Updated: August 2022
Premature cord clamping/cutting
Premature cord clamping (clamping before placental transfusion is complete) has been the norm since ‘active management’ of the placenta became routine. In recent years, research has highlighted the harms caused by cutting the umbilical cord before placental transfusion of the baby. Premature cord clamping results in hypovolemia (reduced blood volume) and is associated with short-term and long-term outcomes (KC et al. 2019; Kresch 2017):
Short term (first 24 hours)
- lower blood volume
- lower oxygen saturation
- higher heart rate (to compensate for low oxygen)
- lower systolic blood pressure (ie. compromised circulation)
- decreased renal flow, and decreased urine output ie. major organs are not optimally functioning.
- lower serum ferritin levels and higher rates of iron deficiency anaemia at 6 months of age
- reduced fine motor function and social development at four years of age.
Awareness about ‘optimal cord clamping’ is increasing amongst parents and care providers (thanks to campaigns such as Wait for White). However, cord clamping during resuscitation is still an area of controversy. This post explores the practice of premature cord clamping when a baby is perceived to need resuscitation.
I was in a research team examining care provider practices during the birth of the placenta (Kearney et al. 2019). In our study, 29.1% of babies had their cord cut prematurely because of concerns for their wellbeing, either to obtain cord blood gases (13.4%), or to initiate resuscitation (15.7%). While the rate of ‘concerns for wellbeing’ was very high in this study, the practice of cutting the cord in these circumstances was not surprising. In hospital-based newborn resuscitation workshops, practitioners are taught to 1. assess the baby, 2. summon help 3. clamp and the cut cord, 4. take the baby to resuscitaire…. etc. However, this approach makes no sense if you consider the physiology of transition to extrauterine life, or the importance of the mother and the placenta in the baby’s transition and any necessary resuscitation.
The physiology of newborn transition
I cover the full physiology of newborn transition in my book Reclaiming Childbirth and in my online course Childbirth Physiology. However, here is a brief overview:
The baby/placenta has a separate blood system from the mother. The placenta does the job of the lungs by exchanging gas (oxygen and carbon dioxide) via the intervillous space between the baby’s and the mother’s blood system. Before birth, a third of the baby/placenta blood volume is in the placenta at any given time to facilitate this gas exchange. After birth, the ‘placental’ blood volume is transferred through the pulsing cord into the baby, increasing the baby’s circulating blood volume. This has two major effects:
- Provides the extra blood volume needed for the heart to direct 50% of its output to the lungs (8% before birth). This extra blood fills the capillaries in the lungs, making them expand to provide support for the alveoli to open. It also aids lung fluid clearance from the alveoli. These changes allow the baby to breathe effectively.
- Increases the number of circulating red blood cells which carry oxygen. This increases the baby’s capacity to send oxygen around the body.
The pattern and timing of the blood transfer from placenta to baby is influenced by several factors – in particular the baby’s breathing and/or crying (Boere et al. 2015). Textbooks and guidelines suggest the transfer takes 1-5 minutes, but some individual babies take longer. While the transfer takes place, oxygen continues to be provided by the placenta until the baby has established their breathing. Stem cells are also transferred into the baby during this time. There is a theory, and some evidence, that these stem cells play an important role in repairing any damage caused during birth. They may actually protect against cerebral palsy! Dr Mercer discusses this in more detail here. You can read my opinion on ‘cord’ blood collection in this post.
A study found that healthy self-breathing newborns are more likely to die or be admitted to SCN if cord clamping occurs before or immediately after the onset of spontaneous breathing (Ersdal et al. 2014). However, most babies can compensate for their lack of blood volume by readjusting their circulation to direct their blood to their major organs. The effects of reduced blood volume will be subtle but present (and long-term). If you get a chance to hear Karen Strange speak about neonatal transition to extrauterine life – take it. She shows photos of the heel capillaries of a baby who has had premature cord clamping compared to a baby who has not. The small blood capillaries are collapsed. They have shut down in order to send the reduced blood volume to the important organs.
Reasons for resuscitating a baby at birth
There are two reasons that caregivers cut an umbilical cord in order to resuscitate a baby. In both cases, their action creates difficulties for the baby. In the first, it can actually create the need to resuscitate.
1. Lack of knowledge, patience (and a bit of panic)
This often happens when a baby is slower to initiate breathing. The baby is still being oxygenated by the placenta but is waiting while the effects of an increased blood volume kick in. This is particularly common with waterbirth babies. These babies have good tone and slowly turn from bluish to pink. It can be difficult to even notice them begin to breathe. Their colour change may be the only obvious indication that they are making the transition. The cord pulses at the same rate as the baby’s heart, so feeling (or watching) it will reassure you that all is well. Unfortunately, the usual response to this situation is to clamp and cut the cord in order to resuscitate the baby. The likely outcome will be that the baby responds to the interruption of the placental flow and the stressful journey away from mother by crying. A worse outcome is that without the placental circulation, the baby is unable to complete their transition and becomes a compromised baby requiring resuscitation.
2. A compromised baby
This is a baby who has had a rough time during birth and might require a little external support to make their transition to breathing. This situation is often a result of interventions during birth such as directed pushing, artificial rupture of membranes, syntocinon/pitocin. It may also result from a tight nuchal cord reducing blood flow just before birth. A compromised baby is floppy and a blue/white colour. They may also have passed meconium during the birth, and their heart rate is slow and/or dropping. This baby could probably do with a bit of help, but most importantly, they need their placental circulation. While the cord is intact and blood is circulating, the baby is still receiving some oxygen, which is better than none. In addition, the extra blood volume and red blood cells will help to circulate any oxygen the baby gets via resuscitation.
Woman-centred, baby-centred, evidence-based resuscitation
Involvement of the mother and family
It is important that the mother, her partner and/or family members are involved in the resuscitation of a compromised baby.
For Baby: The baby has spent months inside their mother and learned her voice and smell. The baby has also learned the voice of those close to the mother ie. partner and/or other family members. To be held close, spoken to and stroked is often enough to initiate breathing. Even if further measures are needed, being held skin-to-skin with their mother is less stressful than being put on a resuscitaire.
For mother and other family members: Being able to see and touch your baby is important in minimising stress. Assisting with the baby’s transition reinforces the power of the parents rather than that of the care provider. Seeing what is happening is less stressful than ‘not knowing’ what is going on. In addition, mothers often instinctively know how to help their baby. I remember one mother telling me she felt her baby needed to be in a certain position on her chest. When she moved him, his breathing regulated perfectly.
Practical suggestions for resuscitation
Research is beginning to emerge in support of physiology and common sense. A recent randomised controlled trial concluded that resuscitation with an intact umbilical cord results in improved oxygen saturations and higher Apgar scores, with no negative consequences (Andersson et al. 2019). The discussion section of this article also cites research demonstrating that an intact cord improves resuscitation and reduces post-resuscitation complications.
However, most guidelines (and care providers) continue to recommend premature cord clamping for resuscitation. In contrast to most guidelines, WHO guidance on ‘delayed cord clamping’ states that “if the clinician has experience in providing effective positive-pressure ventilation without cutting the cord, ventilation can be initiated at the perineum with the cord intact to allow for delayed cord clamping.” Unfortunately, this is contradicted in the WHO guidelines on resuscitation of the newborn which state that “the cord should be clamped and cut to allow effective ventilation to be performed.” As usual, it will probably take many years to change a practice that was initially implemented without evidence.
Care providers often tell me they are unable to perform resuscitation without cutting the cord in a hospital setting because of how the equipment is set up (ie. fixed to a wall). However, paramedics in Queensland now resuscitate newborns without cutting their umbilical cord. If paramedics can do this in less than ideal settings, why can’t hospital staff? A simple bag and mask while baby is in their mother’s arms is all that is needed for the vast majority of resuscitations (not oxygen). On the very rare occasions that cardiac compressions are required, babies can be placed on any firm surface while still attached to their placenta eg. the floor, a small board. Hospitals need to make equipment/staff fit around the needs of the baby and mother – not the other way around.
The maternity system seems to thrive on spending money on unnecessary equipment. Then implementing staff training on how to use this equipment. There have been some feasibility trials assessing the use of a new mobile resuscitation trolley (Blank, et al. 2018; Brouwer, et al. 2019). While the commitment to supporting physiological placental transfusion is great… I’m not so sure another costly and unsustainable piece of equipment is necessary. As I mentioned above, simple equipment works well for out-of-hospital births, and could also work well for in-hospital births. And the already existing standard hospital resus trolleys also work effectively. All birth suites have mobile trolleys available in addition to any wall-fixed resus set ups. When I worked in hospitals, I avoided the wall-fixed resuscitation tables by bringing the standard trolley into the room if needed. I wheeled the trolley over to the mother and baby and plugged it into the wall. The cables and tubes are long enough to allow the IPPV mask to reach the baby-in-mother’s-arms.
One study assessing the use of the new mobile trolley found that having this option significantly increased the likelihood that the baby would be removed from their mother’s chest/arms (Sæther et al. 2020). This finding was for all babies, regardless of whether they needed resuscitation. I don’t find these results surprising. Introduce a new shiny piece of equipment, reinforce its value through staff training, and you will have staff keen to use it.
Another issue care providers bring up is blood gas analysis. This procedure is carried out if the baby has shown signs of distress during or immediately after birth (although some hospitals do this routinely!). It involves taking a small sample of the baby’s blood from the umbilical cord to measure the pH and other elements to determine if the baby was/is hypoxic. This is largely for litigation purposes – it does not alter the care of the baby or the outcome. Many care providers are under the impression that taking this sample requires cord clamping. This results in carrying out an intervention (clamping) known to compromise a baby, so that you can do a test to see how compromised that baby is – which is nonsense. However… if you really want to take a blood sample clamping is unnecessary.
“Sampling of cord blood for gas analysis may be performed on the unclamped cord right after birth without reducing the accuracy of the analysis.” (Thomasso et al. 2014)
I think that the next evolution of newborn resuscitation will be based around working with the placental circulation; and the following is my suggested approach to resuscitation – regardless of setting:
- Try and ensure that the baby does not arrive compromised by minimising unnecessary interventions.
- Do not clamp or cut the cord.
- Give the baby time to transition – if the cord is pulsing, the placenta is providing oxygen… relax and reassure the mother if she needs reassurance. Keep observing the baby for signs of circulation and respiration.
- Do not clamp or cut the cord.
- If the baby requires assistance, start small – gentle stimulation, talking, blowing in their face (all can be done by a parent).
- Do not clamp or cut the cord.
- If further measures are required, take the resuscitation equipment to the baby and resuscitate them in their mother’s arms.
- Did I mention – Do not clamp or cut the cord.
Note: Routine suctioning of the baby is totally unnecessary, invasive and could potentially create problems by stimulating a vagal response (a drop in the heart rate).
Babies are born with their own resuscitation equipment. The placenta not only helps the baby to transition, but assists with resuscitation if needed. There is no reason to clamp and cut the cord of a baby who needs help. Doing so will create more problems for the baby and mother. Anything that needs to be done can be done with back-up from the placenta, and the involvement of the mother.
Learn all about Childbirth Physiology, including the placenta and transition of the newborn in my online course.
- The Midwives’ Cauldron Podcast – placentas and cord blood
- Mercer and Erickson-Owens (2014) – ‘Is it time to rethink management when resuscitation is needed?’ Journal article
- Nicholas Fogelson (Obstetrician) gives a very clear presentation of the research regarding premature clamping in a lecture. The ethics of the research is questionable but hopefully the findings will help to inform a change in practice.
- Very interesting and thought provoking interview with Dr Mercer
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100% agree. Wonderful explanations and reasons for not clamping while resuscitating. The only time I’ve seen that was in a birth center I worked in because the baby needed chest compressions and the midwife didn’t have a hard surface to use.
I had a board made (that fits into a flannel pillowcase), with a cut-out handle, and put the “warm” items on it with the heating pads surrounding all of that. A stethoscope goes in there, too, in the middle, near the top, but not in a place where it can get too hot. The board follows mom around the house as she gets closer to the birth so if we need to do chest compressions, someone will hold the board (which is warm and with blankets warmed to dry the baby, too) while I/my assistant does the CPR. Blessedly, I have not had to use the board for that (please don’t say “yet” in your heads!).
I’ve certainly have used the bag and mask while mom is sitting, standing, standing in a pool and lying in a bed – all without cutting the cord. Even if the cord is shriveled and white, the *connection* to the mother is as vital as the oxygen that comes from a fat, pulsing cord.
Thanks for writing this. Really helpful!
The board and pillowcase are a great idea. I will look into making one myself. Thanks : )
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I do not attend many hospital births anymore but I am always amazed when hospital staff seem to disregard the cord’s function immediately after birth. They really seem to view it as an obstacle more than anything — it gets to the heart of perceiving normal birth physiology as pathological. I recently wrote about a birth I attended last year where the doc could not manage the mother’s two requests for physiologic cord clamping and immediately giving her mother the baby because she feared that placing the baby on the mother’s abdomen would cause blood to back flow into the placenta. How did humans manage to survive the birth process all these years??
It is sad how little is understood about physiological birth. I heard of an obs who thought ‘delayed’ clamping was lotus birth and weird. You can imagine her response when a midwife explained the difference : 0
I just put up pics of the resuscitation board if you’re interesting in seeing it.
Thanks so much!
Thanks for this! I love it!
I never “cut” the cord anymore. I use a burn box and 2 candles and about 1 to 2 hours after the birth I help the parents sever the cord by burning it. Not only does it completely prevent infection of the cord (I work primarily in developing countries) but it is also a very nice ritual – not nearly as abrupt as cutting. It gives us all the time to realized what is happening – the baby being severed from its internal mother and now transitioning into this place. It’s really quite lovely.
Thank you for sharing this. What a beautiful way to separate the baby and placenta.
Great article! 🙂
I too carry a board around, I bought a big bamboo cutting board.
I have not had any success with PPV in arms, as I find it very hard to position for an open airway. The board is helpful so that baby can remain close, yet can position well. I use this in the hospital as well instead of taking baby to the Ohio (resuscitaire). Though I have also seen mamas position their babies instinctively- it’s great!
Also, love the good use of the word “compromised”. It is not referring to babies who are able to self-heal, but those who need some external help.
Thanks for this; it really is the most detailed & informative explanation on the topic I’ve come across thus far. Before reading this, I was mostly armed with righteous indignation when trying to explain my position on premature cord clamping (I prefer that word choice, too). Now I can speak with authority AND passion. I consider myself to be on the slow path to midwifery, & this is quite a find. I’m really inspired & will definitely be a regular reader from now on!
Knowledge is power : )
I came across your blog and enjoyed reading this most recent post. I’m a midwife in the US and have some questions about midwifery in New Zealand. Would you mind contacting me? I’d love to talk to you. Thanks…
Jude – I am in Australia and it is very different in terms of midwifery compared to New Zealand. If you want to know more about Australian you can email me email@example.com
What a lovely article! It is informative, but not too technical. I will include it in my resources available to my doula clients. Most of my clients have researched and know that they want to let nature take its course. This will enhance the reading they’ve (hopefully) already done. Thanks!
Professional Doula, Massage Therapist
Thanks Amy – knowledge is power. Keeping sharing you knowledge with families x
Thank you so much for this article and the references. I had a baby just last night with a tight nuchal cord and she needed a couple puffs of PPV to really get going. I did it right on moms belly, chanting to myself “Do not cut the cord, do not cut the cord” (heart rate was good, just no respiratory effort). However, the nurses on the unit were in an uproar this morning and I just got a call from the director or nursing. She wants some articles to show why I would do such a thing!
I’m not sure where you work but if there is anything I can do to support you let me know. The hospital should be providing supporting evidence FOR the intervention of premature clamping not the other way around! Let me know how you get on. You can email me at: firstname.lastname@example.org
I am in the US, and I am the first midwife to have been granted privileges at the hospital where I am doing births. It is a small, rural hospital that has had the same OB there for about 30 years. So, they are just having to accept a different paradigm!
Maybe you will inspire them to change their practice : )
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Thanks for the great summary Rachel, I love the video of the mother resuscitating her baby too.
What I think is most reassuring is that the oxygenated placental blood is Mother Nature’s reliable back-up system when a newborn is slow to breathe. In my online article (http://www.sarahbuckley.com/leaving-well-alone-a-natural-approach-to-the-third-stage-of-labour) I tell the story of a baby that didn’t breathe for 7 recorded minutes due to thick meconium — long enough for brain cells to die from loss of oxygen — but this baby not only survived but was 100% normal as a teenager, because the attending GP/family physician kept the baby attached to his lifeline by not cutting the cord. That helps us all to breathe easier at birth 🙂
Thanks for the comment and link Sarah!
I also find it reassuring to have the placental circulation intact during transition and I don’t get worried about a baby until the cord has stopped pulsing. However, I am not sure how we can get practitioners to stop rushing in to disconnect the oxygen supply so that they can ‘resuscitate’. One of our midwifery students tried to discuss the notion of resus without cutting the cord with her midwife mentor. The answer was that I (the lecturer) was teaching dangerous practice and was playing with fire – she (the midwife) was in the business of saving babies. Women need to hear more birth stories like the one you have shared and if they are birthing in hospital go in with a written statement about not cutting the cord even during resus. Perhaps the change in practice needs to come from well informed women demanding change.
I’m a mid student and questioned ECC with my preceptor on placement last year. Same old response, that dcc will delay efforts to resus – because midwives can’t put two and two together and resus a baby on its mother? *head bang*
Do be too hard on your preceptor. Midwives tend to learn through experience and peer practice rather than research evidence. Often they are not confident to try something ‘new’ unless they know through observation or experience it will be OK. They are also often working in setting where if anything does go wrong the fingers point and if you are doing a practice that is not common, they point at you. It can be easier and safer to just do what you have always done and not question it. That’s why we need new midwives like yourself who will change future practice : )
I think it is fantastic that more people are becoming aware of implications of premature cord clamping as I had in my own experience, my baby was born and didn’t initiate breathing, folllowed by the midwife rushing my husband to cut the cord and wisk the baby away, all before I had seen him. The ultimate result was that I spent the first few weeks with my new baby feeling like I was minding him till his real mum came. I am now studying nursing with the intention of becomig a midwife and hope that this practice will have changed by then.
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Although I gave birth with a midwife, it was in a birth center in a hospital. We’d specifically requested to allow the cord to pulse until it was finished. My boy came out covered in meconium and the team *immediately* cut his cord and whisked him away. An instant after giving birth, and I was not pleased! He was screaming just fine! Thank goodness my husband stepped in and brought our son to me, eventually, while the “team” continued to work on him. But, that incident is the absolute low point of an otherwise beautiful and natural birth. I wish my “team” had read something like this. Eight months later, my son is thriving. Since regret gets one nowhere, I can only hope that midwives and other birth professionals read your blog.
Unfortunately your ‘team’ were just doing what is common practice and is expected of them (and with the best intentions). You can’t change the past but you can add your voice to a call for a change now. Share this information with others. Women having their baby in hospital need to write this in their ‘birth preference’ and clearly state that even in the case of resus they do not give consent for the cord to be cut.
Have you contacted the birth centre? A letter telling them you had a lovely birth but have concerns about their management of the ‘resus’ might get them thinking. Knowing how hospitals work a letter from a consumer holds a lot more power than a lowly midwife suggesting change.
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Amazing and VERY eye opening article. For those in a dangerous resuscitation this is wonderful and important info. Love the pics and videos, too! Placentas rule!!!
Wow, what a great blog post! When I gave birth to my son, he didn’t start breathing immediately, so of course the midwives cut the cord (even though we had requested that my husband cut the cord – he was very upset about this!) and started resus. At the time I thought this was normal, but now after reading this I know there is a better way to do things. Have bookmarked this page and will be putting this into practice for my next birth. Thank you 🙂
I have observed both premature and delayed cord clamping in my filming of births, and I am a great believer in delaying cord clamping, you can see a home waterbirth where the baby was seriously compromised and the midwife resuscitated baby on the floor whilst still attached to mother – see Aida’s birth diary on mybirth. Tv
I enjoy Reading your posts 🙂
Thanks for the link – I’ve added it to the post 🙂
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My name is Clare and I am a traditional midwife. I was born to know birth and this discussion of keeping the cord connected is something that anyone with any sense would know was not only right but crucial. I have always left the cord connected for a long time at least a few hours and with earlier babies then about 7-8 hours. I wrote this along with a fabulous obstetrician, Dr. Jade McGaff. I loved that she names it PUCM. Physiological Umbilical Cord Management. So here is something we wrote.
Physiologic Umbiical Cord Management
Our premise is that Physicologic Umbiical Cord Management does lead to healthier babies and mothers. Physiological management does not use cord traction, delays cord clamping and does not use oxytocin. Standard practice in hospitals is to immedicately clamp and cut the umbilical cord and administer oxytocin. This severing of the cord deprives the newborn of up to 30% of their blood and creates long term anemia. The administration of oxytocin interrupts the natural hormonal cascade integral to maternal/newborn bonding and successful breastfeeding.
• Anemia, (iron deficiency) in childhood is a serious problem affecting infant in developing countries. Numerous studies show an increase in iron stores in infants with delayed cord cutting. Studies confirmed this for babies examined at birth and at twelve months. Anaemia has an impact on behavior and brain development of babies as iron is important for myelination. Women & Birth(2008)21. 165-170 The importance of delayed cord clamping for Aboriginal babies in Austrailia is a life-enhancing advantage for infants in terms of increased iron stores.
• Delayed cord severing creates an increase in haemopoietic stem cells transferred to the newborn, which play a role in different blood disorders and immune conditions.
• Early clamping may force blood back into the placenta which increases the likihood of antibody sensitization for RH negative mothers who have an RH positive infant.
• For preterm babies this Physiologic Umbilical Cord Management is crucial. “The baby will reflexively switch from placenta life support to its’ own life support system and will clamp its own cord at precisely the correct, physiological time. J.Perinat. Med. 342006) 295-297 Walter de Gruyter, Timing of umbilical cord clamping revisited. J Pak Med Assoc. 59:468;2009
• Studies also report less intraventricular hemorrhage and fewer transfusions.
• Mother Health International does not use any form of induction of labor or induction of placenta delivery. This has resulted in better maternal outcome; less tears, bleeding and spontaneous safe delivery of placentas.
• Cord cauterization is the practice of using candles to burn the cord as a means of separating and cauterizing, while using universal precautions. The flame has similar qualities to moxabustion and brings the yang qi from the placenta and the fire energy into the baby. It has an ethereal and remarkable effect on the baby.
• By heating the cord and driving the last of the blood through the umbilicus you are giving a profoundly tonic treatment for the baby who has just run a marathon. You are “Warming Digestion”(Chinese tx) which stimulates the child to nurse longer and pass meconium quicker, reducing the tendency for jaundice.
• Cord AU reduces the risk of bleeding and entry of infections n infants where there is a lack of clean water. Haiti is a very damp, tropical environment where bacteria and pathogens are numerous.
• We have burned every cord of every baby that has been born at Mother Health International. We have had no cord infections.
• Many traditional birth attendants of developing countries will benefit from cord burning. Many midwives are using dirty, unsterilized scissors, razor blades and even bamboo. Cord burning dries the cord and cauterizes it and the cord will usually fall off within 2-3 days. It does not need to be treated or covered. This greatly reduces any risk of infection to enter the vessels of the umbilicus because it dries it out immediately, discouraging the growth of pathogens.
So keep this information flowing. It is the truth.
With respect and love for moms and babies,
Thank you for sharing this information Clare 🙂
Fantastic article and an astounding collection of birth videos. I hope it’s alright with you that I’ve linked to this article from my most recent blog post http://birthingfromwithinwestchester.com/2011/06/03/pulsing-cord-oxygenated-baby/
Not at all – thanks for the link 🙂
About terminology, I like “Natural clamping”:
“Placenta, clitoris, foreskin, Leboyer against adults’ violence”
Hello, I left a comment on the French version of your blog but I came here to read more comments. For what I see, I might be one of the few non midwives readers of your blog. Maybe this can explain why I am the oy one for was shocked by the ouside birth video. Although I understand how it illustrates your post, I really do not understand why she had to give birth standing, like she’s. “popping an egg”. I found this way of giving birth very disrespectful for the baby…but maybe I don’t understand the whole concept of this birth. Am I wrong to think that ? Can someone explain it to me ?
Except from that video, I really enjoy reading your great post and watching the other videos. I learned a lot, thank you !
Hi Marie. I think most readers of my blog are non-midwives – or at least those who comment seem to be. In regards to the video. My understanding is that the mother was attempting to get to a birth tent she had set up at the end of the garden but didn’t make it. She just happened to be walking and standing as the baby started to arrive. She instinctively drops to her knees as the baby is born. From the baby’s perspective I think this birth was far more respectful than the way in which many babies are treated at birth http://midwifethinking.com/2010/08/07/birth-from-the-babys-perspective/
I’m pleased you enjoyed the post – and thanks for coming over here to post in English 🙂
Me again ! I read the post “Birth from the babys’perspective and I do really understand what you mean about being direspectful with the baby. I loved the last video, truly !
I had 3 c-sections so I didn’t experience all the pushing of giving life naturally. Worse, I was separated for 5-6 hours from my first baby (with any medical reason except that she was born at 1,98kgs (some 200gs under the “hospital weigth limit”)) and was immediately taken outside the operating room without even a skin contact. So I know how this first contact is important. I do hope there are midwives (and obstreticians) in France who think like you and that the way that babies at birth are treated will change soon. I’ll keep in touch with your blog. ;-D
I am sorry that your baby was taken away from you :(. A small baby needs skin-to-skin to help regulate their temperature and initiate early feeding.
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Thanks a lot for your answer. I appreciate it ! I think I was essentially shocked by the way the movie was made. To my point of view, it was too much focused on the physical parts and took off all the beauty of a baby coming into our world. That’s why I said it looked direspectful of the baby. Maybe if the person recording the birth was in front of the mom (and not filming her bottom in big), I’d have thought differently.
Anyway, thank you again for your answer to my comment. I’ll certainly go to the link you suggested me and if you don’t mind, give you my feedback (about the link not about this post).
I’m a third year midwifery student and stumbled across your blog tonight. I am meant to be packing for a holiday – but I can’t stop reading. I am fortunate to have a lecturer who has a similar philosophy to you……I cling to it through every medicalised, disempowering birth I attend at the hospital. I sympathise with the commenter, Marie above, as I also had a C-section (under a general) and had first contact with my beautiful baby boy when he was nearly 3 hours old. We were seperated by 3 hospital floors and in my post operative state, I screamed until my baby was finally handed to me in recovery (apparently it is hospital policy to take baby up to maternity suite – i now work in this hospital as a student and refuse to transfer babies away from their mothers).
I fear for my own practice spending so much time in a tertiary hospital, yet I have been blessed by some amazing physiological births attended through independent midwife placements. When I am back on clinical placement next week, I will come home and trawl through my reflections and blogs such as yours to keep myself grounded.
I can’t thank you enough for the valuable information you share on your blog. You inspire me!
Thanks for your lovely comments Melanie. Don’t worry too much about your time in a tertiary hospital. I started my midwifery career in this type of setting and don’t regret it at all. I learned a lot about birth, how the system works and how to make little differences for individual women (as you are doing too).
You will maintain your midwifery philosophy if you keep believing in women and stay in touch with ‘other ways’ of approaching birth. Midwives in hospitals need good midwives more than those birthing at home. The women who choose to stay home already trust themselves and the process. The ones in hospital need information and their choices supported more actively. Just remember that you are ‘with woman’ not ‘with institution’ and keep your mind open an critical mind. The future of midwifery is safe with students like yourself x
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Very good post. Thank you. Lots of good information.
When my twins were born, the first baby was allowed maybe ten minutes before the cord was cut. When should the cord be cut for the first baby if there are two?
That is, the cord was left in tact until I was moved to the bed to check the possition of the second baby. The babies were 41 minutes apart.
Every twin situation is unique. Some practitioners think you should clamp the cord immediately to prevent any blood from the 2nd twin flowing out of the placenta into the 1st twin. But the likelihood of twins sharing a placental vessel is small. So, some practitioners just wait until the cord stops pulsing or even until the second twin is out. It should really be discussed with the mother and a plan made ahead of time.
I saw two different babies in those videos being blown on in the face after their births….can someone explain to me the reason that the midwife (and mother) were blowing in the baby’s face? I am aware that it will elicit a reflex for babies to HOLD their breaths….is there a reason that these newborns were being blown in their faces? (I have looked online and haven’t been able to find anywhere that it is recommended for a baby that requires resuscitation…?)
Why were they blowing in the baby’s face?
Hi Stephanie – Babies are born with sensory receptors in their facial skin (the trigeminal area). When air is sensed passing over the skin (eg. by blowing) the baby will gasp. This is thought to be one of the many factors that initiates extrauterine breathing and one of the reasons that babies don’t breath under water during a water birth. You can still see this reflex working in babies during a windy day. When the wind blows in their face they gasp. It is not recommended in official resuscitation resources. Official resources often reflect authoritative knowledge ie. knowledge that fits with the history and culture of society – not necessarily what works best. Until a randomised controlled trial is conducted the chances are ‘blowing’ will remain something that many practitioners do because they know it works. Of course if the baby does not respond more invasive resus is needed.
I hope that helps answer your question 🙂
I know about that reflex…but it specifically makes babies gasp and *hold their breath* and actually inhibits breathing. if a baby is in primary apnea, then stimulation to baby alone should be sufficient…and I would think that anything that causes baby to hold their breath would be counter productive.
I had a neighbor once who was RUSHED her baby over to my house knowing that I am a midwife, worried that that her baby wasn’t breathing well. She kept blowing into the baby’s face….until the baby’s lips turned blue and I said, “blowing is causing the baby to hold her breath….give her a second!” Baby turned pink again..I listened to hear and lungs, both perfect.
My own daughter at 2 months of age was outside with a breeze that causes her to hold her breath long enough that it kicked in her moro, fighting and struggling until I protected her (I know, bad mom, right! I felt bad for accidentally subjecting her to that)
but if baby is in secondary apnea, then no amount of stimulation (ie. rubbing, blowing in their face, etc) is going to help. But I am really trying to figure out how a baby in primary apnea would benefit from initiating a reflex that causes them to hold their breath….
(and I’ve never ever ever seen that here in the US….so maybe it’s a cultural/locational thing. I’ve done births in and out of hospitals in 2 different states over the course of 16.5 years and never seen that done until these two videos.) I would dearly love to see a study on this…but I am having trouble logically understanding how this could be helpful. (but, as always, mind open! That’s why I asked this question…always looking to learn new information..)
This is not sustained blowing. One breath = baby gasps (drawing in breath) – because it is not sustained the next thing the baby does is usually cry due to the stimulation. I am sorry I can’t give you a study to back this up but I have seen it time and time again. Of course if the baby does not respond you move onto other resus steps. In fact if the baby does not look good at birth you skip straight to the next steps… it is about assessing the situation and applying the best option rather than following flow charts. I think the best thing about trying this first is that it involves the parents. You are reinforcing their own expertise rather than taking over and saving the day. Try it next time… I promise it works. Practice is at birth is a cultural thing far more than a scientific thing. For example bulb suctioning seems to be a cultural practice in the US even at homebirths – I’d never seen this until watching it on youtube.
I would like to kindly suggest you are WAY over thinking things. In order to gasp, you must first, albeit quickly, in-draw air (aka breath). If you just held your breath there would be no gasping, along with no breathing. The quick gasp would be enough to initiate the transition to breathing.
Also, being a Canadian that had my baby at home, I also know the bulb syringe is not necessary. I would like to suggest that routine practice is actually quite harmful, and I think the bulb syringe contributes to the the abysmally low breastfeeding initiation rates in the US. One anecdotal case is an infant I provide nursing care to, that still has phenomenal feeding problems, due to over zealous suctioning at his very medicalized birth. He is still on a feeding tube @ 6 months old.
I had a homebirth with my first but was transferred to hospital due to my PPH & 3rd deg tears.
2nd birth (in hosp) I was told that (despite my birth plan) cord must be cut immediately so that syntocinon drugs could be administered to me to prevent PPH again.
I’m now pregnant for a 3rd time, is it safe to leave cord and wait and see if I need drugs for PPH? I’m unsure what I should request re cord clamping as I’d like to leave it until finished pulsing but want to provide an informed justification.
Definitely feels like you need to be “information armed against the system” to have a natural birth these days!
Love your blog!!!
You have the right to decline any intervention.
You could say that you want ‘delayed clamping’ unless you have a PPH rather than incase. You shouldn’t have to justify what you want to do with your body/baby. 🙂
Hello, I stumbled across your blog whilst preparing to give birth to my son (first child) and found it to be a breath of fresh air – thank you!
I am hoping that you might be able to shed some light on issues surrounding placenta velamentosa (or point me in the right direction to find some light). According to my passionate wishes my son was born at home, however the midwife soon became very concerned about the placenta and issued the warning that I would “bleed to death” if I did not go straight to the hospital and have it removed by hand under an epidural. It was an incredibly traumatic experience which complete stole away from me the precious first hours with my baby that I had labored so hard for. Of course I did not want to bleed to death, and would like to feel gratitude for the procedure but instead I feel in the dark about this condition and unsure about whether or not I could have had other options. I have thought about reconnecting with the midwife to talk things through (it’s almost a year later) but something of the trauma still surrounds the issue for me and I am not sure I can trust the midwife to tell me any more than she already did.
Holly – I really cannot comment on a situation I was not involved with. The definition of a retained placenta varies. Some hospitals will consider an hour too long to wait. The concern whilst the placenta is still inside is bleeding. If the placenta is having problems separating and partially separates you can have a huge bleed. This is why people get stressed waiting for placentas. This is the rationale for manual removal of the placenta. However, I know homebirth midives who have waited over 8 hours for a placenta without any complications occuring.
I love this information! Thank you so much for sharing. During the birth of my daughter we asked for delayed cord clamping/cutting but we had a long hard push toward birth, and after muconium (sp?) in the fluid and almost 3 hours of pushing they didn’t really respect the delayed cord cutting, they rushed her to the table to “clear her lungs” but she seemed to make noise right after she was born. I was exhausted and bleeding a lot so didn’t have much say in matters, and honestly am not sure what the exact situation was to this day. This time we are using a midwife instead of an ob at a much more baby/natural birth friendly hospital and are hoping again for delayed cord cutting. I know my midwife usually delays cord cutting but is there a way to emphasize the importance right after giving birth? A reminder? My husband was a bit overwhelmed at the moment. I would really love some advice!
I usually suggest writing in your birth plan (and showing it to your midwife on admission)something along the lines of: “My baby’s umbilical cord is to remain intact until I give explicit verbal consent for it to be cut regardless of the circumstances.”
Thanks! I will add that to the plan.
Just reread your article- wonderfully inspiring to continue to practice evidence based midwifery ! Love your work and your passion rachel ?
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This is not your usual response, but a huge ‘Thank you’ from an interested mother of 6, grandmother present for 4 of the 5 births, and now a greatgrandmother. In 1950 I so wanted natural birth and was called a ‘peasant’! No respect at that time for choices. So my first son was delivered using forcepts while I was uninformed and knocked out with heavy drugs. Of course breast-feeding was frowned upon, and, needing supplemental feeding, I choose strange new baggies which later became the better bottle! By 1959, after three more hospital birthings, I was wonderfully able to deliver twin girls, with hypnosis.
Sandy, daughter (# 6) had her child via invitro. She was/is enormusly greatful for her daughter, but again, no choices, At full turm and fine, her specialist Dr. insisted on a CC!
Grandaughter Rachel is now a healthy beauty at 16, but her mother went through a serious depression. Your midwife readers should know about Sandy’s well received book, published by Penguin: Mother to Mother; Postpartum Depression Handbook. Auther is Sandra Poulin.
Thank you for your information and leading edge work. Couldn’t stop reading all!
Thank you so much for reading and sharing your experiences!
What a wonderful, well considered article! I am a midwife and while expecting my DS (born in September) did a lot of research into cord clamping and resuscitation. While the midwives I booked with were perfectly happy with my plans to not cut the cord at all, and if resuscitation was required, to perform it with baby on me, once I was transferred to a consultant led unit I was cornered by the consultant. He declared that it wasn’t possible to resuscitate on mother as it required a flat surface, there was no resuscitation equipment in the birth rooms, and as for not cutting the cord I would have to have syntometrine due to a long labour and therefore would have to have the cord clamped.
Thankfully, the Dr who assisted in DS’s birth respected my wishes. The midwife wanted to take DS away for “a wee whiff of oxygen” but I refused as he was transitioning nicely, and breathing and heartrate were both fine. I hope all those present learned from the experience. I know one of the medical students (who wasn’t at the birth but was in the hospital while I was in labour) did – he came out with the midwife to visit me a few days later, just before the placenta/cord separated. I gave him a copy of one of Dr Sarah Buckley’s articles away with him for further reading.
I think a lot of the problem with implementing ‘new’ practices is because practitioners learn through experience. If they have not seen and experienced something (resus with placental circulation) they will not ‘believe’ or risk trying it. Hopefully those who witnessed your birth will believe and have the courage to change practice. 🙂
The Cochrane Review has apparently moved. The new URL (at least until they move stuff again) is:
Thanks! I’ve edited the link 🙂
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If there is a ABO blood incompatibility, and, you want to avoid a blood transfusion, (which can have severe adverse affects, depending on any allergic reaction the baby may be victim of), it is better to cut the cord. In those cases, the more blood that enters the baby may mean the difference between a mild and severe reaction which could result in additional complications and death. Not enough doctors encourage the use of non-blood alternatives to know if they would even help, but, they certainly wouldn’t have the risk factor of a blood transfusion. If anyone else has had any experience with this type of a problem, please email me your story at email@example.com.
It would be very unlikely that ABO incompatibilty would be diagnosed before birth, as routine testing is not done, nor do antenatal antibody levels correlate well with actual ABO incompatibility in the neonatal period. Given that a common effect of ABO incompatibility is anaemia, it would appear logical to me that one should allow baby to have their full blood volume if at all possible. Yes, the amount of antibodies in the bloodstream would be higher (yet there is no correlation between “delayed” cord clamping and higher jaundice levels), but the benefits to baby of all the other good stuff in their blood is also higher and would give them more resilience, surely?
I’m not sure that is true. The baby’s blood system is totally separate from the mothers. It is unusual for maternal blood to cross into the baby’s blood system. This can occasionally happen as a result of trauma in pregnancy or immediately after the baby is born. However, there is no evidence about how best to avoid this happening (eg. regarding cord clamping). ABO incompatibility is fairly easy to treat. Basically the red blood cells are broken down and the baby develops jaundice and can be treated with phototherapy. In some cases where the breakdown is very fast the baby can develop anaemia… anaemia is also a complication of premature cord clamping – so it may be best for the baby to have his full blood volume to begin with = less significant anaemia.
Anecdotally I attended the birth of a woman who had 3 previous babies – all of them born in hospital (premature clamping) and all required phototherapy for jaundice caused by ABO incompatibility. This baby was born at home and the cord was clamped after pulsing ceased, before the birth of the placenta – she wanted me to take blood to check baby’s blood group. The baby’s blood group was the same as her siblings but she did not develop jaundice.
Do you have any evidence to support the idea that early clamping reduces the risk of ABO complications? I would be interested… and I might be wrong 🙂
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I have been referred to your blog because I recently had my first visit at the hospital (in Brisbane) and they asked me to sign to donate my cord blood which means the cord needs to be clamped early. Now that donation can help save sick kids so I felt it was important. Also I was given a pamphlet to explain it all and NO NEGATIVE EFFECTS were listed at all. I would have signed it on the spot but my midwife suggested I do a little reading and then my natropath directed me here. So here is the thing – I am very open to what you are saying and now think it is probably better to wait but then I feel terrible for putting this ahead of other sick kids in need of cord blood. Is it possible that baby will be fine on delivery and we can then make an assessment that they will be ok without waiting for the cord to stop pulsing or would you just recommend to never cut the cord early? I am really torn! Thank you for any advice.
My advice is that you need to do what feels right for you – and take responsibility for your decision… this is a good foundation for parenting :). I think it is unethical that the hospital is asking parents to sign a form donating their baby’s blood. From a legal perspective giving inadequate information for a procedure (http://midwifethinking.com/2010/09/15/information-giving-and-the-law/) could open them up for actions of assault and battery or if there is a poor outcome (eg. baby damaged due to the consequences of reduced blood volume) a case of negligence.
The use of cord blood is very limited re. helping ‘sick kids’ at this time (there are other sources of stem cells available too). I don’t give recommendations but you need to consider that whether your child looks ‘ok’ at birth will not give you an indication of long term consequences of hypovolaemia (low blood volume) or a reduction of healing stem cells. I predict we will see more controversy arising around this issue as research continues to support delayed cord clamping for health. The World Health Organization is now advocating that all babies receive their full blood volume via delayed cord clamping.
Thank you that is a really empowering response. The more I think about it the more I am convinced by your argument. I have thrown their consent form in the bin! Thanks so much for this blog!
I am a second year midwifery student in Greece and found this article/post truly inspirational. I would like to make a presentation about delayed cord clamping for one of my courses. Hvae you got any pointer on how to proceed?
Only to gather the information and turn it into a presentation 🙂
Ok that’s great 🙂 I just wanted to make sure that was ok…ofcourse I will not take any of the credit for the information. Thank you 🙂
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I learnt that a baby born without cutting the placenta get all the blood he needed for development. Is it true?
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I cam across this article when I was doing some research after my hospital birth last summer. Despite my birth plan, because my water broke before labor began, my doctor insisted I start Pitocin after 12+ hours of no real labor contractions. Eventually I had to have an epidural because there was no break in the Pitocin induced contractions… and the epidural lead to directed pushing. My daughter was slow to breath so they put her on my chest to cut the cord, and swept her away to the corner of the room where they gave her breaths with the machine. The doctors say they do not know whether she was born with collapsed lungs, or if it was the breath machine being too powerful that caused them to collapse (she did have the cord wrapped loosely around her neck twice). The result of all of this was that she spent a week in the NICU with chest tubes to drain the extra air around her lungs, and is fine now, but I often wonder if the Pitocin intervention was the ultimate start of what happened at my birth. Interesting to think that if they had not cut the cord so quickly we might have been able to resuscitate her without the machine.
Thank you for this article.
May I ask, in cases where the cord was cut prematurely, what advice would you give the new mother and father to get things back on track? Example being where baby is on the neonatal unit for monitoring of low haemoglobin and a scalp bleed following a delivery with ventouse, forceps and immediate cord clamping. What steps can they take to correct or minimise the long term impact of the premature cord clamping? I’ve suggested kangaroo mother care but yours and others advice would be appreciated!
Lots of skin-to-skin and lots of breastfeeding. Babies are pretty resilient. I’d also encourage the parents to write a letter to the hospital about their concerns re. the intervention and subsequent impact on their baby. It might lead to a change in practice… or at least discussion around premature cord clamping and the consequences.
Wow. I hope we can use this information in all our births in Our Country.
I had two wonderful home births. The first in Switzerland 13 years ago! Our deautiful daughter arrived in the wee hours, snow falling outside, great central heating inside. After a very long first stage, my second stage was much swifter and she arrived too fast for my midwife to call in a colleague to assist, or to even put on a pair of gloves! 🙂 i was on a birthing stool and she rushed out in one go. Midwife caught her head, bum hit the living room floor! There she lay before us. Cord pulsing beautifully. Not yet breathing, but pink as a cherry,she opened her eyes and smiled up at me and her dad,who was supporting me from behind the stool. Smiled! Really experienced midwife had never seen that before! So, there she was. Pink. Smiling. Not breathing. Midwife started to get anxious. She was without professional backup. Or was she? I am an RN, with many years of critical care experience. I lent forward and felt the cord. Still pulsing. I stopped the midwife as she headed for the O2 mask. “Relax. The cord is still pulsing. She is fine”. We both stayed put, our fingers on the cord. Babe pink and happy on the floor between my legs! After a couple of minutes, the pulsing stopped. Babe didn’t immediately breathe. Midwife lunged for the O2. “Wait” I said. “Remember her CO2 levels have to rise enough to stimulate the breathing reflex! It’s OK!” I instinctively lent forward and gently rubbed her little chest with 2 finger tips. Our babe took a sharp, deep breath. I lifted her to my chest and wriggled across to the matress covered with warmed blankets on the other side of the room. Perfect APGAR scores. The change in thoracic pressures which occur once the cord stops pulsing along with the role played by blood gases on the brain stem are well known. What the hell is the excuse for ignoring such basic, medical knowledge in the birthing process? I thank God every day I became an accidental home birth mother. After 30+ years nursing, the absolutely LAST place I would want to give birth is inside a hospital!
Thank you for sharing 🙂
These videos of your babies being born are A Gift from God. Just beautiful !
I remain alarmed at the ignorance of hospital personel in charge of writing protocols. I am dismayed that legalities are placed before natural transition of babies into the world. Speak up and stop the unecessary practice of premature cord clamping to do cord gasses. This leaves hospital midwives questioning the protocol for best practice. Medical staff need to get serious about moving “towards normal birth”. Great article and one of enormous importance for all staff involved in being with women.
We need to begin talking about premature cord clamping. Saying ‘delayed’ supposed that it should have been other. Clamping is unnecessary too once the cord stops pulsing. Those horrible plastic pegs that are put on most babies are awful. Dental floss does well and saves the stump from being dragged on.
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Hi Dr. Rachel!
I am currently 36 weeks pregnant and am using your site to, as best I can develop a birth plan. I am currently living in Ontario, Canada. I just had my 36-week appointment with my midwife and brought up the idea supported in this article (that babies should be resuscitated on the mother) and she seemed to think that they probably could NOT do this (i.e. they would have to cut the cord in order to resuscitate) due to liability issues (they are trained to resuscitate on a table and she seems to think the cord would not be long enough even if we were to move the table close to me, and also that I might be in the way if they need to resuscitate). I’m just trying to cover my bases and want to know what my rights are regarding this issue.
Just FYI, we are going to attempt to birth in a pool (which I’ve recently heard can slow the baby’s transition to breathing). She says that less than 10% of homebirth babies need the cord clamped quickly/resuscitation, which still seems like a high number to me.
Would very much appreciate your thoughts/advice! So grateful for this website, and hoping I can actually use the essential information you’re providing 🙂
10% resus rate seems VERY high for low risk women birthing without intervention. The World Health Organization supports resus with cord attached. So in terms of litigation it could be argued that to NOT do this is risky ie. may result in a law suit.
Unfortunately institutional cultural norms influence practice far more than evidence or ‘best practice’.
I suggest having a very clear birth plan around cord cutting and resus. And have an advocate with you – eg. a Doula 🙂
Thanks for your reply. I do have a doula, actually, and she’s the one who introduced me to your website 🙂
I’m looking into this issue and will do my best to have a clear plan. I’ve contacted the training provider she told me regulated whether or not she could deviate from her training (the Neonatal Resuscitation Program) and they said that they don’t regulate anything! Hmm… seems like more conversations are in order. To be continued…
Would you by chance be able to send me a link explaining the WHO’s policy on resus with cord attached? I looked at the 2012 guidelines and I wasn’t able to see this explicitly stated.
It is not a policy… it is a statement/recommendation in this document: https://www.who.int/reproductivehealth/publications/maternal_perinatal_health/delayed-cord-clamping/en/
“…if the clinician has experience in providing effective positive-pressure ventilation without cutting the cord, ventilation can be initiated at
the perineum with the cord intact to allow for delayed cord clamping.”
However… I don’t think we need a policy or guideline when we consider physiology of transition and resus. Why would you cut the cord unless transfusion had ceased? I think the onus should be on anyone wanting to cut a cord to demonstrate that intervention is safe… not the other way around.
I’ve just shared photos of a resus at a waterbirth with cord intact on the MidwifeThinking Facebook page 🙂
Thank you so much for collating all this experience and knowledge into one website. I’ve found it invaluable before and after my homebirth!
I experienced pre-mature clamping at my homebirth. I think the hardest bit was the lack of interest the experienced midwife had in anything other than her existing training when we later talked about it. So I hope your website stays up for many years to come informing parents-to-be, and medical professionals alike.
Thank you too!!!!!!!!!!!
All my respect and admiration for you!!!!