We will review three placental transfusion techniques: delayed cord clamping, intact umbilical cord milking, and cut-umbilical cord milking. We will also review resuscitation with an intact cord and the evidence in term and preterm newborns supporting this practice.
A detailed discussion of the physiology and history. The large set of references is a treasure trove for a scholar of cord clamping issues.
Immediate cord clamping produces the major deviations from
Immediate cord clamping (ICC) can destroy the physiology that activates all the life support systems of the newborn child
Rational neonatal resuscitation primarily involves the restoration and maintenance of adequate circulation through the brain and all feto-placental life support organs and systems. Amputation of a functioning placenta, and the blood volume contained in it, is an obviously injurious procedure; the organ most vulnerable to permanent injury is the brain.
Prologue by Faith
Gibson LM, CPM,
California College of Midwives, Midwifery Advisory Council,
MBC, Palo Alto, CA
This information on the value of physiological cord clamping under many diverse circumstances is a game-changer in both the practical and political arena. It is unique in that it comes from a physician-scientist and is not associated with consumer agitation, feminism, midwifery or the controversy over OOH birth. I know that is not a new thought to some, but what is new is that it isn't an opinion, a 'nice idea' or a probability, but an established fact that can be widely applied to improve care.
This study is even better in establishing that reduced medical intervention in normal childbirth is a 'best practice', as the Wax et al meta-analysis was in arguing that more medial intervention is more better. In particular, Dr Morley's paper should be of interest to the health insurance industry and the government-sponsored Medicaid program that pays for 40% of birth in the US.
At the most practical level, it will change how everyone manages childbirth -- normal, term, etc. and esp. for preemies and distressed neonates whose status can be dramatically improved by 3rd stage resuscitation via placental transfusion in the first 1-2 minutes after delivery.
Scientific methods are now able to prove that our standard immediate cord clamping protocol is an intervention that needlessly deprives a baby of a substantial percentage of his or her own blood supply and is one of the most major and potentially lethal inventions possible from the perspective of the baby's wellbeing.
It is the blood in the placental end of the continuous fetal circulatory loop that provides the volume needed to perfuse the lungs at delivery. Without access to its own blood reserve, babies don't have the total blood volume to necessary to maintain normal circulation in the liver and gut. Total blood volume is important in preventing hypoglycemia in term babies and necrotizing enterocolitis in preemies and sick neonates, as well as other or indirect pathologies.
This new scientific information challenges the general assumption that obstetrical intervention is better than biology, including the obstetrical profession's bias towards Cesarean and provides a biologically based answer for why elective CS are not 'better' and safer for the baby. It turns the obstetrical/neonatology world upside down by recognizing both the prophylactic and therapeutic value of normal birth biology, physiological cord clamping and 3rd stage placental transfusion.
While we don't have an equally compelling and concise research paper on other aspects of physiological management from the childbearing woman's perspective (right use of gravity for example), this demonstrates the hubris of assuming that everything 'natural' is automatically suspect or that the normal biology of childbearing is our sworn enemy.
It's sad to realize that the supposedly inconsequential intervention of immediate cord clamping -- used since the 1940s because doctors thought it was a harmless way to prevent the normal physiological newborn jaundice and the occasional case of polycythemia -- turned out be dead wrong. This intervention was taught to millions of doctors in developed countries and used for 70 years before reassessed and refuted.
Regular use of physiological cord cutting practices may explain why countries that are less wealthy and do not routinely medicalization normal childbirth have surprisingly lower NN mortality rates than the US, despite our fancy technology for intervening in delivery and supporting sick neonates in the NICU. This new perspective on the science of fetal-neonatal biology could both prevent problems and improve the care of newly born babies that are compromised for many different reasons.
When one considers the annual expense of NICU care in every developed country, that is a billion dollar opportunity to eliminate unproductive healthcare costs.
This would also make a lot of mothers happy, as they sat there holding their not-shocky newborns, instead of having babies that suffered low blood volume as a result of iatrogenic cord occlusion and needed to be taken way to work on and maybe admitted to the NICU for observation.
Be Standard Practice in Obstetrics from Academic OB/GYN
practices for the fetal to newborn transition - Many common
care practices during labor, birth, and the immediate postpartum
period impact the fetal to neonatal transition, including
medication used during labor, suctioning protocols, strategies to
prevent heat loss, umbilical cord clamping, and use of
100% oxygen for resuscitation. Many of the care practices used
to assess and manage a newborn immediately after birth have not
Primary Injury - Immediate clamping of the umbilical cord
before the child has breathed has been condemned in obstetrical
literature for over 200 years.
Waiting three minutes or longer before clamping a
newborn’s umbilical cord reduces the prevalence of iron
deficiency at four months, a large trial has found.. . .Dr. Ola
Andersson, the lead author and a pediatrician at the Hospital of
Halland in Halmstad, Sweden, pointed out that there were no
adverse effects to delayed clamping.
Failed by George Malcolm Morley, MB ChB FACOG - a great
article about leaving the cord intact, ESPECIALLY for distressed
umbilical cord clamping on iron status in Mexican infants: a
randomised controlled trial
Camila M Chaparro a, Lynnette M Neufeld b, Gilberto Tena Alavez c, Raúl Eguia-Líz Cedillo c and Kathryn G Dewey a
The Lancet 2006; 367:1997-2004
Delay in cord clamping of 2 minutes could help prevent iron
deficiency from developing before 6 months of age, when
iron-fortified complementary foods could be introduced.
review of the literature on umbilical cord clamping.
J Midwifery Womens Health. 2001 Nov-Dec;46(6):402-14.
infants' iron stores.
Mercer J, Erickson-Owens D.
Lancet. 2006 Jun 17;367(9527):1956-8.
Mercer JS, Skovgaard RL.
J Perinat Neonatal Nurs 2002 Mar;15(4):56-75
"Early clamping of the umbilical cord at birth, a practice developed without adequate evidence, causes neonatal blood volume to vary 25% to 40%. Such a massive change occurs at no other time in one's life without serious consequences, even death. Early cord clamping may impede a successful transition and contribute to hypovolemic and hypoxic damage in vulnerable newborns. The authors present a model for neonatal transition based on and driven by adequate blood volume rather than by respiratory effort to demonstrate how neonatal transition most likely occurs at a normal physiologic birth."
This unnecessary episode of transient hypoxia may contribute to anorexia in later life:
Source: Archives of General Psychiatry 2006; 63: 82-8
risk of developing anorexia nervosa and bulimia nervosa.
Favaro A, Tenconi E, Santonastaso P.
Arch Gen Psychiatry. 2006 Jan;63(1):82-8.
CONCLUSIONS: A significantly higher risk of eating disorders was
found for subjects with specific types of obstetric complications.
An impairment in neurodevelopment could be implicated in the
pathogenesis of eating disorders.
Early clamping of the umbilical cord may interrupt humankind's first 'natural stem cell transplant'
The USF review is published in a recent issue of the Journal of
Cellular and Molecular Medicine (14:3).
From a Norwegian Lactation Consultant
Subject: Sweden changes procedure for cord clamping, to reduce anemia
Heard the report on the radio just now. What follows is my
summary of the story as presented on Swedish radio:
Breastfeeding is not mentioned, but I am posting this because breastfeeding is often mistakenly held responsible for a baby's iron status, and it seems that iron is one of those nutrients we are meant to be born with, with a minimal amount being obtained through diet in the first half year of life.
A review of the literature on timing of cord clamping has led Swedish health authorities to recommend that all healthy babies have their cord left intact for two to three minutes after birth, to avoid iron deficiency anemia at the age of four to six months. Current practice is to clamp the cord immediately, ostensibly to prevent jaundice from too high a blood volume.
The review of the literature showed that the risk of jaundice is minimal, but the risk of anemia is significant. The review also showed that the newborn is deprived of important immunologic components of blood when cord clamping is immediate.
They are now planning to recommend that the baby be held at a lower level than the placenta for a minute or so, while it is being dried off and given a chance to 'scream itself up a little' (my translation - it sounds just as bad in Swedish, believe me!). I assume the aim is to get the vascular bed in the lungs properly filled with blood while the cord is intact. They expect to see far fewer anemic children in the second year of life.
It's likely that this is a Cochrane review, though that wasn't
mentioned in the version of the story as presented in the mass
media. One of the authors of the review is obstetrician
Lennart Nordstrom, from Karolinska University Hospital, and he was
interviewed for this story.
of the umbilical cord in full-term neonates: systematic review
and meta-analysis of controlled trials.
Hutton EK, Hassan ES.
JAMA. 2007 Mar 21;297(11):1241-52.
Conclusions Delaying clamping of the umbilical cord in
full-term neonates for a minimum of 2 minutes following birth is
beneficial to the newborn, extending into infancy. Although
there was an increase in polycythemia among infants in whom cord
clamping was delayed, this condition appeared to be benign.
Warning: Fetal Cord Blood Banking - a blog from The Healthy
"Pediatrics", the Official Journal of the American Academy of Pediatrics, has published an article recommending delayed cord clamping.
Let's see if we can't make sure all those OBs at our local hospital know about these new recommendations. (Realistically, some of them are going to wait for ACOG to give the official imprimatur, but we can help the process along by sharing this with clients, nurses, etc.)
"CONCLUSIONS.: Delayed cord clamping at birth increases neonatal mean venous hematocrit within a physiologic range. Neither significant differences nor harmful effects were observed among groups. Furthermore, this intervention seems to reduce the rate of neonatal anemia. This practice has been shown to be safe and should be implemented to increase neonatal iron storage at birth." [Ed.: It's odd that they call "delayed cord clamping" an intervention, since it's essentially delaying the actual intervention, which is clamping the cord. But I guess that from their point of view, it's "natural" for them to rush to clamp the cord, so they have to intervene in their own rush to intervene.]
of cord clamping on neonatal venous hematocrit values and
clinical outcome at term: a randomized, controlled trial. [Full
Ceriani Cernadas JM, Carroli G, Pellegrini L, Otano L, Ferreira M, Ricci C, Casas O, Giordano D, Lardizabal J.
Pediatrics. 2006 Apr;117(4):e779-86.
The following information is from Volume 3, Issue 3 of Research Summaries for Normal Birth, July 2006, from the Lamaze Institute for Normal Birth:
Summary: In this prospective, multi-center trial researchers examined the effect of delayed cord clamping on iron-deficiency anemia and clinical outcomes in term newborns. Two hundred seventy-six healthy women with uncomplicated pregnancies were randomized to three groups: cord clamping immediately after birth, at 1 minute and at 3 minutes. Venous hematocrit (to measure anemia) and bilirubin (to measure pathologic jaundice) were drawn at 6 hours and 24-48 hours after birth. Newborn physical exams were performed by clinicians who did not know to which group the infant was assigned.
Anemia at 6 hours of age was significantly more common in newborns who were randomized to the immediate cord clamping group. There was also a significant difference at 24-48 hours of age (16.8% of newborns in the immediate clamping group versus 2.2% at 1 minute and 3.3% at 3 minutes). Significantly more infants in the 3-minute group had elevated hematocrit levels (polycythemia) at 6 hours of age. However, none of the polycythemic babies exhibited symptoms or required treatment, and this difference did not persist to 24-48 hours of age. There were no significant differences in bilirubin values, rates of neonatal adverse events, or the infants’ weight gain and rate of exclusive breastfeeding in the first month of life. There were no significant differences in maternal outcomes such as blood loss or maternal hematocrit levels.
Significance for Normal Birth: Immediate cord clamping is
a practice that has been performed routinely for decades without
evidence of benefit. Placental transfer of oxygenated blood,
nutrients and stem cells continues for several minutes after
birth. Physiologic principles suggest that the optimal transition
to life outside the womb depends on this transfer. The study
authors note that higher newborn iron levels at birth correlate
with less likelihood of childhood anemia, a condition with
long-term neurologic consequences. Some pediatricians recommend
iron supplementation for breastfed infants, but it may be that by
providing the full complement of iron, delayed cord clamping is
the only iron supplement healthy babies need. As an added bonus,
delayed cord clamping keeps babies in their mother’s arms, the
ideal place to regulate their temperature and initiate bonding and
breastfeeding. This may be an important first step in promoting
non-separation of mother and baby after birth.
Clamping at Birth May Reduce Neonatal Anemia - CME
cordclamp.com - To educate the childbirth professions and the public regarding the functions of the umbilical cord and placenta before, during and after birth, and the injuries resulting from disruption of those functions by a cord clamp.
www.cordclamping.com - The Dangerous Practice of Early
Clamping of the Umbilical Cord - this is an extensive collection
of writing pertaining to the subject of cord clamping. This
site is striving to be the main web repository of scientific and
medical support for allowing the baby to receive an optimal
placental transfusion at the time of birth via an intact cord.
Umbilical Cord from the UK Midwifery Archives
www.lotusbirth.com - This site is maintained by Donna Young, a dedicated advocate of newborn rights to prevent premature cord clamping.
Other sites by Donna:
Dr. Sarah Buckley's
Declaration, Don't Clamp the Cord.
Clamp the Umbilical Cord Early and Risk Injuring Your Child's Brain by G. M. Morley, MB, ChB (Ed.), FACOG
AND RELATED DISORDERS - IS A COMMON CHILDBIRTH PRACTICE TO
BLAME? By George Malcolm Morley, MB ChB
Damage: The Unrecognized Iatrogenic Cause - 20
December 2002 by Cory A Mermer - An article about a specific risk
factor (chorioamnionitis) that is made worse by clamping/cutting
the cord prematurely.
Here's the study showing that the placental tissue contains pluripotent stem cells, in addition to the blood stem cells in the baby's blood. Advocates of lotus birth have claimed that there are immune system benefits to leaving the cord intact for multiple hours after the birth. I wouldn't be surprised if future research showed that some of the pluripotent stem cells from the placental tissue migrate along the cord into the baby's body to help heal birth trauma. It would sure be a huge adaptive advantage!
Amniotic Epithelial Cells.
Miki T, Lehmann T, Cai H, Stolz DB, Strom SC.
Stem Cells. 2005 Aug 9
"Amniotic epithelial cells develop from the epiblast by 8 days after fertilization and prior to gastrulation opening the possibility that they might maintain the plasticity of pre-gastrulation embryo cells. Here we show that amniotic epithelial cells isolated from human term placenta express surface makers normally present on embryonic stem and germ cells. In addition, amniotic epithelial cells express the pluripotent stem cell specific transcription factors octamer-binding protein 4 (Oct-4), and nanog. Under certain culture conditions, amniotic epithelial cells form spheroid structures which retained stem cell characteristics. Amniotic epithelial cells do not require other cell derived feeder layers to maintain Oct-4 expression, do not express telomerase and are non-tumorigenic upon transplantation. Based on immunohistochemical and genetic analysis, amniotic epithelial cells have the potential to differentiate to all three germ layers-endoderm (liver, pancreas), mesoderm (cardiomyocyte), and ectoderm (neural cells) in vitro. Amnion derived from term placenta following live birth may be a useful and non-controversial source of stem cells for cell transplantation and regenerative medicine."
Potential stem cell source found in placentas - Scientists seeking less controversial alternative to human embryos [Reuters, 8/5/05]
stem cells in placenta [Reuters, 8/5/05]
Early clamping of the umbilical cord may interrupt humankind's first 'natural stem cell transplant'
The USF review is published in a recent issue of the Journal of
Cellular and Molecular Medicine (14:3).
It's always bothered me that umbilical cord clamps are rigid and relatively large and firmly attached to the baby for at least the first day of life. What fun is it for a baby to be belly-to-belly with mom when there's this nasty clamp sticking into the tummy? I've seen babies who weren't latching on well because the clamp was pinching, twisting, pulling or poking some part of their body. That's not the easiest way to get breastfeeding off to a good start!
Fortunately, there's an easy solution to this problem . . . the Averbach Cord Bander, invented by Dr. Louis Averbach; it leaves only a tiny rubber band securely "clamping" baby's umbilical cord. It's a bonus that they're environmentally more responsible as the disposable rubber band is very tiny compared to the bulky plastic disposable clamps. (Those reusable, metal clamps were most reusable of all, but they are no longer available, and they were still very poky to babies! Cord tie is also soft and flexible, but may come off as the cord dries and shrinks; this isn't really a problem but can be troubling to new parents.)
The Averbach cord bander is significantly more cost effective as
well - the instrument itself costs $85, but each little rubber
band costs only eight cents, compared with sixty-five cents per
plastic cord clamp. The cost of the instrument is recovered
after only 132 births! All the subsequent births actually
save the hospital money, in addition to helping mom and baby get
off to a better start with breastfeeding. The Averbach Cord
Bander can be purchased from Cascade,
1-800-443-9942, item #3376.]
[Editor's Note - Some midwives say that if you delay cutting the
cord until an hour or so after the birth, there will be no
bleeding at all from the stump. Other midwives say that you
should worry about the cord "bleeding out" for at least 24 hours
and maybe even longer. Many hospitals will leave the plastic
clamp on if a baby is discharged before 48 hours.]
There's a new type of cord clamper and cutter that is even WORSE than the traditional metal or plastic clamps - it's The Joey™ Clamp & Cutter - you won't believe this, but it leaves a big plastic teddy bear face on the baby's belly button. The proportional size for an adult would be about 5 inches wide and 2" high . . . bigger than most western belt buckles! That's got to feel awful belly to belly (for both baby AND mom), and it would catch even more on the diaper than the other types of clamps. In addition, even though this is a very new device, their information about cord care is outdated - they're still recommending alcohol on the cord four times a day. It's Byzantine!
The doctor in the video admits that they use this solely for the
convenience and protection of the care provider, because it
protects against blood splatters when needing to clamp/cut the
cord very quickly, as in the birth of multiples. Well,
here's a suggestion that doesn't compromise the needs of the
practitioners while considering the comfort of the baby. Why
not use the Joey to clamp/cut the cord a few inches long, and
then, later, when there's time to do this in a way that doesn't
threaten the provider's safety, you could recut the cord shorter,
using an Averbach clamp or even cord tie. That's the most
humane kind of clamp for a newborn.
From a parent:
I've been wading through the issues on this and came across an observation that really grabbed me (one of those "A-ha!" moments).
At the moment of birth, the placenta holds a portion of the baby's blood in reserve. Nature (God) designed an amazing system for insuring a smooth transition from womb life to breathing. The blood passing between the baby and the placenta carries oxygen to the newborn (possibly even after the placenta has detached and delivered!) This system is especially useful to the distressed newborn. Midwives have performed medical "miracles" by simply leaving a floppy baby attached instead of clamping, cutting and whisking off to the warming table. Try broaching the idea of performing newborn resuscitation on your belly or bed while the cord remains attached and see what your practitioner says. Might make a good litmus test for determining how committed a midwife/doc is to "natural" birthing.
OK, my A-ha... I read a post from a midwife that
called the placenta one of the baby's organs. How
thought-provoking! What rational human being would even
consider amputating a live organ when waiting just an hour or so
will cause it to expire naturally? The whole idea seems
distasteful when considered in this light. Doctors swear to,
"First, do no harm..." Clamping off a child's blood supply seems
pretty harmful to me.
At separation, the placenta still has oxygenated blood in it, and this continues to be transfused into the baby for an undetermined amount of time, even after the cord stops pulsing.
Really recent research shows that the placental tissue contains pluripotent stem cells, in addition to the blood stem cells in the baby's blood, euphemistically called "cord blood" as if it's any different from the blood in the rest of the baby's circulatory system.
Advocates of lotus birth have claimed that there are immune
system benefits to leaving the cord intact for multiple hours
after the birth. I wouldn't be surprised if future research
showed that some of the pluripotent stem cells from the placental
tissue migrate along the cord into the baby's body to help heal
birth trauma. It would sure be a huge advantage!
Don't Cut The Cord! - a great summary
article with tips for parents planning to give birth in the
Clamping? by Gloria Lemay
Cord Integrity by Gloria Lemay [9/3/09] - I’ve written
before on this blog about the wonderful tether that keeps a baby
close to his/her mother after birth. Here are some more
ideas about preserving the sanctity of the umbilical cord and
being respectful of the hours after birth. Here are some of
the thoughts and ideas I have gleaned over the years about leaving
the umbilical cord intact until at least the placenta is birthed
(extended delayed cord clamping) or not cutting it at all (lotus
Interventions - "Early clamping of the umbilical cord: Cutting
the ties that bind" by Cory A. Mermer - a longer article,
but well worth the read!
Five Good Reasons to Delay Clamping
Risks of Premature Cutting of the
Umbilical Cord, with some tips on encouraging the hospital
staff to provide the best care for your baby.
Civil Action to Protect Baby's Umbilical
Cord- a caring parent suggests threatening legal action
against providers who clamp or cut the umbilical cord without the
A response to an obstetrician’s opinions on delayed cord clamping - This article responds to common unfounded opinions with current scientific evidence about fetal/neonatal physiology and delayed cord clamping.
One of my labor coaching clients discussed delayed clamping with her OB - the response was that if they didn't clamp the cord, all the blood would drain out of the baby.
Oh, now it occurs to me that maybe the OB didn't understand that
the point was to delay both clamping and cutting.
Maybe she thought the woman was talking about cutting the cord and
not clamping it? That's the only way the OB's remark makes
I cut my daughter's cord about 2 hours after birth and there was
not a single drop of blood coming out. So, delayed cutting needs
no clamping if you wait long enough.
The idea re-surfaces every couple of years that a baby's circulation will be overloaded with RBCs and he'll develop polycythemia or severe jaundice if he's held "below the level of the placenta". The idea gets dumped each time and then rises again!
There is NO relation to polycythemia, jaundice and time of cord clamping. RBCs are higher when cord-clamping is delayed. Immediate cord clamping deprives babies of their NORMAL blood counts, delayed cord-clamping gives them their NORMAL blood counts. The lower rbcs of immediately clamped babies are associated with anemia and jaundice. The higher rbcs of delayed clamp babies are associated with normal hct/hgb as late as age one year -- and are NOT associated with jaundice.
The position of the baby is irrelevant unless there is a two foot
difference. A baby held elevated more than two feet above the cord
can become hypotensive if the cord is still patent, and if there
is a fetal/placental transfusion. A baby held more than two feet
below can acquire more RBCs -- although this hasn't been linked to
any problems (an earlier claim from the 70s was debunked). It was
even routine for many decades for doctors to hold the baby below
the level of the placenta in order to encourage a higher
At birth, a baby has full control over the flow of blood into the
placenta, through the arteries, and the baby shuts these down once
there's adequate oxygen coming from the lungs. After that, there's
no longer any incoming pressure from arterial blood to move the
blood out of the placenta and into the umbilical vein and back
into the baby. But the uterine contractions that are busy
separating the placenta and stopping the mother from bleeding to
death are going to be generating a lot of pressure into the
umbilical vein, regardless of the gravitational forces. And the
valves are going to keep it from flowing back to the
placenta. You would expect a net transfer of blood from the
placenta into the baby's body regardless of whether the baby is
held above or below the placenta.
In 1801, Erasmus Darwin, grandfather of Charles Darwin, warned
against the early clamping off the cord. He wrote, "it would be
very injurious to tie 'the navel-string' too soon" and urged that
clamping be delayed until the infant has breathed repeatedly and
all cord pulsation ceased. [Darwin E. Zoonomia. Vol III 3rd ed.
From Williams' Obstetrics, 1929, p. 358: "The question as to the proper time for tying the cord has given rise to a great deal of discussion. Formerly it was the custom to ligate it immediately after the birth of the child; but Budin showed that 92 cubic centimeters more blood escaped from the maternal end of the cord after early than after late ligation, thus indicating that that amount was lost to the fetus by early ligation. Schucking demonstrated the same fact by weighing the child just after birth and again after the cord has ceased to pulsate. Budin believed that this amount of blood was drawn in the circulatory system of the foetus by thoracic aspiration, while Schucking held that it was driven into it as a result of the compression of the placenta by the contracting uterus.
"I have always practiced late ligation of the cord and have seen no injurious effects following it, and therefore recommend its employment, unless some emergency arises which calls for earlier interference.
"After ligation of the cord, the child should be wrapped in a
piece of flannel or blanket prepared for the purpose and laid in a
safe place until the placenta is born and the mother has been
cleaned up and made comfortable." [I include this last sentence as
a glimpse into another time when the newborn was regarded as an
object, unconscious and unfeeling.]
Early umbilical cord clamping risky
10 May 2007
University of Granada
MedWire News: Clamping the umbilical cord early is not justified and may do more harm than good, research shows.
Recently there has been a trend towards clamping the umbilical cord immediately after the baby is expelled instead of letting the blood flow stop naturally.
But Catalina de Paco Matallan, from the University of Granada, says that this new practice lacks studies to confirm its benefits.
She analyzed the umbilical cords of 151 newborns from full-term pregnancies, 79 were cut within 20 seconds and 72 cut within 2 minutes of the baby being expelled.
Umbilical cords cut a few seconds or a few minutes after birth contained similar amounts of hematocrit or hemoglobin.
It also took a similar amount of time to remove the placenta among babies with early and late clamping and there was no difference in the mother's bleeding after birth.
De Paco Matallana says this means her study "has not found any scientific evidence to suggest that the practice of early clamping is advisable or to justify the abandonment of late clamping in newborns from full-term pregnancies."
Early clamping also meant that babies were more likely to need oxygenotherappay after birth.
De Paco Matallana concludes: "There are convincing findings for
and against the two different types of clamping analyzed in this
study, which shows not only the complexity of the problem, but
also that research in this field may not be controlled enough or
practical approach to timing cord clamping in resource poor
van Rheenen PF, Brabin BJ.
BMJ. 2006 Nov 4;333(7575):954-8.
spontaneous vaginal delivery as part of the management of the
third stage of labour.
Soltani H, Dickinson F, Symonds I.
Cochrane Database Syst Rev. 2005 Oct 19;(4):CD004665.
AUTHORS' CONCLUSIONS: It is difficult to draw conclusions from
such a small number of studies, especially where the review
outcomes were presented in a variety of formats. However, there
does appear to be some potential benefit from the use of
placental cord drainage in terms of reducing the length of the
third stage of labour. More research is required to
investigate the impact of cord drainage on the management of the
third stage of labour. [Note that cord drainage can be effected
even after cutting the cord by not clamping the placental side of
the cord, or unclamping it after the cord is cut. The open cord
can simply be allowed to drain into the placenta bowl.]
delayed cord clamping in term infants born to Libyan mothers.
Emhamed MO, van Rheenen P, Brabin BJ.
Trop Doct. 2004 Oct;34(4):218-22.
"Delaying cord clamping until the pulsations stop increases the
red cell mass in term infants. It is a safe, simple and low cost
delivery procedure that should be incorporated in integrated
programmes aimed at reducing iron deficiency anaemia in infants in
analysis of a usual neonatological conduct.
Acta Physiol Pharmacol Ther Latinoam 1998;48(4):224-7
This research found that delayed cord clamping does increase the
number of red blood cells in the baby's body, causing a transitory
polycithemia not associated with any problems. [Editor's note - I
wonder if the peak at 12 hours is because that's the crossover
point where the baby is able to replace fluids in the blood from
the digestive tract. It would be interesting to have some studies
to show the correlation between the baby's "using up" the fluid
from the blood and beginning to break down the bonus red blood
cells for iron stores.] This study postulates that much of
the jaundice attributed to clamping the cord after it stops
pulsing is actually caused by routine vitamin K administration,
which was omitted in this study.
Anne Frye had this in her Holistic Midwifery (Vol II: Care During Labor and Birth, 492):
(Regarding postbirth uterine ctx): The placental venous pressure (the pressure in the umbilical vein) is 49 mm Hg between contractions; as the contraction peaks, it rises to as high as 102 mm Hg. High venous pressure during pushing and immediately after birth moves blood from the placenta into the baby. The spiral arteries of the uterus under the still-attached placenta supply oxygen as the blood is transfused in successive spurts with each uterine contraction. Thus an uninterrupted supply of oxygen-saturated cord blood continues to flow to the baby for as long as the placenta is attached to the uterine wall, normally at least three minutes after birth....
However, she goes on to quote a study by Gunther (1957):
Poor uterine contractility allows umbilical venous blood to
flow in either direction. Thus, the baby should be
held below the level of the placenta in these cases.
[I'm not entirely sure what is meant by 'poor uterine
contractility,' but if the placenta followed the baby right out,
perhaps it would be a good idea to bring it right up level
with the baby, which she mentions several times as a good
idea for a completely physiological third stage.]
study of the relationship between the delivery to cord clamping
interval and the time of cord separation. Oxford Midwives
Midwifery 1991 Dec;7(4):167-76
There was an unexpectedly higher rate of breast feeding at home in the late clamped group which did reach statistical significance. Overall the trial provides no clear evidence for the benefit of early cord clamping.
- considerations for choosing the right time].
Z Geburtshilfe Perinatol 1982 Apr-May;186(2):59-64
. . . Renal function is increased and effective renal blood flow associated with the blood volume of the newborn. In cases of caesarean section a higher incidence of respiratory distress occurs if placental transfusion does not take place. In utero placental transfusion occurs if the fetus is hypoxic obviously to increase the oxygen supply to the fetal tissue. In conclusion: "In order to give the newborn the blood, that it need physiologically cord clamping should be performed not immediately after birth, but one should wait as long until the umbilical vein has been empty and is collapsed."
Timing of Cord Clamping is section 5.5 in CARE DURING THE THIRD STAGE OF LABOUR (from the World Health Organization's Care in Normal Birth: A Practical Guide Report)
Late clamping (or not clamping at all) is the physiological way of treating the cord, and early clamping is an intervention that needs justification.
Have you read joseph chilton pearce's book, The Magical Child? On pages 48-50 he cites research done by william f. windle:
"He was concerned about childbirth practices. specifically 2 questionable procedures: the widespread, automatic use of premedication and anesthetics and the usual practice of cutting the umbilical cord as soon as the baby's body was clear. there has never been a textbook on obstetrics that did NOT stress leaving the umbilical cord strictly alone so long as any activity is detectable in it.
"He made the simplest of tests. he took pg monkeys and treated them to all the benefits of modern medical practices: he administered anesthetics in a body-weight ratio equivalent of that given the average laboring human mother in the hospital. at the birth of the infant, he cut the umbilical cord at the average time he had found practiced in hospitals. in every case, his newborn monkeys could not get their breath and had to be resuscitated.
"The mothers, dazed by the drugs and greatly lengthened labor (which anesthetics automatically cause), could do little assist. windle had to step in to keep the little creatures alive. and how long was it before these medically delivered infants achieved some normality, got their limbs under them, and began some preliminary semsorimotor learning? some two to three weeks.
"He performed autopsies on some of these helpless infants and found in every case that their brains harbored severe lesions of a type resulting from oxygen deprivation. he was able to keep some of the monkeys alive (and it took outside help; it was beyond the monkey's abilities) until they had matured and achieved apparent normality. when he autopsied some of these apparently recovered monkeys, he found that their brains STILL harbored exactly the same lesions found at birth. the damage done at the beginning proved irreparable.
"He next studied human infants who had died following known birth histories of anesthetics, low apgar scoring, premature cutting of the umbilical cord, and so on. autopsies showed that these infant brains harbored exactly the same lesions he had found in his oxygen-deprived monkeys. cases of children who had similar birth histories but who died at age three or four were then studied, and where possible, autopsies were made. again the brains were found with the same lesions.
"Windle pointed out the obvious. in those first critical moments when the lungs must make the transition to producing all the oxygen for the young body, the system expects to call on the reserve supply held in the placenta. a drugged mother immediately means a drugged infant, and a drugged infant cannot get his breath. artificial means must be used. breathing is then clumsy, slow, inefficient. the cutting of the umbilical cord at this time denied the infant the reserves of oxygen at the most critical pint in his life. a vicious double bind is imposed.
"Newell kephart, director of the achievement center for children at purdue university, finds learning and behavior problems resulting from minor undetected brain injury in 15 - 20% of all children examined. goldberg and schiffman estimate that 20-40% of our school population is handicapped by learning problems that may be related to "neurological impairments at birth."
"Windle closed his report, published in Scientific American in
1969, with this comment: our experiments have taught us that birth
asphyxia lasting long enough to make resuscitation necessary
always damages the brain..... a great many human infants
have to be resuscitated at birth. we assume that their
brains, too, have been damaged. there is reason to believe
that the number of human beings in the USA with minimal brain
damage due to asphyxia at birth is much larger than has been
thought. perhaps it is time to reexamine current practices
of childbirth with a view to avoiding conditions that give rise to
of A Fetus: Circulation and Breathing by Gerard M. DiLeo,
M.D., F.A.C.O.G.- I finally got some insight into why
obstetricians like to cut the cord so quickly. This OB
states that it is necessary to cut the cord because it's the
oxygen deficit that causes the baby to start breathing. I
wrote a long response to this
Early Clamping Denies Baby Blood
Supply for Pulmonary Perfusion
There's a lovely article entitled Cord
Clamping Injure the Newborn? by George M. Morley in the July
1998 OBG Management (pp 29, 30, 33-4, 36). Brief
description: "While exploring the feasibility of saving placental
blood for autologous NICU transfusion, the author found a
disturbingly obvious alternative: If cord clamping is
delayed to permit normal placental transfusion, the need for
newborn transfusion often could be eliminated." The
article goes into a lot more detail than I have seen before on the
mechanism for how delayed clamping benefits the baby), and he
actually advocates leaving baby attached for resuscitation until
cord stops pulsating .
Ob. Gyn. News, Feb 15, 1992
Advises Against Early Umbilical Cord Clamping
Dr. M. Jeffrey Maisels
"If the cord is not clamped, the placenta gives the infant the equivalent of 20 cc of blood per kilogram of body weight within these first 3 minutes. This placental transfusion in the normal infant is equivalent to the amount of blood given to an infant in profound shock, he said at the conference also sponsored by Boston Univ School of Medicine."
"When cords are not clamped early, the third stage of labor is one-third shorter and the total mean blood loss after delivery is substantially less than when cords are clamped early.
This might be because when cords are not clamped, the placenta is allowed to give up its volume of blood. It thereby contracts and separates more easily from the uterine wall, Dr. Maisels said."
Ob. Gyn. News
Vol 19, No 24
Advises Not to Clamp Cord Immediately
"...the placenta provides a safety valve for any raised central venous pressure because blood may flow backward through the umbilical vein."
"Hence, this provides the infant with the best opportunity for achieving a normal blood volume and hematocrit and avoiding many of the problems of maladaptation to extrauterine life."
"With cord clamping immediately after deliver, as much as 166 ml of blood may be trapped within the placenta, with the baby showing signs of hypovolemia, low blood pressure, and intense vasoconstriction. Then engorged placenta is likely to be bulky, stiff, and enlarged, presenting problems of passage through the retracting cervix."
"A typical placenta delivered after immediate cord clamping
weighed 725 g and would just pass through a ring 79 mm in
diameter. After draining out the blood, the placenta passed
through a 62 mm ring..."
Avoid all clamping. One of those old texts that said the pressure
on the vessel by clamping, can have some sort of effect in keeping
the foramen ovale open (and I'm sorry, I can't remember the exact
mechanism.) Here we began to realize that it might be foolish to
assume that all the switch from fetal to neonatal circulation
really occurs in that first five minutes, and that it is more
reasonable to assume that some changes and equalizing happens AS
LONG AS ANY CIRCULATION EXISTS OUTSIDE THE BABY. So, in order to
prevent circulatory problems, the WV midwives started not clamping
the cord at all. And this necessitated waiting (usually 2 hours)
for there to be NO PULSE at the umbilicus. So when the placenta
delivers, we wrap it in a chux with a twist tie, place it next to
the baby, and bundle both in a blanket. [Only clamp stump if
bleeding when finally cut.]
"Discuss fetal circulation and the changes in it at birth." - This is a nice discussion, but some of the information is in conflict with the direct experience of those who attend births. In particular, the neonatal changes are alleged to happen very quickly, within a few minutes, which is not supported either by the research or by the experience of birth attendants.
Fetal Circulation & PPHN -
One minute delay in umbilical cord clamping boosts iron status of newborns.
Investigators at the University of Connecticut, Farmington, and
the University of California, Davis, told the Experimental Biology
'96 audience that newborns whose umbilical cords are clamped one
minute after pulsation stops have much higher hematocrit levels
than infants whose cords are clamped immediately after delivery.
Dr. Rafaela Perez-Escamilla reported that 88% of infants with
immediately-clamped cords had hematocrit levels below 33 at the
age of two months. In comparison, only 42% of infants whose cords
were clamped after the one-minute delay exhibited iron deficiency
anemia at two months of age.
I always cut the cord rather fast I must say, within a few
minutes. I suppose because I was taught that the longer it takes,
the more problems with jaundice you can expect. And I know this is
not always true, but somehow it is very hard to change a habit of
Most of my parents request that the cord not be cut until it's
done pulsating, and I like that transitional source of oxygen, as
limited as it might be. Our babies are generally held above the
level of the placenta, so we're not draining blood into the baby,
and I don't see jaundice problems. Have only had one kid in the
last 50 or so under bili lights. Most cords are cut before the
placenta delivers, but not always. It doesn't matter to me either
way - I'm quite flexible with the whole thing.
Our local hospital loves to send transported home birth babies to
NICU for polycythemia because the "midwives let the cord pulse too
long". So which is it, babies receive too much blood, or babies
are being drained of too much blood?
There's no simple answer to the question. If there was, it would have been found long ago.
Most of the components of the question have been stated already.
In the cord: Blood in the pulsing arteries is going toward the placenta. Philosophically speaking, it may help to remember that this is not away from the fetus, since the placenta is an organ of the fetus. It is away from the heart, not away from the fetus. So the arterial blood in the umbilical cord is not leaving the fetus, any more than the blood going to the head is leaving the fetus. The non-pulsing venous flow is away from the placenta and toward the heart. No body knows what shuts it down or even if it shuts down. Personally, I think it does, in response to fluid volume. There's some evidence that it does.
In the baby's abdomen/pelvis: The umbilical arteries take off the iliac system. They seem to be oxygen sensitive (or something) such that when the oxygen levels rise from fetal low levels to neonatal much higher levels, the arteries squeeze down tightly and cut off further use of the placenta.
In the baby's chest: The ductus arteriosus seems to react the same way to the drop in pressure of the pulmonary vasculature (or something) to shut down the shunt of poorly oxygenated blood to the aorta.
My spin on all this is that the baby may still benefit from the use of the placenta as an organ of respiration until the cord pulsing stops. I presume that the reason it's still pulsing is that the baby's system is not yet satisfied with oxygenation from the lungs and wants to keep on the placenta a little longer as an auxiliary source. To put it another way, cutting the cord is an amputation of a body part. I want to be sure that body part is useless before I amputate it, the same as I would want to know that your arm was useless before I amputated it. Only if I thought your arm was a danger to you would I amputate it before it was useless-for example if it had cancer. So I can think of perfectly good reasons to amputate a placenta prematurely, for example in certain bleeding circumstances.
So if the primary issue is not wanting to amputate an organ
prematurely, the secondary issue is blood volume shifts. After
birth, if the arteries stop pulsing, there is no more blood going
to the placenta. The only thing that can now happen is blood
coming from the placenta, unless the vein shuts down, which nobody
knows. So maybe the whole issue is moot. But if the vein shuts
down in response to fluid volume, that would be perfect, so that
each part of the transformation cascade from fetal to neonatal
circulation would be orderly. First, in response to lowering the
pulmonary vessel resistance, the ductus arteriosus closes, sending
oxygen depleted blood to the lungs instead of to the lower body.
This raises the oxygen content of the lower body automatically.
Then the blood in the lungs gets oxygenated, raising total body
oxygen enormously. In response to this, when the babe feels good
and oxygenated, the umbilical arteries shut down, preparing for
the amputation of the placenta. Then the baby's blood volume
sensors monitor fullness, and when the time is right, shut down
the vein so that no more blood comes from the placenta. If all
this is correct, then nothing you do with the baby's position
(within limits, now; I don't mean holding them as far up or down
as you can just to make a point) should determine what the final
blood volume is. And sure enough, so far no one can point to any
evidence that you can influence final blood volume, except mess
with it by premature amputation of the placenta and hope that
everything goes all right (and usually it does.)
ummmm, not true on this one. There is an extensive volume of literature that you can influence hematocrit and iron stores by delayed cord clamping. A recent reference is
of iron deficiency: Placental transfusion is a cheap and
BMJ 1996 Jan 20;312(7024):136-7
I've snipped a bit of the text of this article:
estimated volume of placental transfusion varies from 20%-60% of the existing blood volume (54-160 ml) depending on the time of clamping and the position in which the infant is held before clamping. Linderkamp and colleagues estimated that the amount of placental transfusion is 35 ml/kg of birth weight when term infants are kept at the level of the vaginal opening and the cord is clamped 3 minutes after birth. The same authors have recently investigated placing the neonate in the mother's abdomen and clamping the cord only once it stops pulsating....They found that these babies had blood volumes 32% higher than babies whose cords were clamped immediately after birth.There were a bunch of other studies on prevention of iron deficiency anemia in kids in 3rd world countries (Guatemala) and benefits of delayed cord clamping in preemies. My medline review did not find any major problems with delayed cord clamping....there is some hyperviscosity and decreased lung compliance, but this seems to be overcome by the benefits of increased iron stores.
Prevalence of Iron Deficiency in US Remains Above 2010 National
[Medscape registration is free]
"The estimated prevalence of iron deficiency was greatest among 1- to 2-year-old toddlers (7%) "
--- United States, 1999--2000 - CDC's MMWR October 11, 2002
I intended to make the point that whatever you did with the baby, within reason, was neutral as far as ultimate blood volume, and that the problem was not what you did with the baby, but whether or not you amputated the placenta prematurely. The references above support that idea, especially with regard to the increased blood volume in babies who were placed on mom's abdomen compared to those who were prematurely amputated. According to legend, if you hold baby high, blood drains into the placenta, and if you hold baby low, blood drains out of the placenta. Lindercamp showed that even putting baby high (on belly) blood volumes were still higher anyway, compared with premature clamping.
Sorry to be unclear. The literature supports not clamping until
baby indicates she doesn't want any more placental function by
shutting down arterial flow to the organ, signaling she's ready to
have it amputated.
I agree with the way this is phrased. Let's shake ourselves of the notion that delayed clamping gives "extra blood" to the baby! Early cord clamping prevents the baby from getting the blood he would have gotten if the birth had occurred under normal, natural circumstances. It deprives the baby of a variable amount of blood.
If we can prove that interfering with this NORMAL process is beneficial, then we should clamp/cut cords immediately. If we can't prove a benefit - or if we can prove a harm -- then we should continue or return to the historical timing of cord clamping. Humans did not, COULD not, do immediate cord clamping before the invention of a clamping device (about 150 years ago, I think). Immediate cord clamping is a very recent routine advocated in the US in the 30s as a means to lessen the amount of maternal anesthesia passing to the baby, and pushed in the 50s to "reduce the incidence of jaundice".
Where's the evidence that early cord clamping is beneficial? There is theoretical worry of increased jaundice and polycythemia. But there is NO evidence to support this.
I really don't give the Guide to Effective Care quite the same status as the Bible[GRIN] - --I DO think it helps us to gain perspective, and I seriously believe we should refer to it more often.
According to the research analysed by the Guide, there is no difference in early versus late cord clamping in one and five minute APGARS. There are higher hct at later dates BUT no increase in jaundice in delayed clamped babies (yes, it DOES increase hct, but not enough to raise the incidence of clinical jaundice ). It does no harm to the baby to delay cutting the cord....
But, catch this. GTECPG pg 239
Pre-empting physiological equilibration of the blood volume within the fetoplacental unit (early cord clamping) in this way may predispose to retained placenta, postpartum haemorrhage, FETOMATERNAL TRANSFUSION, and a variety of unwanted effects in the neonate, respiratory distress in particular.So the evidence seems to demonstrate HARM in our American routines of immediate cord clamping! Unless someone can document benefits, then I think it's far past time to abandon the practice!
As an independent midwife in Melbourne Victoria, I can give you
my experience of not having cut a cord, even when the babe is
wearing it like a handbag (over the shoulder, around the neck, at
least once around the body!!!) in more than 10 years and I find
that these babies don't get jaundice. In fact I cannot think back
to a babe I have had recently who HAS been jaundiced.
If the pulsating cord is showing that the baby has a beating heart then surely some blood could be getting through to the placenta. Then because fetal pO2 is lower than maternal pO2 there is a diffusion gradient and it will diffuse into the baby's blood.
If the placenta is still attached, then it can form part of the resuscitation process....
(It makes one wonder just how much pitocin/syntocinon a baby gets
if mom is given a routine shot with the birth of the baby's
I find, though, that in those severe situations, the cord most likely has already gone limp, so at that point, the baby is not benefitting anyway from the umbilical support.
I guess I weigh procedures in order of priority at the given
situation. Does that make sense?
Respectfully, no it doesn't.
If there is no heartbeat, and no respiration, artificial respiration may kick-start the entire process and therefore the pulmonary route of oxygen administration should be used if possible. However, sometimes that route just isn't available, and resuscitation may still proceed by cardiac stimulation/compression independently of efforts to establish the airway, if only you haven't already burned your bridges behind you by screwing up and cutting the cord. Let me give an example.
Mom comes in to hospital without calling ahead. Says she thinks she's about to have baby. Taken to L&D where nurses don't take very long finding that the head is already out. They stat me from the call room only about 60 feet away.
I arrive dressed in trousers (put on trousers literally as I ran down the hall, honest, didn't want to terrify mom) and nothing else 20 seconds later to find baby out and covered with thickest mec I'd ever seen. It resembled old dry toothpaste. Couldn't see any facial features, not even the nose, secondary to too much mec paste. Wiped it off in a hurry, nurse monitored the cord after offering to cut and being told NOT. Couldn't suction the mec-plugged the full strength wall suction.
I had to literally curette the mec out with a ring forceps. Don't you know I was so horrified I was crying? I bet that upset the mom, but what do you do? I finally got down to the vocal cords, and for some reason the mec was thinner below the cords and could be suctioned. Total time to get mec out enough to suction and establish an airway was nearly 7 minutes. You know that's long enough to completely fry a brain, don't you?
Meanwhile the nurses had been doing chest massage the whole time. Pulse rate at first assessment was 0, but with massage, which could be felt in the cord, and therefore technique monitored to get best cardiac output, eventually a spontaneous pulse rate of about 40 was felt at 4 minutes. We kept the chest massage going anyway and spontaneous pulse climbed up to 120 and pulse became full and strong by about 5 minutes, at least 2 minutes before the baby received so much as a whiff into the lungs.
That baby last I heard was in school doing OK.
If you try to convince me that babe would have survived at all without the use of the placenta, you've got a tough uphill battle ahead of you. It is precisely in the most dire emergencies that cutting the cord is the worst of all possible things you can do. In our humble little remote hospital in the middle of nowhere, we accomplished a better result than the finest medical center could have done with cutting and handing off to the neo team. In fact, the neo did call us later after the transfer and asked us how we accounted for the baby's survival with so long without air. When we said we didn't cut the cord, he was amazed and said he'd like to try it sometime. Duh.
As for instructional courses to the contrary, do what the
instructor tells you to do, pass the course, and then go forth and
do the right thing.
It is my strong belief that once the majority of a baby has
passed through the mid pelvis the supply of 02 through the cord is
non-existent. A pulsating cord ONLY indicates that the baby has a
beating heart and a stable blood pressure. Oxygenation is
contingent upon gases diffusing across the placental membrane. And
that just ain't happening anymore. If you have a shoulder dystocia
you feel a strong need to get the baby born; because the longer
the baby is stuck, the lower the Apgar. Same with breeches. Once
the uterus has been significantly reduced in size, the placenta
starts to buckle, and placental function goes down. A drowning
person has a strong pulse for a period of time; but he ultimately
dies from anoxia. The advantage to not cutting the cord quickly is
that the baby gets more of his blood. This whole notion that a
pulsating cord is indicative of oxygenation is a great leap of
faith. There has been more then a few underwater birthed babes
that have required resuscitation because they were left under
water till the cord stopped pulsating.
WHAT???? I have got to hear your basis for this...can you quote
some sort of evidence that supports this...or even explain the
physiology behind this theory in more detail? Any books that
explain it? Why do you have this belief, it must come from
somewhere. This is not anything I have ever heard before
anecdotally, and I have never read it anywhere. My experience in
550 births surely doesn't support this theory either. MID-pelvis?
You mean the whole baby? Once the baby is OUT? I'd love to hear
A pulsating cord ONLY indicates that the baby has a beating heart and a stable blood pressure. Oxygenation is contingent upon gases diffusing across the placental membrane.I'm confused! :)
If the pulsating cord is showing that the baby has a beating heart then surely some blood could be getting through to the placenta. Then because fetal pO2 is lower than maternal pO2 there is a diffusion gradient and it will diffuse into the baby's blood
Diffusion ALWAYS happens as long as there is a concentration gradient (1st Law of thermodynamics applies here). The greater the gradient, the faster the diffusion.
How can you be sure that it isn't happening any more?
The advantage to not cutting the cord quickly is that the baby gets more of his bloodAnd so, as long as it is still there, there's always the possibility that whatever O2 is in the umbilical vein can get back to the baby as long as his/her heart is beating adequately to maintain enough pressure for blood to return to the baby's circulation. Isn't that what others have been using as their argument against cord amputation?
With shoulder dystocia and some breeches, I thought that the problem came from pressure on the cord from the pelvis exceeding the baby's arterial pressure and therefore the blood can't circulate to the placenta and back again to the baby - the problem is a mechanical one not one of lack of diffusion. Yes, and the longer the baby is stuck then the worse the Apgars would be; because until that pressure is relieved there's no effective circulation and no possibility of O2 reaching the babe.
If the baby is then delivered and his/her heart is still beating (or can be induced to beat by resus.), then because fetal oxygenation has reached such low level, the diffusion gradient is greater both across the placenta and between foetal blood and foetal cells - and therefore O2 transfer would be expected to be more efficient.
It's probably not enough to stop brain damage once it's has happened, but surely it could give the baby a boost. The possibility seems strong enough reason not to cut, because once it's gone the only way to get O2 into the baby is via the lungs. If it's still intact, then surely there are two possible routes for oxygenation?
Once the uterus has been significantly reduced in size, the placenta starts to buckle, and placental function goes down.Yes, I think size is part of it; but it's the arterial pressures in the baby that change immediately after it's taken a first breath. At the same time, oxytocin makes the uterus contract and the "living ligatures" around the uterine blood vessels stop the flow of blood on the maternal side. Either way it alters the pressure differences across the placenta and then it starts to peel away and fold down.
A drowning person has a strong pulse for a period of time; but he ultimately dies from anoxia.True, but in a drowning person, the lungs have already been inflated and alveoli can become filled with water - then the concentration gradient is no longer maintained and O2 can't diffuse across the alveolar membrane. Anoxia will follow. In a baby, if the lungs haven't yet inflated - different situation.
There has been more then a few underwater birthed babes that have required resuscitation because they were left under water till the cord stopped pulsating.The problem in those situations seems to have been exactly that; the babies were left under the surface for far too long. Guidelines in this country from the Royal College of Midwives is to bring the baby to the surface IMMEDIATELY. Babies should NOT be left under the water.
I also wanted to ask about the post saying that there is no more
oxygen perfusing the placenta once the uterus starts to buckle.
Therefore there is no worry about cutting the cord even while it
is still pulsing. I would think that if that were so then all the
more reason not to cut the cord and so reduce the baby's blood
supply. Isn't there still O2 in the blood after a complete pass
through the body. My understanding is that blood reaches the
lungs/placenta still containing O2 just not at 96-100% capacity.
so if there is a 40% saturation level wouldn't a greater blood
volume increase the O2 level as a whole? Or are you saying that
the amount of blood reserved in the placenta is not sufficient to
make a difference?
OK, let's leap our faith out in a different direction.
Oxygen is a very small, simple molecule, which diffuses extraordinarily well through the placenta, but its transplacental effects in pinking up a baby are somewhat ambiguous when the babe is being resuscitated and also receiving oxygen via the lungs.
So let's look at a different molecule. Narcan. It's a large, bulky molecule that diffuses poorly through the placenta compared to oxygen. So if there is no oxygen enrichment via the placenta as you suggest, then there should be even less chance of getting Narcan to a baby via the placenta after the baby has been born.
Yet one of the tricks that I find most satisfying working in a technology-intense environment is that babies are not-infrequently born depressed from being born too quickly after narcotics were given to mom, and the whole unit panics as the floppy baby is born. Since I always order a syringe of Narcan drawn up any time one of my gravidas is given any narcotic, in the midst of the panic, I order the amp of Narcan to be given IV push to mom. The nurse is invariably stunned and asks me if I don't mean IM to the baby, and I usually have to repeat myself. She then gives the amp to mom, and in less than 20 seconds the baby abruptly wakes up and becomes fully alert, without me doing any stimulation or any other resuscitative thing at all. In fact, sometimes I've already given the baby to the mother by that time.
It's a lot of fun, is usually quite disruptive to the OB unit, which gets all abuzz about it and wants to know where I learned it. When the neo team gets there they are always puzzled about why they were called. Then by the next time it happens, everybody has forgotten the previous event and the whole thing repeats as if it were the first time such a thing had ever happened on the unit before.
So if Narcan goes swiftly across the placenta to baby, and
diffuses much more poorly than oxygen, I rest my case.
I have a practical question to ask about all this. How is your
delivery set-up configured so that you can resuscitate with O2
while cord is intact? Where I work, the O2 is attached to the
infant warmer, and would not reach the mom in bed. Hmm, I guess we
could always detach the Laerdal and attach it to the maternal O2
supply in the room...
You've answered your own question. You grab mom's O2 cause she isn't needing it at the moment.
Of course, there would be some that would complete the circular
reasoning that O2 is on the cart because that's where babies are
resus'ed, therefore babies need to be resus'ed on the cart because
that's where the O2 is. I say, the best O2 is in the cord, so
everything else has to be built around the cord's location.
Coincidentally, on the ob-gyn list, somebody posted the
speculation that the placenta continues to serve as a depressed
infant's major O2 source for several minutes. Somebody else had
the same thought that I did, which is to doubt this based on the
likely decreased perfusion of the placenta as soon as the uterus
collapses with the expulsion of the fetus; it seems that it would
lose much of the total surface area of contact, though it retains
enough to still be physically "stuck" there.
I think the timing of when this occurs is influenced by the use of pitocin. In a physiological birth the placenta stays attached (and we assume functioning) for longer than with active third stage management (pitocin IV or IM with the shoulders). I don't think The uterus "collapses" a great deal --immediately --with expulsion of the baby. We usually see a gradual firming up before contractions resume five or ten minutes after birth (without pitocin).
Also, someone asked about cord tying and mentioned the drop in temperature being an possible influence on the cessation of bleeding. I've got an old physiology book which looked at such things -- and referenced experiments which would be forbidden now. (these are excerpts from an prior post)
Cords- cutting, etc -- "physiology of the newborn infant -- Clement Smith 1946 --it has a lot of research reports would would be banned for ethical reasons today). The author refers to the "constriction effect caused by oxygen increase". Testing showed that in response to the baby's breathing the O2 levels in the cord ((Sorry bob, I don't know how they checked this)) nearly triple within 60 seconds of respiration. .
He cites experiments demonstrating three effects on the cord after birth:
He concludes that we would probably function as well as any other mammal without cord clamping "particularly if, as with animals, a long remnant were left attached, but tradition, convenience.... and a certain amount of care against unlikely accident decree that the cord be clamped and severed".
There's also experimentation which shows continuation of placental circulation after expulsion, the placental circulation doesn't cease immediately with the birth of the baby.
It reports an experiment by Haselhorst and Stromberger in 1932. They "injected Congo red dye into the umbilical vein of the pulsating cord and measured the time elapsing before the dye reappeared at the same site. The observers found that in one series of infants born in the normal manner this period was 60 seconds, while in others delivered by elective Caeserean section from the non-contracting uterus, the time was 30 seconds. .. The circulation so measured must have included the extensive circuit of the placenta as well as that through the body...."
So I think this rather proves that the baby's circulation still
includes the placental unit -- rather than the frequently taught
modern view that the cord just pulsates without any placental
involvement. The circulation continues its' rapid course through
the baby, through the cord, through the placenta, for "a period of
time" after birth. Even if it's only a few minutes, those first
moments can be the most significant of the baby's life. If the
placenta is still attached, (and if we presume it's still
functioning) then it can form part of the resuscitation process.
Your last sentence gets to the critical "if." That fetal blood still circulates through the placenta does not imply that it is still exchanging gases with the maternal intervillous spaces. I think the best way to test this would be to have the mother breathe 21% O2, but an isotope of oxygen, not regular oxygen. Then cord blood could be tested for the presence of the isotope, and perhaps a correlation between time of clamping and what % of the O2 in the cord blood is isotopic could be determined. There should be no ethical problems with this at all.
I don't mean a radioactive isotope. Just one with a
couple of extra neutrons. Detectable and measurable, but the
effect on the body is precisely the same as with regular oxygen.
(This is used commonly in metabolic experiments where the oxygen
utilization needs to be measured precisely.)
Has anyone seen the birth video of water births in Russia? I
watched one in school. It seems VERY clear to me that the cord and
placenta in those births are continuing to do their jobs of
supplying O2 to those babies. They are allowed to stay under water
for so long after birth! I don't remember exactly how long, but it
was a lot longer than done at water births in the States. I'm not
supporting this practice, but I do think it tells us a lot about
what's going on with the cord and placenta after the birth of the
Detailed Information from an Expert in
The Fall 1986 issue of Mothering has an article entitled "Delayed Cord Clamping". This is the only article I have come across with great references on this seemingly "controversial" topic. I am interested to hear if there are others with more "current" studies done on this.
According to this article: "If a blood pressure gauge is placed on an unclamped umbilical cord, it will pick up pressure rises as high as 60 mm Hg with each uterine contraction. This indicates that these contractions are intimately involved in the transfer of placental blood through the cord. A striking pressure rise, which persists through the first few hours of life, is also evident in the baby's vena cava and right atrium of the heart. All studies on this indicate a significantly higher systemic pressure in infants who have been clamped late (90% in the first nine hours) and conversely, a significant drop in those early clamped infants (70% of systemic by the second hour, and almost 50% of systemic by the fourth hour). [Moss, Arthur J, MD "Placental Transfusion", PEDS 40:1 ^V July 1967]"
Some interesting statistics:
"The placental blood normally belongs to the infant, and his/her failure to get this blood is equivalent to submitting the newborn to a severe hemorrhage at birth. [De Marsh, QB, et al "The Effect of Depriving the Infant of its Placental Blood", JOUR AMA ^V 7 June 1941]"
"Deprivation of placental blood results in a relatively large loss of iron to the infant. [De Marsh, QB, et al "The Effect of Depriving the Infant of its Placental Blood", JOUR AMA ^V 7 June 1941]"
"The time of cord clamping may be involved in the pathogenesis of idiopathic respiratory distress syndrome (the earlier clamped, the more respiratory distress). [Saigat, Saroj, et al. "Placental Transfusion and Hyperbilirubinemia in the Premature" PEDS 49:3 ^V march 1972]"
"Placental blood acts as a source of nourishment that protects infants against the breakdown of body protein. [De Marsh, QB, et al "The Effect of Depriving the Infant of its Placental Blood", JOUR AMA ^V 7 June 1941]"
"Studies have shown that immediate cord clamping prolongs the average duration of the third stage and greatly increases maternal blood loss. [Walsh, S. Zoe "Maternal Effects of Early and Late Clamping of the Umbilical Cord" LANCET ^V 11 May 1968]"
And for the argument that delayed cord clamping will increase a babe's risk of hyperbilirubinemia (jaundice), Mothering eloquently says this:
"Among other drugs, pitocin inductions and epidurals have been conclusively linked with nonphysiological neonatal jaundice (this is not normal, breastfed jaundice). Any drug administered to mother or baby must be viewed with a "jaundiced" eye, for it is likely to compete with bilirubin sites on blood protein, causing more bilirubin to be free to contribute to jaundice.
In an all-out effort to prevent the possibility of jaundice,
obstetric practitioners have reasoned against delayed cord
clamping, since it increases the volume of red blood cells ^V
which, in breaking down, will produce increased levels of
bilirubin. True, hyperbilirubinemia may be prevented in premature
and "medicated" infants by early clamping; however, in a normal
delivery of a full-term, unmedicated infant, there are untold
advantages to delaying cord clamping until after the placenta has
Enkin, Keirse, Renfrew, & Neilson, (1996). A Guide to Effective Care in Pregnancy & Childbirth, (2nd ed), p. 239. New York: Oxford University Press.
Active management of the third stage of labour usually entails clamping and dividing the umbilical cord relatively early, before beginning controlled cord traction. Pre-emptying physiological equilibration of the blood volume within the fetoplacental unit in this way may predispose to retained placenta, postpartum haemorrhage, fetomaternal transfusion, and a variety of unwanted effects in the neonate, respiratory distress in particular. Delayed cord clamping results in a placental transfusion to the baby varying between 20 and 50 per cent of neonatal blood volume, depending on when the cord is clamped, at what level the baby is held before clamping, and whether oxytocics have been administered.
Early cord clamping leads to higher residual placental blood volumes and heavier placentas, but these observations have no clinical relevance. The duration of the cord clamping does not appear to influence the frequency of postpartum haemorrhage, although numbers are small.
Allowing free bleeding from the placental end of the cord reduces the risk of fetomaternal transfusion, which may be important with regard to blood group isoimmunization.
Early cord clamping results in lower haemoglobin values and haematocrits in the newborn, but these effects are minimal at six weeks of age and undetectable at six months after birth. Neonatal bilirubin levels are lower in babies born after early cord clamping. It is difficult to draw relevant information from the trials about the effect on clinical jaundice. No detectable differences were noted in the trials that reported on this.
This issue is of particular interest in the care of preterm
babies, where early clamping is often carried out to facilitate
resuscitation. Theoretical considerations suggest that a
delay of as little as 30 seconds may have important clinical
benefits for these babies. Further information is needed.
We don't clamp until right before dad (or whoever) cuts. So it
goes like this: Baby comes out, mom & dad ooh and ahh while we
dry Baby, cord pulses for a bit (sometimes dad's like to feel that
and think it's really cool), cord pulsing becomes faint or quits,
Mom has separation gush, midwife holds onto cord with a sterile
gauze square and guides placenta out while Mom pushes. Then we or
sometimes dad put cord clamp near Baby, we clamp a few inches away
with a hemostat, steady everything with a gauze square underneath
to catch any blood, Dad cuts cord, mom and baby get into bed or in
a chair to nurse. The End. :-)
I used to cut the cord as soon as it stopped pulsing. Now for
most of the births, the cord is cut after the birth of the
placenta, when we are ready to take the placenta to the other
room. Occasionally I cut it sooner if I feel there is some reason
to get the placenta birthed but the maternal end is left unclamped
to allow the placenta to drain, shrinking it down, shearing it
from the uterine wall. If a baby is at risk for jaundice, the cord
is cut sooner and very close to the umbilicus to limit the amount
of blood being reabsorbed back into the infant. I sometimes even
allow the cord stump to drain JUST A LITTLE to further reduce the
amount of risk with jaundice. NOT ENOUGH TO CAUSE
Many here have delayed cutting the cord for two or more hours. If
you notice, the cord is still pulsating at the umbilicus for about
this length of time, even though there is no pulsation in the
middle. So what we do is deliver the placenta into a chux, loosely
twist it around the cord and tie it off with a twist tie. We
bundle baby and placenta together in a position much like in
utero, and wrap both with blankets. When we do cut the cord, there
is very little bleeding if any, and more often than not, we use no
clamp at all. Obviously, if the cord leaks, we clamp it, as we do
if there is a medical emergency necessitating clamping the cord.
Yes, we also find it makes us do whatever baby needs in terms of
resuscitation right there with mother since being still attached
keeps baby close. But also my partner feels there must be some
physiologic message between baby and placenta in essence saying,
"I don't need you anymore; you can go ahead and detach." (Stretch
receptors, biochemical signals,...????) Anyway, she says she waits
on placentas much less now than when she clamped first. I've only
been a part of the cut after the placenta is delivered routine,
and I realize the numbers aren't very big, but we rarely wait more
than 10 minutes for a placenta--usually much less. It seems very
natural to me. Baby comes out and goes into mom's arms, is dried
and stimulated if necessary, everyone oohs and ahs over baby for a
few minutes while one of us gets clean chux and a pan under mom,
the cord might still be pulsing a little by now. Soon it looks
limp and we tell mom that whenever she gets a little contraction
she can push out the placenta and get into bed. (She might be
sitting beside the bed on the floor, having delivered in a squat
or hands & knees.) Often suggestion is enough and the placenta
soon comes. Then we are free to help dad, mom, siblings or whoever
the parents want to cut the cord in a leisurely fashion.
We routinely let the cord completely stop pulsing at the
umbilicus. This takes anywhere between 1 1/2 to 2 1/2 hours after
birth. We cut the cord, and ligate only if it keeps bleeding,
which is rare. My partner insists she has seen less jaundice as a
result, not more.
The doc said that clamping the "mom side" of the cord (or, worse
yet, milking it) can cause reflux of the baby's blood into the
mother's circulation and lead to Rh sensitization and other
antigen/antibody disasters. I was amazed to see that hardly any
blood came from the cord--I'd always thought that mothers could
bleed out from not having the cord clamped.
I do this mostly also, by letting the extra blood out from the
placenta you allow the volume of the placenta to diminish and I
feel that allows it to come out quicker in some cases. I have
tried it both ways and feel this way is preferable.
This thread on NNR made me wonder if anyone has noticed a
tendency for maternal hemorrhage, when not cutting the cord, to be
reduced. I have never seen a full resuscitation but have heard
that when the baby needs it the mom often hemorrhages. Perhaps
this is her distress for the baby or less attention being paid to
the mom, which ever, I would think keeping things close might help
I think that trauma tends to lend itself to more bleeding. I have always suspected that the cry and touch of a baby tells the mother's body that the baby is here and that is some way protective, just as I have noticed that having lots of skin to skin contact with babies seems to stimulate milk supply increase even if the baby is not nursing (moms pumping for preemies and doing kangaroo care have consistently commented on increase in milk supply with the skin to skin care).
Obviously certain complications of labor that may lend themselves
to the need for resuscitation of the baby such as a long hard
second stage, or worse, shoulder dystocia, also are associated
with more hemorrhage period.
After discussing the practice of not clamping/cutting the cord
until after the delivery of the placenta a year ago last Jan., I
have not had even one pp hemorrhage and have waited no longer than
20 minutes for any placenta. I AM SOLD.
I have had a very noticeable reduction in moms who not only pph
but just bleed heavily. I have not been cutting the cord until the
placenta is born for a year and a half now and I have had one pph
since then which was a mom with a very short cord who wanted to
hold her baby closer, I cut the cord, and SHE BLED!!.
More bleeding? Absolutely! Weeping womb--literally!
I think I might be able to answer this one. Since I am hospital based (mostly) and do hct the day after birth on the baby, I can tell you that I see don't see much difference on babies where I deliver the placenta before cutting the cord and when I cut the cord before it quits pulsing. Occasionally I see higher hcts if I cut the cord early, but the hct is really high - like > 60, which sets the kid up for jaundice, IMO.
If the kid comes out really bad, and I have to cut quick and rush
him to warmer for resuscitation, I DO see hct in the range of 45,
instead of the usual 50-55.
You probably only really "need" to clamp and cut the cord quickly
when the baby requires active resus.
Actually, this is when we especially DON'T cut the cord unless it
is completely flat with absolutely no pulse, and then don't think
we've taken the time to cut the cord if we are busy resuscitating!
Well.....there are some who would say that during a resus is exactly when you DON'T want to cut the cord. Why cut the baby off from it's oxygen supply? Just so you can administer your own oxygen out of the shiny container (please note sarcasm)? Depending on where the birth takes place (i.e. in a not-broken bed) and whether or not peds is around to take over and exactly how bad the baby looks, you can resuscitate a baby without detaching it from it's life line first. Just throw a towel down on the bed and work on the baby between the mother's knees (or even on her abdomen).
I did a waterbirth a few weeks ago where the mom pushed for three hours (not all of them in the tub, thank you). We had a slight (is there such a thing) shoulder dystocia (as expected) and the baby came out a little "slow". The kid was just laying there on mom's chest, seemingly not quite getting it that he should breathe now. The nurse was getting worried and came at me with the instruments to clamp and cut the cord. I thought for about five seconds....when the baby was underwater, as I was bringing him around he was moving his arms and legs, so I hadn't been worried, despite the trouble getting him out......well, since the baby seemed so happy underwater, and I really thought he was OK and I didn't want to unnecessarily put the baby through a resus and get the parents all freaked out.....so I quickly picked up the baby and dunked his body back in the water, carefully keeping the head out...the baby immediately wailed and we were all happy.
The only comment my boss made the next morning was to ask me
where in the NALS book it recommends full body immersion as the
first step in resus.
Well, yeah, if the cord is white we might as well cut it to make working on the kid a bit easier. But if the placenta is till functioning (if the cord is still patent and pulsing) . I think sometimes an intact functioning placenta helps the baby bridge the gap to extra-uterine life , far better than our resus skills do. I think it helps buy us some time during resuscitation. Might as well keep it intact and use that extra minute or so of extra life support.
I know there's another school of thought that clamping the cord
"forces" the baby to breathe and thus encourages better
resuscitation response. I've never seen research comparing the two
methods: resus with intact (functioning) versus resus with cut
cords. Of course in standard settings the baby is detached and
handed to the person doing resus on the warming table on the other
side of the room[GRIN] so it would involve a whole redecorating to
set up a comparison study!
I know this is going to sound off the wall (maybe it is off the wall) but I consider resuscitation a contraindication to cord clamping.
I think of the placenta as the primary respiratory organ until full lung function is evident. I don't like to ask a baby to be dependent on lung function alone when the lungs are struggling. Furthermore, I sometimes want to give a babe a drug during resuscitation, and the easiest way to do that is to give it to the mom, where it can go straight IV pretty easily, and thence across placenta to babe. When babes are in trouble they have almost no IM absorption whatever.
Especially when I get a depressed baby from epidural or narcotic, I won't let the cord be cut while I'm working on the babe. IV narcan to mom wakes up the babe inside of 15 seconds if the card is still open.
I find you can do any resuscitation you can think of with babe right in mom's lap or beside her in bed, and although it's terrifying to watch somebody working on your baby 2 feet from your nose, I bet it's even worse not knowing what's going on because babe was whisked away out of your sight.
So even though I'm an outlier on this one, I especially
don't do aggressive placental amputation when babe is doing
I completely agree!! Even in cases where the cord has been limp and white, I have resusced a baby to find that the cord then pulses again...and it starts before the baby really does, so it's giving me extra help.
I have also seen completely limp white cords come back to life
when the baby does. I theorize that at that point baby gets much
needed oxygenated blood. At any rate, I know that babies can be
resuscitated on mom, and why bother to take the time to cut? My
stillborn baby, 18 years ago, had that kind of mec. Of course cord
was cut -- and he was only worked on for FIVE minutes -- protocol
at the time. His heart rate was 140 ten minutes before he was
born,(cesarean) and then started plummeting. What difference would
it have made if I had held him, or even talked to him, while his
cord was attached, and they worked on him? Will never know. Was
present at a transport several years ago where baby's heart rate
was 144 in the minute before his forceps, OP birth. His cord was
cut and they attempted to resuscitate him, but he never drew a
breath. Parents were never given a reason for his death. We always
have grieved that his cord was cut, and are less likely to
transport now, than before.
Regarding waiting for the cord to stop pulsating before clamping.
I think this makes physiologic sense because it allows gradual
shunting of blood flow from fetal circulation to infant
circulation with the initiation of respiration. If you look at the
faces of the newborn if you clamp the cord right away they do
grimace, and I am not sure if this is painful to them or not, but
I would rather err on the side of gentleness. That is there is no
emergent or distress situation. Also, holding the infant below the
level of the placenta while waiting for the cord to stop pulsating
may increase bilirubinemia down the line. Most term newborns can
probably handle it but I wouldn't chance it with pretermers or
otherwise at-risk newborns. At one time we used to milk the cord
toward the infant before clamping. And before that I can remember
not clamping the cord, but delivering the placenta and hanging it
above the resuscitating unit to transfuse as much blood as we
could into the newborn. That was a long time ago.
Though I (unfortunately) have NO reference, I was taught in
training that an extended time to cord clamping with the infant
below the perineum was a risk factor for hyperviscosity and
neonatal jaundice (do to increased rbc breakdown in the newborn
period). Too much rbc mass is a greater and much more frequent
problem than too little in the newborn - at least in my well fed
When I was in medical school, there was a study going on at
Boston City Hospital, in measuring the amount of blood transfused
into the infant by clamping after pulsations were stopped. and the
conclusion was that the hct rose around 2% if you did not clamp
the cord right away. I do not know if this was published.
Studies have been done on delayed clamping of the cord and it
leads to a significant transfusion of blood to the baby, which may
not be a big deal for the term neonate, but significantly
increases subsequent hyperbilirubinemia in the premature infant.
I have seen reports recommending that the cord not be clamped
until it has quit pulsing. I'm not impressed with the reasoning or
the science behind it.
I would be interested in hearing synopses of any research
on the subject. I had always thought that this recommendation was
made for emergency and home births only because there was no
completely reliable way to prevent hemorrhage from the cord. If
there is effective oxygen transport still occurring through the
placenta, I suppose it could be somewhat protective until the
infant succeeds in transition to postnatal circulation.
I was able to find several articles regarding the timing of cord clamping. It looks to me that the routine practice of early cord clamping arises from concerns related to significant placental to fetal transfusion. This practice, particularly when performed with the fetus in a dependent (below the placenta) position results in a impressive transfusion and rise in neonatal hematocrit and blood viscosity. This appears to be of particular concern in the preterm infant where hyperbilirubinemia is exacerbated (1,2)
However one could postulate that the placement of the infant on the maternal abdomen at term may result in less gravitational effect and have limited physiologic significance. Nelle et al. appear to have published one experiment 3 times and demonstrated that with the newborn on the maternal abdomen that the delay in cord clamping still results in a significant transfusion and increase in blood viscosity.(3) I did not see any data on the physiologic consequences of this transfusion at term.
I personally do not rush to cut the cord, neither do I await
complete cessation of pulsing before clamping. It probably is
unwise to clamp the cord early in fetuses who may be anemic or
volume depleted (i.e. tight nuchal cords or hemolytic disease) and
equally unwise to clamp the cord late for fetuses at risk for
polycythemia (i.e. IDM's)
what is the deal about waiting until cord pulsations stop? I hear
this from time to time, and have certainly seen patients put it in
their requests for birth management, but I've never been able to
figure out why anybody thinks this is a physiologically
significant event or transition point. Anybody care to explain the
rationale to me?
well, waiting means mom and baby get to stay together a bit
longer since no-one can grab the baby to stick it under the
warmer! And it's pleasant to just hold the baby without feeling
there's a rush to cut and clamp the cord. But there are
physiological reasons too...
Yes, For instance: Isn't the baby entitled to receive ALL of his or her blood supply? If we whack the cord 3 seconds after the kid is out, then we leave 1/3 of its blood supply in the placenta. HELLO? Is anybody getting this????
I know that the medical people think that this goes against the
physiology of jaundice.... but I (as do many,many other EXPERTS)
believe that this is precisely why my clients babies do NOT get
jaundiced. I usually do not cut the cord for at least an hour. I
tuck the placenta gently next to the mother in a chux pad. When
SHE asks... then we have her or the daddy cut the cord. There is
enough going on in the early period following birth. So why worry
about something as trivial as cutting the cord?
Well, this assumes that more blood is better, and that remains to
be proven. Surely there is some upper limit of what is an optimal
blood volume and hemoglobin concentration, but I doubt that we
really know what it is. Since the baby will be working furiously
to break down all its fetal hemoglobin, it's not clear to me that
more is better.
well, I think I'd take the opposite line. I'm sure we all agree that early cord tying/clamping is a VERY recent invention -- practiced routinely only in a few countries and only since the forties (with some old-doc and midwife holdouts). It is neither natural, normal, evolutionary or historical.
Early cord clamping is an innovation -- an intervention in a
natural process -- and I would suggest that IT needs to prove
itself. It shouldn't need to be proven that "more" blood is
better, but that LESS BLOOD is better!
Shouldn't the question be to prove that the baby does NOT need the extra blood, and that early cord clamping is an improvement over a 2+ million year evolutionary process?
Why should the burden of proof fall on those who wish to return
to the natural practices of childbirth, rather than to those who
have implemented the (many) interventions without RTC to prove
that they are necessary (or even an improvement of the process)?
So how much more blood is needed to perfuse those system which weren't essential before birth? Lungs. Certainly the digestive track needs greater perfusion, liver, etc.
William's obstetrics says, "At term about 3/4s of the total
hemoglobin normally is hemoglobin F. During the first 6-12 months
of life, the proportion of hemoglobin F continues to decrease
eventually to reach the low level found in erythrocytes of normal
adults." I can't off hand recall the normal lifespan of
erythrocytes but this to me does not seem a furious pace.
I'm a great one for a spot of comparative physiology. Humans, as far as I know, are the only placental mammals who routinely clamp the cord. The practice probably originated with a handy bit of string or something similar. In most others, birth happens and then the placenta is delivered sooner or later. (Many bite the cord and eat the placenta - but I can't think for now what other primates do.)
I don't quite know WHY the practice of cord clamping first started. Maybe something to do with a very human need to keep busy and "tidy things up"? Always wondered. But it's amazing just how many students will blithely write (in their essays about the fetal/adult circulation) something about the baby being delivered, taking a breath and the cord being clamped - even for other species!!! - everyone seems to take it completely for granted that it is done.
Another of the things I'd been wondering about for a very long time is what is the actual stimulus for a baby to take his/her first breath? This came to the forefront of some discussions about the safety of waterbirth and whether the baby would breathe while under the water. There's review of this topic in Br. J. Obs. Gyn about April 1996 written by Johnson.
I think it's pretty hard to sort this one out because there is often such a difference between what actually happens at human births and what might be described as physiological birth. I haven't read the WHO article Patrick has quoted yet, but there was an earlier one (1985, I think - Having a baby in Europe) which began by accepting the fact that no-one really knew what physiological birth is. Because they are rare. Even traditional birth practices almost always involve some kind of "intervention" in the strictest sense of the word. So taking a look at what other mammals do can be one way (and I hasten to add that it's only one way) of looking at this issue. Homebirth midwives can tell us all a lot I think.
In the normal course of events, the second stage of labour is over and the newborn is delivered. The next section (without the accompanying diagram - sorry, but I can't get the computer to include it but you'll find something similar in most standard textbooks) comes from one of my handouts:
Establishment of Independent Existence
Throughout development in the uterus, the foetal lung and digestive tract do not function (in terms of ventilation and digestion/absorption of dietary nutrients) since gaseous exchange and nutrients are provided from the mother via the placenta. Fig. 2 shows a simplified diagram of the ante-natal and post-natal circulation. Before birth, pressure is highest in the foetal pulmonary artery and this determines the direction of blood flow through the foetus and placenta.
At birth, the sudden inflation of the lung reduces the resistance of pulmonary vessels and blood flows through them rather than the ductus arteriosus causing a fall in pulmonary arterial pressure. Cessation of flow to the placenta increases foetal blood volume, leading to an increase in the pressure in the systemic circulation. Valves guarding the foramen ovale close and prevent blood from flowing from the right atrium to the left atrium. The reversal of pressure gradients further increases blood flow in the pulmonary artery to boost the supply of blood to the lungs. In addition, the ductus arteriosus contracts in response to increased pO2 and its closure is complete within 10-15 hours of delivery. It is not clear how the ductus venosus closes but this step is essential in completing the transformation from antenatal to postnatal circulation.
In other words, once the newborn has taken the first breath (probably the major physiological stimulus for this is the temperature change from birth canal to air), blood is diverted to the lungs and the systemic circulation and away from the placenta. And as this "shunt" happens, the cord will begin to stop pulsating because placental perfusion with fetal blood is no longer necessary. At this point, whether the placenta is delivered or not, the newborn has established a greater degree of independence from the mother and is now breathing air for the first time. And it cannot go back to the previous existence. Seems a physiological transition of some significance to me.
Clamping the cord before the newborn has spontaneously taken a
breath and/or before pulsations stop will serve to raise arterial
CO2 and the newborn will become acidotic and hypoxic. Both, in
their own ways, powerful stimuli for breathing. The baby gasps for
1. route to the low resistance placental circulation remains patent providing a safety valve for any systemic raised blood pressure. can be critical if baby asphyxiated or [preterm as raise pulmonary and central venous pressures may exacerbate difficulties in initiating resps and accompanying circulatory adaptation (dunn 1985)
2. shortening of time to placental separation and reduced maternal blood loss - when cord is left unclamped Botha (1968) demonstrated mean duration of third stage was reduced from 10.5 to 3.5 mins & blood loss reduced by half
3. reduction in length of time for the cord to separate postnatally
4. transfusion of full quota of placental blood to the newborn - may constitute as much as 40% of the circulating volume and therefore is important in maintaining haematocrit levels
( care should be taken re height at which baby positioned in
relation to mum and effect of gravity on returning blood volume
also not to use oxytocic prior to completion of labour as this may
precipitate a strong uterine contraction with resultant over
transfusion to baby).
I attended a birth this morning where the mom birthed a beautiful
placenta with a plump pulsating cord. Does that mean that the baby
was stall getting O2 and nutrients from the mother? A
pulsating cord indicates fetal circulation not a functioning
I have seen this, too. It sure blew my theory that the baby
was getting O2 as long as the cord pulsed.
Well, it makes sense that a detached placenta won't be getting more oxygen from the mom, but since the blood in the placenta and cord are already oxygenated, then the baby is still getting oxygen, even from a detached placenta.
The baby actually continues to get oxygenated blood from the placenta even after the cord has stopped pulsing. After all, the pulsing is the blood moving away from the baby in the two shallow arteries. The deeper vein apparently remains open even after the cord has stopped pulsing. There is, in fact, no scientific evidence of when or if this flow stops. The best thinking is that the baby's body closes the umbilical vein when the baby's blood volume has reached the right levels.
So, it seems that you can't go wrong leaving the umbilical cord alone . . . the baby's body will normally do all the right things at the right times.
As far as "nutrients" go, I think the primary value of the extra
blood volume is the iron (for the next six months) and the fluid
(to make up for low-volume colostrum).
My concerns for c-section babies having violations of immediate
cord clamping done on their pulsating umbilical cords, are the
facts that even c-section babies can have the Lotus Birth, no
clamping of the umbilical cord, ever. The baby can be
correctly taken from the womb as a sealed unti with the placenta
and cord still attached. The secret of healthy babies,
whether vaginal born or c-section is a warm room, keeping both the
placenta and cord warm and baby too. This prevents
hypothermia, cold, stopping the flow of blood into the
owner/baby. Thus, babies who had sufficient blood volume and
pressure intended to flow through the lungs, are deprived.
They then become the next victims of anemia, one of the greatest
problems of youth today. Starts at birth of blood deprivation
between 4 ounces to 6 ounces of blood denied the baby by the
clamp. Clamps are only necessary for two conditions: (1) a
torn cord and (2) placenta previa. Placenta previa needs an
justification why a surgeon cut through the child's
lifeline. It means the surgeon did a horizontal cut rather
then a vertical cut for placenta previa. Likely because he/she
made haste for a c-section birth.
We did a lotus birth and loved it. The placenta is such an
amazing organ, I have a profound new respect for it. We often make
plans for our births but we forget about the how to manage the
birth and postpartum of the placenta. We were amazed how connected
and sensitive our little boy was to our placenta. He released his
cord on the fourth day which coincided with the day that he became
grounded on this earth. Lotus birth kept us in bed, the biggest
journey was once from the bedroom to our birthing room for a
change of scenery. It taught us to respect the transition time and
incredible changes that newborns are making as well as giving me
time to heal and rest. Lotus birth provided us with sacred space
in which to bond as a family, it brought a new awareness to both
of us. There are many reasons to lotus birth, most are personal,
some are just common sense (like leaving the cord uncut so that
baby can get the vital stem cells that people are choosing to take
out of the cord and store in blood banks). Letting nature work is
an incredible and healing process. We also did placenta prints and
on the full moon following his birth we planted the placenta in a
pot with a tumbling rose bush on top. We kept the cord which sits
on our altar. It is an amazing reminder of how close we needed to
be and how close he still needs to be.
for Lotus Birth from Women of
- A Ritual for our Times, by Sarah J. Buckley, MD
Umbilical Cord Clamping --
It Seldom, If Ever, Needs to Done - Lots of great resources
A new book, Lotus Birth by Shivam Rachana, has finally
been published in November 2000. For order
information, contact her at firstname.lastname@example.org.
BIRTH - What it is all about - It is when you do not cut the
baby's umbilical cord from the placenta. You let it fall off
when it is ready.
Cord - Or Not! - Lotus birth
You can read about lotus birth in Sacred
Birthing, Birthing a New Humanity© by Sunni
Karll, You can read more at the Sacred Birthing
The Uncut Cord
- a book by Donna Yemaya (formerly Donna Losoya), and her
web page - Yemaya
Lotus Birth Resources
pictures of a lotus birth baby.
The above article encourages keeping the placenta as dry as
possible. Other people have told me that keeping the
placenta in a casserole dish with cool water that is regularly
refreshed will keep it from smelling unpleasant. These same
folks said that the umbilicus is a muscle that cuts off the cord
on its own. I'm not sure whether they meant the stemming of
blood flow through the blood vessels of the cord or the entire
My midwife keeps the placenta attached for 2 hours following the
birth, she says this is the 'old fashioned' way but it's her
practice and her babies don't lose weight following the
birth. After 2 hrs, the umbilicus atrophies and there is no
bleeding. What has everyone else seen?
When I first heard about cord cutting, I thought it was just a new-age fad, adding a cumbersome ritual to the birth without other benefits. However, I'm intrigued by the promise of reduced jaundice and better breastfeeding, so I may give it a try.
“The flame brings the yang qi from the placenta and fire energy into the baby. It has an ethereal and remarkable effect on the baby. It is the core. The umbilicus is the entry place to all abdominal organs. By heating the cord and driving the last of the blood through there you are giving a profoundly tonic treatment for the baby who has just run a marathon…. Cord burning reduces the risk of bleeding and entry of infections. You are warming digestion which will reduce the tendency for jaundice, besides just creating a strong baby which means a good nurser.”
The umbilicus is the entry way to all abdominal organs. It
is the core. In traditional Chinese medicine it is a belief that
the placenta holds the Ch'i (life force) of the baby and by
heating the cord it sends that Ch’i to the baby and he is
therefore “warmed” by this energy. It is preferable they have this
warmth or heat at birth. Cord burning provides this warm energy.
It will reduce the risk of bleeding and entry of infections. You
are warming digestion which will reduce the tendency for jaundice,
besides just creating a strong baby which means a good nurser.
They have a nice little primer on how to manage cord burning, and they sell burn boxes.
A friend of mine, who is also a midwife tried this, burning
through the cord, last year on her own baby. It didn't work very
well. The cord was so thick that it took forever, it sizzled and
crackled, the smell was "interesting", and it was really hard to
position everything so that the baby was protected but the cord
wasn't left really long. I think they got about half way through
before they gave up and cut it the rest of the way.
I remember reading in Special Delivery that Rh- moms should have
cords cut immediately.
Might have been. I think that our efforts to protect the baby by
clamping the cord immediately might have contributed to
rh-sensitization . I'll see what some old posts say...
Is there anything we can we do to help protect their babies? We've always been taught that we should do early cord clamping when expecting an Rh positive baby from an Rh negative mom -- in order to reduce any 'extra" blood and antibodies getting to the baby. Probably still a reasonable idea -- but what about that other end of the cord?
From Guide to Effective Care (etc!) discussing early versus late
cord clamping..... "Allowing free bleeding from the placental end
of the cord reduces the risk of FETALMATERNAL TRANSFUSION, which
may be important with regard to blood group isoimmunization". In
other words, let it bleed free unclamped... This effort to reduce
fetomaternal transfusion rather supports the claim that our
routine management of third stage -- immediate clamping,
controlled cord traction, manual removal etc -- may exacerbate
blood incompatibility problems (by creating a higher risk of
'blood mixing"). Comments?
On early cord clamping, "It increases the likelihood of FM
TRANSFUSION as a larger volume of blood remains in the placenta."
yes, that's what GECPC says too. Early cord clamping causes fetal- placental transfusion. But "we" were taught to clamp early to help the baby avoid extra maternal antibodies and the extra load which might increase the (potential) pathological jaundice in an Rh positive baby! But we were "potentially" increasing the possible sensitization of the mom! As would practicing active third stage management (early clamping an controlled cord traction)....
Is the best advice to clamp the cord to the baby immediately and
open the maternal end to drain (assuming no undiagnosed second
twin!)? Or can we just assume that if we keep the baby level with
the placenta, we can keep the cord intact and unclamped -- baby
will not get any "extra' blood, and mom won't get any fetal blood?
What are others doing?
Stats show no difference in apgars, there are higher hct at later dates BUT no increase in jaundice in delayed clamped babies (yes, it DOES increase hct, but not enough to raise the incidence of clinical jaundice ). Check out Guide To Effective Care Etc.... It does no harm to the baby to delay cutting the cord....
But, catch this. GTECPG pg 239 "Pre-empting physiological equilibration of the blood volume within the fetoplacental unit (early cord clamping) in this way may predispose to retained placenta, postpartum haemorrhage, FETOMATERNAL TRANSFUSION, and a variety of unwanted effects in the neonate, respiratory distress in particular."
So there may be some HARM to early cord clamping!
Collecting Cord Blood for Typing -
Guide for Student Midwives By Gloria Lemay
The directions for obtaining the cord blood are usually written
and included in the cord blood collection kit, but are pretty much
standardized. They want you to collect the sample between
the birth of the baby and the delivery of the placenta. I
never do that, however, because we do not cut the cord until after
the placenta has birthed. You will obviously get more blood
volume if you collect the sample the way they suggest. If
you delay until after the placenta births, there will be less
blood in the cord vessels, and the venipuncture will be more
difficult. You should wipe the cord Vein with an alcohol
wipe, and do a simple venipuncture as close to the vein insertion
at the placenta as possible. Hold the placenta in a
container slightly above you so at least you have gravity on your
side somewhat. I am usually able to get at least 50 c.c.'s
in this manner.
If we need cord blood (usually only for Rh- moms) we get it with
a syringe from the vessels on the fetal side of the placenta. Only
once has this not worked--at my own birth! The vessels were very,
very small and collapsed when the midwife tried to insert the
syringe. The cord was very limp by this time and they couldn't
milk any blood out of it by then. This time we're planning on
getting cord blood while the placenta is still attached, via a
syringe in the cord. I have an Rh- mom due right now where I
intend to try this method for obtaining cord blood.
When the woman has had a physiological third stage, you can take
the placenta out of the basin and plop it onto a disposable
incontinent pad on a table. Bring the pad/placenta to the
very edge of the table and allow the cord to hang over for a
minute or two with a hemostat on the end. All the blood
that's trapped in the veins on the placenta will run down and you
can get an inch of blood in the bottom of a test tube easily when
you remove the hemostat. You might need to trim the end of
the cord by a half inch.
It was on this list one year ago that I got the hint to use a
Vacutainer, tube, and needle to obtain the cord blood without
clamping or cutting the cord. I have been doing this ever since
and it is GREAT!! I always get the blood I need easily, and I have
had NO PPH since beginning this practice. I have also not had to
wait more than 15 minutes for any placenta to deliver itself.
An alternative is to draw blood from a large vessel in the
placenta using a vacutainer and tube.
I do not cut the cord until after placental delivery - (mostly, I
have waited an hour and half for the placenta and had no
problem getting cord blood (1 Vacutainer) off the fetal placental surface aiming from the cord entry site down the blood vessels toward the outside of the placenta.
I just looked this up today. In Anne Frye's "Understanding Diagnostic Tests..." She states that you can draw blood from the still pulsing vessels with a large syringe. You have to cover the hole you've made with a finger or blood will spray. Pierce the top of your Vacuum tube with the needle, and let the vacuum draw the blood out of the syringe. Or, if your syringe was big enough that you don't need any more blood than you have, you can remove the stopper from the tube and the needle from the syringe and gently squirt the blood into the tube. You have to get the blood in the tube right away before it has a chance to clot.
Obviously, you need an assistant to help with this - or to grow
an extra set of hands.
I use a 50cc beaker to let the blood run into then pour it into
the tubes. I do not do cord bloods on all birth, only Rh- and hx
I have to collect blood too, but I also often cut the cord AFTER
the placenta is out. I just get a 10 cc syringe with an 18 gauge
needle and suck some from one of the veins in the cord. Sometimes
have to hit 2-3 veins but no problem getting the blood. I do
mostly hospital births.
We are required to get 2 tubes of cord blood to send to the lab.
If you wait until the cord stops pulsating before you clamp and
cut, are you still able to get your cord blood sample?
Don't know about 2 tubes, 1/2 to 1 usually no problem. You can
still draw blood out of the placenta vessels as well as milk the
Yes, I rarely cut the cord until after the birth of the placenta
and routinely draw bloods from the veins close to the body of the
placenta or directly from the veins on the placenta itself.
One of my moms went into labor and I ended up talking them
through it over the phone. She is Rh neg so I knew we needed to
get cord blood. I had them find something similar to a blood tube
that we could use. The dad found a medicine syringe. It worked
great! Fortunately the lab techs were flexible :-)
One other trick for these situations; labs can use a section of cord for the sample.
Clamp or tie a LOOP of umbilical cord (just double it over and tie it or put a rubber band tight) then cut from the placenta and put it in a plastic bag or leakproof container.
This trick saved me once when I was called unexpectedly to a
birth with only my prenatal bag -- no tubes, kelly's etc.
This subsection addresses issues of collecting blood from the
umbilical cord at a waterbirth, both for Rh determination or any
other kind of bloodwork, or for stem cell harvesting/storage.
I have done both but not at the same birth. It's hard enough getting the routine cord blood specimen at a H2O birth. When you do the cord blood collection for banking, that's all you do at the birth. You just hope that mum and baby don't have any problems because you will be "with cord."
One of the main reasons I like the waterbirth is the smoother
transition to extra-uterine life for the baby and it would detract
from one of the most intense moments that life has to offer if you
had to drag the new mother from the tub to try to collect cord
blood. I personally think the two options are mutually exclusive.
I disagree -- I don't think collecting cord blood is that big a
deal. And we do get routine specimens as well. You
would probably want to get her out of the water pretty quickly
after the birth, but we do that anyway. Then just clean off
the cord, collect the blood, voila.
Standard procedure of collecting cord blood from the cut end of
the cord and directly into the bag will not work terribly well. We
used the alternate method of prefilling 20 cc syringes with the
designated anticoagulant. Following sterile procedure I start near
the cut end of the cord and draw from any pockets of cord blood I
see in the cord, working toward the placenta. My largest harvest
comes from the large vessels on the surface of the placenta. Usual
harvest is between 30 and 50 cc, but the stem cells are very
concentrated in volume.
Pacific cord blood has a representative who has verified that the stem cell harvest doing this consistently results in smaller volume harvest, but greater numbers of stem cells. And since the cord has stopped pulsing by 5 minutes post birth, none of the cord blood harvested will deprive the baby of the cord blood transfusion it normally gets with optimal (delayed) card clamping.
Usually, I get the mom out of the water for the birth of the placenta, and am able then to do venipuncture on the cord for the blood sample, or just open the clamp (if the cord has completely stopped pulsing and the cord has been clamped), run the blood into a container and immediately pass that off to an assistant to collect it into the tubes. I am not sure here whether you are asking about collecting blood for stem cells or merely for Blood Group and Rh for RhoGam determination. Stem cell collection requires a significant amount of blood (about 30 cc.s around here, but probably varies with the facility). Obviously, you only need about 3-4 cc.'s for Type, Rh, and Coombs.
Once, I missed the birth by 12 minutes; mom was Rh Negative, and I was easily able to obtain sufficient blood from the placenta by venipuncture for the necessary samples.
It is easier to do out of the water than in, I am sure, and I
typically encourage mom to get out of the water for the placenta
anyway, for aesthetic reasons ( even that amount of blood in the
water, seems like a whole lot of blood and makes people nervous!).
I keep the birth stool next to the tub for just that purpose...
Collection of cord blood for stem cells needs to be done
immediately following the birth of the placenta, which needs to be
facilitated rather immediately. I swear I will make a nurse
come to do it next time, because it takes a lot of time, time that
should be spent monitoring the mom and baby and enjoying the holy
moment instead of messing around with cord blood. So anyhow, water
birth is cool, but she needs to go to the bed within a few minutes
to get the placenta coming.
I get mom out of tub for placenta -- usually about ten or fifteen minutes after birth (I think the placenta stage seems more leisurely in waterbirths -- seems to take a while for contractions to start again after the birth of the baby). Anyway, I get mom out as the others do, but I much prefer to move to a chair beside the tub instead of getting her lying down! Mom gets comfy in her chair, wrapped in blankets cuddling with baby while we wait for placenta -- which usually seems to come relay quickly after the mom's movement into an upright position.
Collecting blood for sample is easy with mom in the chair beside
the tub --- seems this might be a good time for doing stem cell
collection (have never done it though).
Don't horse around with needles in a water tub. I usually get the Mom out of the tub and lying down on a plasticized surface--couch with shower curtain over it and then thick, warm towels on top of that. Cord is left alone until the placenta births. After birth of placenta, in a leisurely fashion, cord is cut by Dad and placenta is taken to kitchen and plenty of blood can be dripped from the cord into a test tube for Rh determination. I'm against cord blood collection for stem cells. I think it's a ridiculous money making scheme with dubious possibility of benefits.
I have taken cord blood for stem cell preservation, yet never clamp/cut the cord before it completely stops pulsing, and in some cases not until after the placenta has birthed. I have to assume that the necessary volume of blood has already been transferred to the newborn if the placenta has been discarded by the body!
I think it is possible to use umbilical cord blood for research or storage purposes without compromising the newborn's volume. Although, the tendency in the hospital would be to efficiently withdraw the blood before the cord stops pulsing or the placenta has birthed - you are correct on that score - especially if there is monetary gain to be made......
In our home births, I believe both purposes could be
We have collected stem cells after several water births. The
mother stayed in the tub about 5-10 minutes after the birth then
got out to the birth stool so that we could clamp the cord and
insert the syringe into the cord. It was definitely a quicker exit
from the tub than we would advocate normally, but it was
acceptable because the parents knew beforehand that they were
making that choice.
This is from the office of Brain Therapeutics Medical
Clinic, experts in stem cell use for treating strokes: "The
baby's health should not be compromised - if it is, it's not being
done ethically." I couldn't agree more! This is strong
support for avoiding premature clamping of the umbilical cord!
for cord blood banking. Department of Health.
Linden JV, Preti RA, Dracker R.
J Hematother. 1997 Dec;6(6):535-41.
"The collection of cord blood should not result in any deviation from normal obstetric procedures (e.g. for time of clamping).
"3. In utero (prior to placental delivery) and ex utero (following placental delivery) collection methods are both acceptable and have comparable efficacy. Use of a closed or semi-closed system (bag or syringe) by venipuncture of the umbilical vein under aseptic conditions is recommended.
"a. The collection procedure should present no foreseeable harm
for either the mother or child or compromise the cord blood
I like these guidelines from the National Marrow Donor Program.
"Cord blood can be collected from the placenta either while the placenta is still in utero after the cord is clamped and cut and the baby is removed from the area, or after the placenta has been delivered, referred to as ex utero"
They talk about waiting until the placenta has been delivered
normally and then collecting the cord blood from what's
left. They probably would prefer that the cord be clamped
immediately after the birth, but they're not explicit about
this. I'm glad to see that they're sensitive to the baby's
need for oxygenated blood from the placenta for at least a few
minutes after birth, anyway.
How soon after birth does the cord need to be clamped and/or cut in order to collect blood from the cord or placenta?
Research is clear that cutting the cord less than five minutes after the birth deprives the baby of oxygen as it takes some time for successful completion to newborn circulation. And it also takes the blood away from the baby, who needs the blood to fill the newly expanded pulmonary vessels and to re-fill blood vessels elsewhere in the body that were squeezed during the birth process. In addition, when the cord is clamped/cut too soon after the birth, the baby is at higher risk for requiring a transfusion or late-onset newborn anemia.
So, I was wondering whether technology has progressed to the
point where cord blood can be collected later than five minutes
after the birth, so that the baby's well-being is not compromised.
A Rich New Stem Cell Source: Research on Umbilical Cord Matrix [Kansas State University - 24-Sep-2004]
"Kansas State University researchers have discovered a novel and
potentially inexhaustible source of stem cells isolated from the
matrix of umbilical cords. These cells have a remarkable
propensity to develop into neural stem cells. . . .The cushioning
material or matrix within the umbilical cord known as Wharton's
jelly is a rich and readily available source of primitive stem
cells, according to findings by Troyer and Weiss."
For more about stem cells, see the National Institutes of
Commercial Cord Blood Banking - (Nov. 19, 2001) -
[Medscape registration is fre] "The Royal College of Obstetricians
and Gynaecologists said commercial umbilical cord blood banking,
in which stem cells are stored indefinitely in the hope they might
help treat future illnesses, could not be recommended at present.
Private Cord Blood Banking: Experiences and Views of Pediatric Hematopoietic Cell Transplantation Physicians - AAP article from 2009
Private cord blood banking: experiences and views of pediatric hematopoietic cell transplantation physicians. [full text]
Thornley I, Eapen M, Sung L, Lee SJ, Davies SM, Joffe S.
Pediatrics. 2009 Mar;123(3):1011-7. doi: 10.1542/peds.2008-0436.
Dana-Farber Cancer Institute, 44 Binney St, Boston, MA 02115,
CONCLUSIONS: Few transplants have been performed by using cord
blood stored in the absence of a known indication in the
recipient. Willingness to use banked autologous cord blood varies
depending on disease and availability of alternative stem cell
sources. Few pediatric hematopoietic cell transplantation
physicians endorse private cord blood banking in the absence of an
identified recipient, even for mixed-ethnicity children for whom
finding a suitably matched unrelated donor may be difficult.
Cord Blood Banking for Potential Future Transplantation [1/1/07] from the AAP (this statement was retired May 2012)
A number of private for-profit companies have been established that encourage parents to bank their children’s cord blood for their own autologous use or for directed donor allogeneic use for a family member should the need arise. Parents have been encouraged to bank their infants’ cord blood as a form of "biological insurance." Physicians, employees, and/or consultants of such companies may have potential conflicts of interest in recruiting patients because of their own financial gain. Annual disclosure of the financial interest and potential conflicts of interest must be made to institutional review boards that are charged with the responsibility of mitigation of these disclosures and risks. Families may be vulnerable to the emotional effects of marketing for cord blood banking at the time of birth of a child and may look to their physicians for advice. No accurate estimates exist of the likelihood of children to need their own stored cord blood stem cells in the future. The range of available estimates is from 1 in 1000 to more than 1 in 200000.51 The potential for children needing their own cord blood stem cells for future autologous use is controversial presently.51 There also is no evidence of the safety or effectiveness of autologous cord blood stem cell transplantation for the treatment of malignant neoplasms.51 Indeed, there is evidence demonstrating the presence of DNA mutations in cord blood obtained from children who subsequently develop leukemia.52 Thus, an autologous cord blood transplantation might even be contraindicated in the treatment of a child who develops leukemia.The AAP issued this statement in 2009:
. . .
Physicians consulted by prospective parents about cord blood banking can provide the following information:
Cord blood donation should be discouraged when cord blood stored in a bank is to be directed for later personal or family use, because most conditions that might be helped by cord blood stem cells already exist in the infant’s cord blood (ie, premalignant changes in stem cells). Physicians should be aware of the unsubstantiated claims of private cord blood banks made to future parents that promise to insure infants or family members against serious illnesses in the future by use of the stem cells contained in cord blood. Although not standard of care, directed cord blood banking should be encouraged when there is knowledge of a full sibling in the family with a medical condition (malignant or genetic) that could potentially benefit from cord blood transplantation.
Cord blood donation should be encouraged when the cord blood is stored in a bank for public use. Parents should recognize that genetic (eg, chromosomal abnormalities) and infectious disease testing is performed on the cord blood and that if abnormalities are identified, they will be notified. Parents should also be informed that the cord blood banked in a public program may not be accessible for future private use.
Because there are no scientific data at the present time to support autologous cord blood banking and given the difficulty of making an accurate estimate of the need for autologous transplantation and the ready availability of allogeneic transplantation, private storage of cord blood as “biological insurance” should be discouraged. Cord blood banks should comply with national accreditation standards developed by the Foundation for the Accreditation of Cellular Therapy (FACT), the US Food and Drug Administration (FDA), the Federal Trade Commission, and similar state agencies.
The total circulating blood volume in a neonate at birth is 70 -
80 ml/kg birthweight with early clamping and slightly higher with
delayed clamping (Myles). the placenta and cord generally contain
45 ml/kg birthweight. In absolutely optimal conditions (in other
words, not a drop of cord blood remains in the cord, you would
have to have a baby of around 5 to 6 kg to get your "more
than a cup" of stem cells.
Cryo-Cell - America's Fastest
Growing Commercial Cellular Storage Company, Offering Affordable
Cord Blood Stem Cell Preservation
"Some mothers, obstetricians, midwives and doulas prefer to wait until the cord stops pulsating before clamping and cutting it. The cord blood collection process should not interfere with normal birthing procedures, and it may begin after the cord stops pulsating."
Cord Blood Registry - 1-888-CORDBLOOD
the Cord Blood Registry Collection Kit - "Cord blood should
be collected as soon as possible, within 10 minutes of birth. "
and "(To maximize collection from placenta, aspirate cord blood
while placenta remains in utero. In utero collection is also
preferred for cesarean deliveries.) "
For most births, we were able to collect an adequate amount of
blood. The time between birth of baby and birth of placenta had
little to do with the success of the collection. The time between
birth of placenta and collection of the blood had more impact - if
we waited too long, the blood clotted in the vessels. We generally
set up a spot to do the collection when getting set up for the
birth so that one of the midwives could be responsible for getting
it started and still be attentive to the needs of the woman or the
other midwife. I sometimes taped the tubing to the cord so I could
just let it flow while doing other things.
I've been reading with great interest the current thread regarding early vs. late cord clamping, which has brought a question to mind. From reading that I've done on my own, as well as discussions I've had with birthing professionals (midwives and OBs), the consensus seems to be that most lean towards delayed clamping.
My question is this: How does this issue relate to cord blood storage? It's my understanding that the cord must be clamped as quickly as possible in order for the procedure to be worthwhile. As a doula, I will undoubtedly have clients who have some knowledge of cord blood storage, and I want to be able to inform them of both the pros and cons of the early clamping that this requires.
I had been approached by a cord blood bank representative prior
to the birth of my first child, and after researching the concept,
decided that I wanted my baby to receive the benefits of her own
cord blood, and discussed this issue with my caregiver. Her cord
wasn't cut and clamped until it ceased pulsating From the
information I had at the time, I didn't want to deprive that
particular child of the benefits gained by receiving the cord
blood after birth. Are there any references that anyone can cite
stating the pros and cons of letting the child receive their own
cord blood at birth (delayed clamping) vs. potential benefits to
that child (or other children in the family) by clamping early and
storing the cord blood? The bulk of the information I've found has
been from the cord blood storage companies, and the data was
decidedly one-sided, with no tangible references cited. I don't
want to pass on hearsay - I'd love to hear your opinions, of
course, but I would really like to have some concrete data
regarding this topic, so my clients can make truly informed
decisions in this matter.
Last week I had a client give birth and she wanted her cord blood
collected. Have you performed this task yourself? Did it take a
lot of time, do you see it interfering with the other needs of the
woman and newborn? I am asking you this because some midwives here
are concerned about it and suggest that a nurse be hired by the
couple to draw the cord blood?
I find the stem cell collection process is very 'compatible' with
the majority of hospital deliveries due to the physical set ups
and the practice of routine immediate cord clamping,
however, I find that this practice in a 'active' (H20?),
physiologically managed home birth potentially 'intrusive'. It
seems to redirect the energy in a way which is different from the
usual focus. I make a point of using 'informed consent' when
parents request this service by reminding them that my first
responsibility is to mom and baby and that I will not guarantee
collection if my attention is demanded elsewhere.
Some midwives are concerned about the risks to them of
using a very large bore hollow needle to do a venipuncture on the
cord. Some practices are now declining to recommend or
encourage for-profit cord blood donation, and will not provide any
literature on it to any of their clients.
Being a doula, I have not personally done this, but have been present when it was done. The collection is a simple procedure. After cord is cut (1-2 min max after delivery) and baby is removed, a supplied alcohol prep pad swabs a site near the end of the cord and a syringe that contains heparin is inserted in the site on the umbilical vein and the blood is slowly extracted. This is repeated twice more, once about 1/2 way down the cord and again close to the placenta. 40CCs is considered a good collection, and I know that in at least one case, almost 200ccs was extracted. It's simple, over in a couple of minutes and then the whole kit goes to dad who is responsible for sending it to the storage facility.
This procedure takes only about 5 minutes total. Usually a nurse handles the collection in a hospital setting while the doctor or midwife deals with the mother and baby.
This seems a little extreme to hire a nurse to do the draw. Even
the dad could do it with a little instruction. I have seen nurses
do it after the placenta is removed in a c/s. I could do it. It's
really not a tough thing. Several of the midwives I know who do
the procedure leave their assistant to do the collection if there
is a reason for them to be VERY busy with mom and baby. Otherwise,
it can be done with the baby on mom's tummy while waiting for the
placenta to be delivered.
How many of you are getting requests about saving cord blood for
stem cell storage for future bone marrow transplants? We have had
a few ask about it (home birthers, too) and we got the literature.
It seems very daunting...you need to collect about 150 cc, be
absolutely sterile, etc. etc. No cord pulsing for sure. The
potential for liability around this is incredible IMHO....what if
the specimen gets contaminated? You've only got the one chance to
get the blood.
Actually the procedure is really not terribly difficult. As a Cord Blood Educator for the Cord Blood Registry, I can assure you it is a simple procedure and I have personally been present to see it done. The cord may be pulsing or not. The sterilization process is simply using a sterile needle and heparined syringes (provided in the kit) and wiping off the insertion points with an alcohol swab. There is no liability to the health care professional doing the phlebotomy and if the specemin is not usable, the couple does not have to pay the storage facility anything beyond the 1 time family registration fee.
There are several forms the health care provider gets from CBR.
One is a form absolving the health care professional of liability.
Another is a form that documents that the family got information
on the procedure and whether they elected to do it or not (in case
they need it later and want to charge the health care provider
that they never got the information indicating that they could
have this collected). Other material indicated the survival rate
in related transplants vs. unrelated transplants and the relative
costs, diseases that are currently being treated with cord blood
stem cells, and other pertinent information. There are a couple of
videos available if you want to use them in your practice and CBR
will provide them for free. These are currently being redone to
reflect a change in the collection procedure because the heparin
is no long already in the syringes when the collection kit is
Information package that we got from a Vancouver BC company stated that the cord had to be clamped within 15 seconds of the birth.
No offense, but with all the other things that I am required to do informed choice discussions on (Maternal Serum Screening, Group B strep swabbing, home Vs hospital, pain relief, etc., etc., etc., etc.)...this is going to be one more thing that I am going to have to discuss, whether parents wish to talk about it or not.
I still feel that "simple" or not, it can be difficult to obtain
the amount of blood that our information told us we were to
obtain...this, plus cord blood for group and type, cord blood for
gases (which is routinely required in some hospitals). I've seen
it difficult enough to get routine cord bloods...let alone
I recently attended a lecture presented by an RN who works for a
cord blood collection/storing company. A major part of her job is
talking to hospital lawyers about liability. The woman consenting
to cord blood banking signs a consent form that releases the
hospital, physician or midwife of any liabilities surrounding the
collection and handling of the cord blood. The company is Cord
Blood Registry. For an info packet, containing studies, a sample
consent form, a pamphlet to put in your office for clients, and a
video of the correct collection procedure, call:
The presenter stressed that they need 60 to 150 cc of blood, although any sample should be sent because they were able to save 30cc once. The client is responsible for bringing the kit to the birth with heparinized syringes and instructions for collection. She is also responsible for the blood once it has been collected. It gets FedExed to the Cord blood Registry.
The studies in the packet are: Sugarman, Reisner, & Kurtzberg. (1995) Ethical Aspects of Banking Placental Blood for Transplantation. JAMA, Vol.274, No. 22
Wagner et al. (1995) Allogeneic sibling umbilical-cord-blood transplantation in children with malignant and non-malignant disease. The Lancet, Vol. 346, No. 8969, pp.214-219.
We've gotten several requests from clients to donate when they
show up at the hospital, and we didn't know anything about it. But
it has to be set up months in advance between the client and the
company. It's a good thing to talk about during prenatal visits so
they can decide and have time to arrange it.
We saved cord blood for the baby's own use (as well as siblings)
but we definitely did NOT cut the cord early! Not at all. You can
still do it after cord stops pulsing!
Wow! I am so impressed. There certainly is some blood left in the cord and placenta after the baby gets everything it needs, but this is the first time I've heard this fact used for the baby's benefit.
Every time I've heard anyone talking about getting cord blood for
stem cells, they've mentioned the "need" to clamp/cut early. I've
heard the time for clamping/cutting as being between 15 seconds
and 1-2 minutes max.
I worked with CBR for 2 years. I found it quite controversial with many on the subject of clamping and cutting. On the other hand, I have heard heartwarming stories of children being successfully treated with their sibling's cord blood when they couldn't find a bone marrow match. Medically there are many benefits to cord blood over bone marrow and with anything there are advantages and disadvantages. It is important for families to discuss these issues in detail with their health care provider to determine what is their best option in their individual circumstance.
As for the instructions that come with CBR's collection kit, it
states "as soon as possible". It is up to the family and the
doctor to determine what that time frame is. I really am not sure
of the collection procedures for other companies. I am sure they
are basically the same. The biggest difference in the cord blood
companies is their storage methods and price.
The mission of Lamaze Publishing and iVillage is to bring
important medical information to expectant parents. I have
stored both of my children's Cord blood and am proud to join them
in this effort. Together it is our hope that someday the
collection of cord blood from every newborn will become a routine
It is my hope that someday newborns will not be asked to be blood donors. According to the Red Cross, "To give blood, you must be healthy, at least 17 years old, and weigh at least 110 pounds." Most babies at birth are unstable, 0 minutes old and weigh less than 10 pounds.
"Cord blood" is a euphemism for "your baby's blood". It belongs in your baby's body, which is where it would naturally flow if the process weren't interrupted. If you wouldn't let someone take blood from your baby's arm, don't let them take blood from your baby's umbilical cord because it's heading towards the arm.
Donation of "cord blood" and premature cutting of the umbilical cord both carry some serious risks: