blood when the birthing woman is Rh negative. Should one wait until the cord has stopped pulsating – and find there is probably little blood to collect or clamp the cord whilst pulsating and take the sample then unclamp the cord? Or none of the above?!
I look forward to hearing your views, Charlotte
Answer: Thanks for asking, Charlotte. Here’s something I wrote for Midwifery Today which will give you detailed instruction on Collecting Cord Blood
When the mother of a newborn baby is Rh negative and the father is Rh positive, there is a good chance that the baby will be a positive blood type. Blood in the umbilical cord and the placenta will be the baby’s blood. Here are instructions on how to obtain a sample:
1. At the time of birth do not rush the clamping and cutting of the cord. I like to see the placenta birthed (this will take approximately 30 minutes) before clamping and cutting of the cord.
2. Take the bowl with the placenta to the kitchen and get everything together before taking your blood sample. You will need
2 pairs of nonsterile gloves to protect yourself from body fluids
1 container with a lid in which to put the placenta
1 blue waterproof 17- by 21-inch underpad
1 3-cc syringe and needle
1 purple test tube with stopper (Check with your local hospital to determine what color stopper they prefer. The purple stopper tube has an anticlotting chemical in it to prevent the blood from clumping.)
3. Before putting on your gloves, write the necessary information on the label of the test tube in very tiny printing. Remember: it is very important that blood samples not get mixed up at the hospital. You will get along well with the blood bank if you mark your samples carefully. In my area, we print the mother’s full name and date of birth, the title “Cord Blood,” baby’s date of birth, and mother’s personal health number. When you get to the blood bank, they will also want you to fill out a requisition. On that form, I put my name, pager number, the physician’s name, and the mother’s date of birth and personal health number. I also write for the order “Type infant cord blood for screening of Rh negative mother.”
4. Now that you have all your supplies together and the tube is labeled, take the cord blood before inspecting the placenta. Pull the placenta out of the bowl and put it on the blue pad so that it is sitting on the counter with the cord draped over the edge of the counter; the clamp is on the end of the cord. You want to keep the label of the tube clean and legible, so you may want to change your gloves or wipe blood off them on the blue pad’s edge. Take the lid off the tube and hold it at the clamped end of the cord. Take off the clamp and allow the blood to run into the test tube. When a half-inch of blood has accumulated in the bottom of the tube, close the tube and rock the blood back and forth. If you can’t get enough blood you may have to squeeze the blood down from higher up in the cord. Occasionally you may have to run the 3-cc needle into one of the vessels on the fetal side of the placenta, draw back on the plunger to extract the blood, and then squirt it into the test tube.
5. Now you can do a complete inspection of the placenta and then put it away with a lid on it in the refrigerator.
6. When you take the test tube to the lab, ask the technician to page you with the results as soon as possible. If the baby’s blood is Rh negative, ask the lab to fax a copy of the record for your records. If the baby’s blood is Rh positive, the lab will require a blood draw from the mother’s arm. The maternal sample is taken to the lab and checked for baby’s blood cells. If there are none in the mother’s blood, a low dose (120 micrograms) of WinRho (Rhogam in the United States) is given. If baby cells are present in mother’s blood, I have had as many as 900 micrograms prescribed. The package includes instructions on how to give the injection intramuscularly. It is given into the large muscle on the upper outer quadrant of the thigh. If you have to give more than 300 micrograms, you must give it in multiple sites. Injecting anything under the skin can cause harm, so be very careful you are sure of what you are doing and that you’ve had good instruction.
— “Collecting Cord Blood: Guide for Student Midwives,” by Gloria Lemay, first published in The Birthkit Issue 35 Continue reading
It’s the Canadian Thanksgiving this weekend and the weather here on the Pacific Coast is just beautiful.
Here are some of the things that are annoying me or uplifting me on the internet right now:
If you were an elephant mother, giving birth in captivity with a bunch of humans with flashlights and cameras looking on, and your baby didn’t breathe or show any signs of life for two minutes, what would you do? This mother elephant has a novel (but effective) method of infant resuscitation.
In the wild, birthing elephants are surrounded by the other females and those midwife elephants have their bums pointed toward the birth and their faces looking out for predators on the landscape. I often think about that at births and turn myself the elephant way to afford the mother privacy and protection.
This little elephant is born in the caul which is a good luck charm but the part I didn’t like about little Riski laying there lifeless for two minutes is that her cord has separated from the placenta. In elephants, it snaps in the second stage and the baby has about 20 minutes worth of oxygen stores. If his mother wasn’t such a big, dangerous animal, the zoo staff would have been in there “resuscitating” and we wouldn’t have this demonstration that most mammals will come around on their own when the mother is medication-free. I’m glad that human babies don’t drop with a thud and the cord can be preserved to help balance the oxygen levels for some time after birth. This little female elephant was also born breech (the hind legs and tail presented first) which seems to be the most common elephant presentation.
Flu season is upon us but I haven’t talked to anyone who is getting the shots. There seems to be a very healthy skepticism in the population at large. This is a link to an interesting little interview with Dr. Oz. Seems he has taken the swine flu shot on the air (would like to know if the pharma companies paid him big bucks to do that) but his wife is not taking it nor will his children.
With Halloween coming up, do your whole family a favor this year and say “NO” to candy. School absentees go way up right after Halloween and Easter. Keep your kids well by being vigilant about their diets.
The people I know who have had the flu this year say it’s the same one that went around a few years ago where, it comes back with a vengeance if you try to rush getting back to work before full recovery. If you get the flu, don’t panic. Get to bed with lots of warm fluids and stay there until you have fully recovered for a few days.
Nobel Peace Prize
Why should President Obama receive the Nobel Peace Prize when he hasn’t quickly fixed all the problems in Gaza, Afganistan and Iran like I told him to? Because who he is in his being is a man of peace. He’s gentle and loving to his wife. His daughters look like they’ve been adored by their Daddy from the start. He brings a black university professor and a white policeman together and gives us all a demonstration of what we could do with the irreconcilable differences in our lives. That is how we create peace on earth. One man can’t be expected to do it. We all individually can affirm that “peace begins with me” and then take actions appropriate to that. It’s a lifetime job. I am constantly apologizing for being a trouble maker and creating dissent. I probably will till I’m taking my last breath.
When the Nobel Prize is given to Obama, I think it’s being given to every kind, decent man in the U.S.A. When we give a Peace Prize to those who promote peace in our families and communities, we are the even grander recipients of the peaceful ripples that go out and out into the bigger world.
This world and it’s troubles are a complex puzzle. I think the Nobel Prize Committee should be awarded the Nobel Peace Prize for making us all look at the deeper meanings of the word “peace” and awarding the prize this year to a man who has the whole world in his hands and is willing to hold it gently. His wife and daughters will now be able to point to the Peace Prize anytime he gets upset with them and that will be a good thing, too.
This blog post by a father of three explores the love/hate relationship that many people have with their midwives. I always like to see things from the perspective of the men.
By Eric Lee
Human Foolishness in obstetrics
There has been a discussion on the British midwives list about a bizarre product that is being sampled to obstetric units. It’s a gel that has no pharmacological effect but that the promoters want practitioners to believe will help make births go smoother.
All I can say is that I’m glad I didn’t have to swim my way through “bioadhesive” gel when I was born 62 years ago. What a bunch of baloney. I only wish I had the chutzpah to manufacture some sort of garbage like this to medical professionals and could get rich on stupidity. Maybe in my next life.
HAPPY THANKSGIVING TO MY CANADIAN READERS and please know that I give thanks for all of you who read my blog, leave comments (hint, hint) and link to me. I appreciate you. Gloria
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.
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). Conclusion:
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
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
> 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.
I’ve just been reading on the Lactnet list that the Swedes are implementing a policy of leaving the umbilical cord to pulse for three minutes after birth in order to prevent anemia in infants. This is in accordance with the latest “science” which was published in 2007. I’m mystified why a country takes until October 2008 to announce implementation of a meta analysis that was published in 2007 in a respected medical journal but I suppose that long delay is not as bad as countries who have just ignored the study completely e.g. the U.S. and Canada.
It is a matter of the utmost frustration to me to think about the fact that we need a meta analysis of studies to tell us not to amputate a pulsing organ from an infant as soon as the cord becomes visible and clampable. What “science” was ever used to start this interference in the first place? Absolutely none. It started as a matter of convenience and reaction. Convenience, in that the obstetrician could remove the baby from his/her sphere of responsibility and hand the baby over to a nurse or second physician. This allowed the obstetrician to get on with pulling the placenta out and suturing the episiotomy. Reaction, in that many babies have been anaesthetized so deeply by epidurals that their apparent lifelessness could be stirred into immediate response by cutting off the oxygen supply and forcing that infant to breathe/cry/respond and thereby relieve the anxiety of the attendants. Never mind that the baby lost up to 40% of its blood volume (Mercer 2002) and would become anemic in the first year of life. In their ignorance, physicians attributed infant anemia to insufficiencies in breast milk. Basic rule of obstetrics: when in doubt, always blame the mother and/or the baby.
The “science” in obstetrics often follows the lead of the alternative birth movement which points out the obvious. Unfortunately, it rarely goes all the way with backtracking on a bad practise. For example, when we had many parents in North America objecting to caustic silver nitrate being used in the eyes of the newborn, the medical profession finally came out with the idea of less caustic erythromicin ointment. Yes, the ointment doesn’t burn, but it still interferes with the newborn’s vision at an important time of imprinting and using antibiotics unnecessarily is inadvisable. It’s interesting that no eye treatment of newborns is done in the U.K. or Australia. So, a half-measure was tossed at North American parents to appease them and stop the demands for change.
We see the same mentality in so many areas of maternal/infant care—they just don’t get it! When we want mothers and babies kept together, skin to skin, in order to facilitate breastfeeding, the next thing we see is nurses jamming the nipple into the mouth of a baby who is just relaxing and not interested in nursing right at that moment. When the staff don’t understand that the pregnancy, birth, breastfeeding and recovery from birth are all one continuum, there is a frantic need to have “rules” and bend the mother/baby dyad to fit into those rules.
With this cord pulsing idea, what we see in actual practise in hospitals is:
1. the meta analysis is ignored and instant cord clamping still takes place
2. someone is assigned to watch the clock and 3 minutes is the exact cutting point as if that is somehow dictated by science (obviously it is not).
3. doctors invent a complicated explanation for withholding the baby from the parents for the time that the cord is pulsing i.e. “I have to keep the baby below the level of the placenta”. If that were true, why do babies do so well at homebirths where the midwife places the baby on the mother’s belly immediately and leaves the cord alone for over an hour?
To keep the cord intact, we have the science. We have the instincts. We have all the knowledge we need to leave an infant’s placenta alone without any harmful consequences whatsoever. Now, what will it take to change the hospital practice worldwide? As the consumer demand for homebirth increases, that may be the impetus for institutional change.
Henci Goer shared her frustration with UCLA Hospital on her blog when her premature grand daughter was born. The little girl’s umbilical cord was amputated immediately. I think it’s a big wakeup call to the rest of us that the woman who wrote “The Thinking Woman’s Guide to a Better Birth” can’t get evidence based care for her own family member.
This umbilical cord cutting issue is just one more reason why parents give birth at home for the safety of their child. If parents are planning to go to a hospital to give birth, I recommend that they plan a “Lotus Birth“. Keep the baby, placenta and cord all together until they bring the baby home. I’m sure the hospital will provide them with a cord clamp and they can be assured that their baby has received his/her full complement of blood from the placenta. I’ve even read that a few midwives in Australia have managed to have Lotus Birth for clients that needed cesarean section.