Your baby has just been born.  Would you let someone draw their blood and remove 30% of their blood volume?

I became a midwife before I birthed my own babies.  People often ask me how my practice changed after I became a mother and gave birth.  All midwives advocate for the needs of babies, but giving birth to my own baby afforded me a more direct and visceral connection to the baby’s birth experience than I had previously known (among other things!).   I am more deeply attuned to how the both mother and baby experience labor, birth and the hours after birth — physiologically and emotionally;  From their passage out of the pelvis (or abdomen) to their first moments touching, hearing and smelling each other, it is a sacred and biologically unique time.

Harmful cord clamping practices are one of the first interventions experienced by most babies born in the US.  (Sometimes they are also needlessly bulb-suctioned or removed from their mother).  Cutting the umbilical cord within seconds of the birth, also known as premature or early cord clamping, is a routine practice of hospital births attended by physicians.  It is another intervention that has become so second-nature to physicians, and has gone largely unchallenged in the delivery room.

Dr. Nicholas Fogelson is a minority advocate for  ”delayed” or normal cord clamping within the medical community .  While he aptly draws a parallel between premature cord clamping and blood-letting in his latest video series, he is candid about just how far he has come in his practice:

For the majority of my career, I routinely clamped and cut the umbilical cord as soon as it was reasonable.   Occasionally a patient would want me to wait to clamp and cut for some arbitrary amount of time, and I would wait, but in my mind this was just humoring the patient and keeping good relations.  After all, I had seen all my attendings and upper level residents clamp and cut right away, so it must be the right thing, right?…….

Here you can clearly see the red, oxygen rich blood still in the cord that is about to be severed. This baby did not receive that cord blood that nature intended her to have.

Here you can clearly see the red, oxygen rich blood still in the cord that is about to be severed. This baby did not receive that cord blood that nature intended her to have.

During pregnancy, the baby’s blood circulates in a constant loop in and out of her body.  It flows through the body, back into the cord to the placenta, then back through the cord into baby’s body.  This pattern of circulation continues until shortly after the birth when the placenta separates from the inside of the uterus.  By the time the placenta separates, virtually all the oxygen-rich blood in the placenta and cord (up to 40% of the baby’s total blood volume) has made its way back into the baby.

Why do physicians cord the cut so soon after birth?  Most believe that babies if babies receive their full blood volume from the placenta they will have too many red blood cells (polycythemia) and become jaundice.   They aim to prevent this by clamping and cutting the cord immediately after birth which stops the flow of blood from the placenta into the baby.

Also, it happens to be extremely convenient for the Swiss clockwork *ideals* of a hospital. Cutting the cord right away allows staff to get on with two other routine postpartum practices: active management of third stage (which includes early cord clamping, pitocin and pulling on the cord to extract the placenta) and routine baby assessment.  While the doctor facilitates the birth of the placenta, nurses can move the unattached baby to the warmer to perform their standard newborn care and assessment.  On the warmer, babies are typically suctioned, dried, swaddled, perhaps given oxygen, etc.  Some mother-friendly hospitals have begun to perform newborn care on mom. (In homebirths, these things are almost always done on the mother’s abdomen, or just beside the mother, with the cord intact).

In hospital births, physicians typically clamp and cut the cord moments after birth, and often before giving the baby to the mother.

In hospital births, physicians typically clamp and cut the cord moments after birth, and often before giving the baby to the mother.

In premature cord clamping we have an intervention that has become almost universally embedded into hospital birth on account of convenience and a desire to avoid jaundice –  the only trade-off is a loss of up to 40% of baby’s blood!?  Despite popular medical opinion, research favors delayed cord clamping for both preterm and term babies and has not found a significant association with either polycythemia requiring treatment or jaundice requiring treatment.

Two meta-analysis addressed the subject in the last five years — the JAMA and Cochrane reviews.  While the Cochrane review did report a small increase in jaundice requiring phototherapy among late cord-clamped babies (5% as opposed to 3% in the early clamping group), these results were based on one particular study that has been criticized by experts and physicians for a number of good reasons.  It is an unpublished PhD paper written by one of the review authors, and since the study was not published or peer reviewed its design raises a number of questions: we don’t know whether the physicians referring to treatment were blinded, whether confounding factors were accounted for, or what threshold for treatment was used 12 years ago in Australia when the study was undertaken.  The JAMA review found no increase in jaundice requiring phototherapy.

I’ve seen a good number of jaundice babies in my years attending homebirths, so for argument’s sake let’s say babies who have delayed cord clamping do develop more jaundice.  Is really worth significantly reducing their blood volume in order to reduce their odds of becoming jaundice?   Jaundice is “physiologic,” meaning normal.  Many healthy babies will become jaundice regardless of when their cord was clamped.  The vast majority of newborns with jaundice are normal and healthy and do not require medical intervention.  Depriving infants their full blood volume is not a reasonable response to something as common as jaundice.

The placenta has been born and the parents are ready to clamp the umbilical cord. The baby has received her full blood volume.

Why should we leave the cords alone?
It would be senseless and highly dangerous and to remove a third of the baby’s blood from their body before they were born, but doing this immediately after birth has become the norm.  Reknown physician and author of Zoonomia, Erasmus Darwin, recognized the danger in premature cord clamping in the 1800s:

Another thing very injurious to the child, is the tying and cutting 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. (Zoonomia)

A little more physiology can help us understand why that blood is vital: Immediately after birth, babies transition from breathing amniotic fluid to breathing air.  This change requires the heart to pump far more blood to the lungs than it had before.  All the blood from the placenta and cord is needed in this process. The blood from the placenta also sends more oxygen around the body.  This transition process can take longer and be more difficult if the cord is cut early, preventing the baby from receiving her or his full blood volume.  In these cases babies often require supplemental oxygen — oxygen that would have been supplied by the umbilical cord.  We know now too that keeping the cord intact during resuscitation actually helps babies who are having trouble transitioning and breathing.  (Check out this new innovative mobile warmer unit from the UK that allows babies to be resuscitated with their cords intact).

 

Preterm babies also benefit greatly from delayed or physiologic cord clamping.  The benefits of keeping their full blood volume extend beyond the newborn period into infancy as well.  Babies have greater hemoglobin (iron) levels in the months after birth and benefit from the stem cells, antibodies and other life-sustaining components of their blood.

This cord was still pumping blood from the placenta to the baby when it was clamped. You can see blood in the vessels; the blood pressure gives the cord its shape.

This cord was still pumping blood from the placenta to the baby when it was clamped. You can see blood in the vessels; the blood pressure gives the cord its shape.

This cord has finished pumping blood from the placenta to the baby. You can see only a residual amount of blood through the cord. It is pale, flacid, thin and elongated.

This cord has finished pumping blood from the placenta to the baby. You can see only a residual amount of blood through the cord. It is pale, flacid, thin and elongated.

How do you know when the cord is ready to be cut? If the cord is still fat, taught, and spiral-ey, it’s not time to cut yet.  If blood forcefully spurts out when it was cut, it was cut prematurely.  It is almost always just as easy to wait until the placenta is born to cut the cord.  At homebirths, midwives typically wait to clamp and cut the cord until it  has stopped pulsing or the placenta has been born.  Waiting for the placenta also ensures that mothers and babies remain undisturbed in those precious and finite moments after birth.

I encourage women whose care providers insist on premature cord clamping to familiarize themselves with the subject and ask their physicians if they are aware of the body of research supporting delayed cord clamping.  You are your baby’s best advocate!

Resources:

Leaving Well Alone: A Natural Approach to the Third Stage of labour  –  Sarah J Buckley, MD

Delayed Cord Clamping Should Be Standard Practice in Obstetrics  –  Nicholas Fogelson, MD

Cord clamping researcher Judith Mercer talks about her study of delayed cord clamping for preterm, very low birth weight babies

This exceptional short video features renown midwives and physicians discussing cord clamping practices and the effects on babies: We Can Be Much Kinder

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  1. June 14, 2011

    Erin, very happy to see you blogging on this topic. As a staunch believer in ‘lotus birth’ I could only hope to see that one day our hospitals will start letting placentas be delivered before making the cut. A couple of really radical doctors, Dr. Morhely and Dr. Peter Dunn, did some experimentation on this subject in the 70′s I wish people would revisit their findings because they are quite profound. What was noticed,( in what most would consider an unethical experiment,) a needle was inserted into the umbilical vein immediately after the birth of the baby and a tube was attached to this and this was then attached to a sphygomanometer. This was a way to measure pressure and such after the birth of the baby. What was realized was with the birth of the placenta a huge surge of blood and whatever is carried with it ( oxytocin, other hormones, stem cells, endorphins-natural pain killers) is sent to the baby when it is squeezed through the birth canal, but there was also noticeable transference during the placental contractions leading up to the birth of the placenta. So what are we really depriving babies? More than is realized. Also, in regards to polycythemia, once the placenta is out the cord starts collapsing and getting thin and stops pulsating. At this time it is common to hear the attendants say, ‘the cord is not pulsating, we can cut” WRONG. If you feel at the navel of the babe it is still pulsating, Dr. Morhley noted that the baby is actually regulating its blood volume! The umbilical vein is valveless and allows for the baby’s physiology to regulate this. What I have noticed is that Lotus babies, babies whose cords are not cut for at least 24hrs rarely get jaundice and babies whose cords are cut within 2 hours or so, usually get really jaundice. Is this because we interrupted the biological dance between baby’s physiology and it’s placenta? I believe in a zen approach to this subject. Placenta and baby are formed simultaneously, why not let them fall away in the same manner? as above so below. I have wrote an extensive paper on this subject, I believe in it with every bone of my body! And in the words of one of my favorite Greek philosophers Aristotle ‘Nature does nothing uselessly”

  2. Sharon #
    June 15, 2011

    Very nice, and the comparison pictures of a early clamped cord and late clamped cord perfect.

  3. Natalie #
    June 16, 2011

    I will start by saying that I am a fan of letting nature take its course. I like to wait unless there is a VERY good reason to cut. I had one child who’s cord was so short I couldn’t bring him up onto me. He was cold, and it seemed weird to be trying to care for my child while he was stuck between my legs. I asked to cut the cord after about five minutes of trying to work with the cord length. However, my general experience in the hospital isn’t just about getting the cord cut early, it is also an extremely high stress environment. Honestly, I don’t want to deprive my baby of extra blood AND have people talking loud and moving my baby around aggressively. The last child I had was a homebirth transfer (3 days of ROM w/GBS and not steady contractions). After five contractions thanks to smelling some pit I gave birth on hands and knees. Oddly, I was the calmest person in the room. Nobody in the room who worked for the hospital had seen an unmedicated birth or any position other than lithotomy! Of course they wanted to cut the cord fast because surely the baby must be in danger. My biggest concern wasn’t the blood the baby wasn’t going to receive, but the general attitude of the people trying to help. I had to hide my baby in my arms so they couldn’t get to him, and I agreed we could cut the cord if people would calm down. Needless to say, he was my only child with significant jaundice, and he did require in hospital phototherapy at 5 days old. What I would really like to see is a greater respect for a natural event. We need to maintain a level of calm before and after a child is born. In some cases we need to move quickly, but do it with respect and reverence for a natural process. So many things are done out of fear regardless of the evidence in front of providers. Honestly, are you truelly seeing better outcomes when the cord is cut before physiology takes care of things? Where is the evidence that there is a significant improvement in the life of the mother or child if you cut the cord, clean the baby, and swaddle him or her up within the first five minutes of life?

  4. June 28, 2011

    Thank you for writing this article! I am a mother who experienced her baby’s cord being cut BEFORE he was born. My son already had cord compression due to nuchal cord and it was cut many minutes before he was born! The cord was clamped upon discovery after interrupting my contractions by digging around and trying to loop the cord. Words cannot describe how it feels to try to push your baby out without budging knowing they have severed him from his life supply. When the cord was cut there was no evidence it was causing any problem because I had only just finished giving birth to his head, he hadn’t rotated and I hadn’t had another contraction. This happened in 2004 by a midwife, many years after midwives were teaching each other the somersault technique. You can see horrid hospital birth videos on YouTube where they are still clamping and cutting nuchal cords – instructing the mother to stop pushing so they can cut the baby’s cord FIRST. I shared our traumatic birth experience and the issues it caused my son as a hypovolemic newborn (and associated developmental delay) at http://www.giftedbirthsupport.com/birth-story-nuchal-cord. Once again, thank you for contributing to the efforts to stop premature cord clamping!

  5. Beckie #
    June 29, 2011

    Quick question to the author or any other knowledgable peeps. What about if cord blood samples are required for Ph’s or Rh Neg etc? And how long can the cord be left if pitocin/ syntometrine is required?

    • newbe #
      May 6, 2012

      yes, I was pondering the same thing. active management of third stage of labor has been proven to save mothers lives from PPH, how can I have the best of both worlds and leave the cord unclamped?

      • Kim #
        June 17, 2012

        most of the blood is transfused by 3 minutes. If you clamp then and then milk the remaining amount in the cord from the placenta towards the clamp you can get enough for a blood type.

        FIGO and ICM have CHANGED the definition of Active management of third stage – in 2004. they no longer recommend early cord clamping – they recommend all women be offered IM or IV oxytocin after the birth of the baby and within 1 minute, gentle controlled cord traction (after delayed cord clamping and uterine contraction, and fundal assessment and massage after the placenta is born.

  6. kgjames #
    August 17, 2011

    Thanks, Erin, for this excellent informative post. Because I had been such a “problem” already for the OB who ended up attending my daughter’s birth, I didn’t challenge the immediate cord clamping. I had done a LOT of research on cord clamping and knew the benefits of delaying it and the harms that can occur when the cord is cut immediately. This was one of the MANY reasons I desired a HBA2C.
    ~ Kimberly http://labortrials.wordpress.com

  7. December 8, 2011

    Very interesting and thanks so much for sharing.

  8. Shannon #
    January 4, 2012

    Thank you for sharing. I do have a question though, I have to have c-sections when I have my babies, is it possible for the doctors not to cut the cord so soon during a c-section also?

    • February 8, 2012

      Shannon, YES! As a doula I have supported a couple who had a lotus c-section. Basically, the OB has to remove the baby and the placenta as quickly as possible, so the only real difference will be that someone has to stand and hold baby while s/he removes the placenta. So more inconvenient for them, but otherwise not an issue. Unless baby needs resus (and even then there is a case for not cutting the cord immediately, but you wouldn’t get that option in a section). You would have to advocate quite strongly for you choice though – perhaps a doula would be able to help you there.
      Good luck to you!
      <3

  9. Tabitha #
    January 4, 2012

    I was just at a birth where the midwife drew the cord bood from the base attached to the placenta, to take for RH- factor.

  10. January 4, 2012

    I love to read such wisdom from women about birth from babys’ perspective – we were all there once! And for most of us, the memory of the trauma is burried deep in our consciousness (as a Professional Rebirther I assist the release of this trauma for clients having realised the value to personal healing of doing so) often affecting our relationships with each other and the world around us.
    My thought is – will there be less violence/war/agression in the world when we realise that birth without violence is not only possible but an ideal to be cherished and practiced at every opportunity?
    Thankyou for your beautiful wisdom and important work …. janina

  11. Jessica #
    January 16, 2012

    This makes me wonder about cord blood transplants. We banked our youngest’s cord blood because he had a brain injury in utero. If we had just waited to clamp and allowed him to absorb the remainder of his cord blood, would a costly transplant have been necessary later on in life? Could he receive the same beneifts naturally, without medical intervention and the DMSO preservative required to transplant them?

  12. April 15, 2012

    Previledged to read all posted comments on delayed cord cut.Its absolutely a fact and so needs to be practiced,maybe except in HIV Aids women as it will increase the chances of the New born getting it.It’s a healthy practice.thx.

    • April 15, 2012

      Joshua, I have read the guidelines recommending immediate clamping and milking blood *away* from the baby in the cases of HIV…however the scientific literature showed there was no biological evidence this was necessary or prevents transmission of HIV. It is a theoretical assumption based on the idea that normal placental functioning, continuing in the minutes after birth for placental transfusion, can increase risk of maternal-fetal blood mixing. So while there isn’t evidence this happens during placental transfusion and transmits HIV, these babies are subjected to a significant hemorrhage.

  13. CNicole #
    April 15, 2012

    Wonderful article. One correction though, it was not Charles Darwin in that quote, but Erasmus Darwin (http://en.wikipedia.org/wiki/Erasmus_Darwin) http://www.bmj.com/rapid-response/2011/10/28/informed-consent-cord-clamping-ask-erasmus-darwin

    • April 15, 2012

      Thanks for the correction Nicole. I believe someone else has also corrected me. Better change that!

  14. NALUBOWA SAFINA #
    January 11, 2013

    I produced my son Ahmad at 8months and the doctors told me he has jaundice do you think it had to do with the way they cut the cord.

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