The Umbilical Cord: When do we clamp it?

Clamping the umbilical cord immediately at birth was something that I was taught to do as a routine part of 'delivery' management. The reason for clamping the cord so quickly, I was told, was to stop the baby getting unnecessary blood because the extra blood would be all the more for the baby to process and they would be at risk of becoming jaundiced, caused by the breakdown of all the fetal blood cells.  A nuchal cord (cord around the neck of the baby) was felt for and cut before the shoulders and rest of the baby was born.

Added to the problem of extra blood with an uncut cord, was the fact that the woman was routinely injected with a synthetic form of oxytocin to hasten third stage. The injection of the synthetic oxytocic in third stage made the uterus contract. Authorities believed that if the cord wasn't cut swiftly, the uterine contractions caused by the injection would cause an even greater surge of blood into the new baby, causing the baby to be overloaded with blood and at even more risk of jaundice. 

Once I started working with childbearing women in a one to one way in private practice, the need to clamp and cut the umbilical cord immediately at birth was challenged by the women I worked with. They wanted the cord to be left alone until it stopped pulsating. Some even wanted the placenta to be born before the cord was cut. A few wanted the placenta and cord to be left attached to the baby and allowed to drop off itself, a process called Lotus birth.

The literature was mixed in regards to the advisability of leaving the cord to pulsate or clamping immediately. The opposed camps had reasons such as jaundice, blood volume, postpartum haemorrhage rates to explain their particular views and reasons for their recommendations. The reasons for cutting the cord have been proven to be spurious.  There is however a lot of evidence for leaving the cord alone.  Women and midwives have been talking about and promoting leaving the cord alone as a best practice strategy for several decades now and the evidence for doing so is only getting stronger.  Have a look at the way the cord changes in the minutes after birth.  The evidence for leaving the cord intact is also clear in the case of nuchal cords. Leaving them alone, gently 'somersaulting' the baby to untangle the cord as the baby is born works perfectly and there is no risk of having the baby's oxygen supply prematurely interrupted.  As beautifully explained on the Midwife Thinking blog, the oxygen carrying capacity of an intact cord is the baby's first line of resuscitation after birth. Our medical colleagues have been slower to take up the idea of leaving the cord alone. However a 2011 report has confirmed that iron stores are improved when the cord is left to stop pulsating. A more recent review found that "newborns with later clamping [were heavier and] had higher hemoglobin levels 24 to 48 hours postpartum and were less likely to be iron-deficient three to six months after birth, compared with term babies who had early cord clamping".


A wonderful demonstration of why the umbilical cord should be left alone is provided by Penny Simkin in this video.

Hope for a more balanced approach to the topic of cord clamping or leaving it alone is on the horizon as an obstetric doctor in the US has written about what he calls 'delayed cord clamping' and has produced the following videos for The Grand Rounds on this topic.

Delayed cord clamping Grand Rounds 1

Delayed cord clamping Grand Rounds 2

Delayed cord clamping Grand Rounds 3

Delayed cord clamping Grand Rounds 4 

For more information on the umbilical cord and placenta, go to Rachel Reed's Midwife Thinking blog.  There is a post on the placenta in birth films on this blog here.

Another aspect that hasn't really been explored in great detail as yet, is the perfusion of the newborn's brain at birth. My thinking is that leaving the cord alone allows the newborn's brain to be optimally perfused and ensures that the neuronal connections that proliferate in response to birth to wire in the best possible way, especially when the baby is skin to skin with her/his mother and exposed to the multisensory stimulation that occurs in a physiologically mediated birthing experience. The question to be asked is "do babies suffer subtle brain damage through premature clamping of the cord and less than optimal sensory experiences at birth?" I suspect they do.


Some women want the cord clamped and pulled to get the placenta out as quickly as possible, others see the placenta as the spiritual twin of the baby and want to keep the baby and placenta together.  There are many reasons for leaving the transition to extrauterine life and resuscitation system alone, what's your view?

I can see the day dawning when we look back and say "remember when we used to think that cutting the umbilical cord prematurely was a good thing to do" with incredulous amazement.

Postscript: There is an article (8th October 2014) in the Journal of Midwifery and Women's Health on clamping the umbilical cord at birth. Called "Is it time to Rethink Cord Management when Resuscitation is needed" the article provides compelling evidence for leaving the cord intact and resuscitating a compromised infant by the mother's side.

Post Postscript: A landmark paper published 26th May 2015 has added evidence to my theory of brain & gut damage associated with early cord clamping:

The authors concluded:

Delayed cord clamping (CC) compared with early CC improved scores in the fine-motor and social domains at 4 years of age, especially in boys, indicating that optimising the time to CC may affect neurodevelopment in a low-risk population of children born in a high-income country.

PPS A non peer reviewed article discusses the issues of hypovolaemia in newborns caused by premature cord clamping says this:

Modern human childbirth is “managed” obstetrics, designed to avoid complications and to preserve physiology – a normal, healthy outcome. However, management often intrudes on physiology, producing unintended consequences.

and raises concerns around the potential for multiple organ damage, including brain damage with premature cord clamping.

Now for anyone not yet convinced of the value in leaving the cord to do its magic, this post from AWHONN on a Placental Transfusion for Neonatal Resuscitation after a complete Abruption may help you to change your mind!

Time for practice change everyone!

Where's the Placenta in Birth Films?

The placenta is an ignored organ in birth films. 


The following film is beautiful, but the cord is cut early and there is no placenta! I can't help but wonder why.



The way the woman gives birth so calmly and consciously in this video is a delight.  I love the way the tank enables the family, the midwife and the doctor to see what is happening without interfering or interrupting the woman's 'flow'. I also love the way the woman uses her hands to birth her baby's head and how she engages with the baby when the baby's head is born.  This woman was obviously well prepared for the birth of her baby.

BUT - where is the placenta???

The birth of the placenta is missing from most videos.  The fact that the placenta is missing from birth videos sends the wrong and incomplete message about birth.  Giving birth to the placenta is the third stage of labour. The third and fourth stage of labour, during which time the woman adjusts psychologically, physiologically and spiritually to the birth of the baby, are vitally important parts of the birth process. This period is a 'peak experience' time; one where women get surges of the 'love' hormone oxytocin if the environmental conditions are optimal. These surges in oxytocin are essential for optimal psychophysiological functioning for bonding with the baby, contraction of the woman's uterus, haemostasis and the initiation of lactation. 

The placenta is an awesome organ and needs to be given due respect and acknowledgment for the mighty role it plays in the beginning of life.

Many cultures have the Tree of Life symbol which is said to be a metaphor for the placenta; artworks across millenia demonstrate this potent recognition of the placenta's role in the life of a fetus and baby.  Not only is the symbolism missing in modern life, even the placenta itself is written out of the mainstream artform - that of videos.

Ignoring or dismissing the placenta comes at a cost.  Women don't know they have a placenta to birth; if they do know, they don't know the magnificence of it. What that means is they think birth is over when the baby is born. Unfortunately, thinking birth is over sends the wrong message to the neural networks and hormonal system.  Safe birth requires conscious engagement in the process.

A key lesson of modern neuroscience is that a change in the focus of our attention changes our brain firing patterns and changes the neurochemicals associated with the firing pattern. The practical application of this lesson is that our physiology responds to our thinking. The thought that birth is over when a woman doesn't realise that the birth of the placenta requires attention, especially when the feeling of relief is profound and/or the woman is disturbed/distracted from her baby and birth process can result in a blocking of the release of oxytocin.  A drop in the level of oxytocin can  predispose the woman to excessive blood loss because her uterus doesn't get the chemical messages it needs to contract well and seal off the placental site. The attentional network that I suggest is optimal in birthing the placenta and keeping safe in third and fourth stage of labour is the attentional neural network associated with fascination. When a woman is fascinated with her baby, she is safe and her physiology works as it ought. Disrupting, distracting or in any other way interrupting the fascinating network bodes trouble. Midwives have a duty of care to ensure the birth environment is conducive to women's fascination with their babies being enhanced and potentiated; a key aspect of midwifery guardianship. .

I've written a theoretical paper, with my colleague, Professor of Midwifery, Dr Kathleen Fahy,  on midwifery guardianship in the third stage of labour. You can access the abstract here. 

We also conducted a cohort study which showed that women who had active management of third stage were 7-8 times more likely to experience excessive blood loss in third and fourth stages of labour than women who were well prepared and, together with their families and midwives, had a mindful approach to the birth of the placenta.

The answer is: let's talk up the placenta, make sure women know that third and fourth stages are an integral and important part of labour and include the birth of the placenta as an integral part of any film about birth.
 
On this Mother's Day,  the recognition that knowledge is power and education about the placenta is lifesaving and helping women to stay safe in childbirth is a good thing to think about!