Wednesday, March 21, 2007

Cord cutting

I don't know whether to feel glad or sad at reading this article about delayed cord cutting from the Toronto Star. I'm glad that medical studies are finally focusing on how leaving the cord intact after birth significantly improves a baby's condition. (Or should I say, " cutting or clamping the cord immediately after birth significantly worsens a baby's condition." It's not that delayed cord cutting is an added "benefit," but that early cord clamping is a "harm.")

Thing is, this shouldn't be news at all! Doctors and midwives have known this for hundreds of years. Anne Frye's textbook Holistic Midwifery extensively documents this, if you want more detailed information.

Here's a quote from Erasmus Darwin (grandfather of Charles Darwin) in 1801:
Another thing very injurious to the child, is the tying and cutting of the navel string too soon; which should always be left till the child has not only repeatedly breathed but till all pulsation in the cord ceases. As otherwise the child is much weaker than it ought to be, a portion of the blood being left in the placenta, which ought to have been in the child.
I have a few issues with the newspaper article, as glad as I am that the topic has made it into the news:

1. The picture. Okay, I see lots of gowned people surrounding a newborn baby. Where is the MOTHER??? Why isn't the baby on her chest??!! Images like these reinforce the idea that birth is a medical procedure, and that the mother is really not all important in the whole process. It reminds me all too much of the Monty Python sketch I posted earlier.

2. Researcher Eileen Hutton's quote: "It's an intervention that has the potential to have a (positive) impact on a large number of babies and at a very low cost. This benefits the baby without any real down sides for mom."
NOT cutting the cord is an "intervention?" I vehemently disagree. Clamping and cutting the cord is the intervention; leaving the cord intact is simply normal human physiology.

Erasmus Darwin. Zoonomia. Vol III 3rd ed. London 1801:302


  1. There was actually an article in one of the professional journals (Journal
    of Midwifery and Women's Health) a few months ago about this very thing. The
    article was generally in favor of delayed cord clamping. The advantage of
    this is, as your article says, that the baby receives more blood from the
    placenta and thus is less likely to be anemic in the weeks after birth. The
    supposed downside is that there is a theoretical possibility that babies who have
    this extra blood will have a greater chance of developing jaundice in the
    days after birth. Babies generally have high blood counts when born and as a
    normal physiological thing, break down some of their red blood cells within a
    day or two after birth. The breakdown of the red cells releases substances
    that can contribute to jaundice. It is very common (to the point of being
    considered normal) for babies to become somewhat jaundiced on about the third
    day. If a baby is visibly jaundiced, the pediatrician will run a bilirubin test
    to see just how high the level is. It should not be >20. Some
    practitioners use the jaundice possibility as a reason for not delaying cord clamping.
    However, jaundice can usually be prevented if the mom breastfeeds the baby
    early, thus causing the baby to expel meconium, and keeping the baby well
    hydrated. Normal physiologic jaundice can be treated by exposing the baby's skin
    to sunlight or "bili lights" which are fluorescent lights. This helps the
    baby break down and expel the bilirubin. The JMWH article was in favor of
    delayed clamping, believing any theoretical risk of jaundice was outweighed by
    preventing anemia. I was taught in school, for the same reasons, that cord
    clamping should be delayed when possible. Occasionally a baby will need serious
    resuscitation, and then it is usually necessary to detach the baby and move
    him/her to a warmer where the nurses can do that. In most cases, even if a
    baby is a little slow to get going, the extra blood, and oxygen as well as long
    as the placenta has not separated from the inside of the uterus, will only
    do the baby good and will actually do more good than other resuscitative
    measures. The nurses can give the baby oxygen and stimulation while the baby is
    on the mom's belly with the cord still attached and pulsating.

  2. Precisely, Rixa, intervention indeed!!! Here's the sense in which that would be an intervention: intervening with an often harmful, non-evidence based obstetric regime. Intervening with institutional protocols in the name of the health and safety of newborns in institutional care.

    I am relieved to hear the president of the Canadian society of OB-GYNs promise that "this will definitely be examined". Commenting on study that is itself a meta-analysis already, of 15 earlier papers examining a total of 2000 newborns! Sounds like they just can't wait to do some serious soul-searching...

    He even says that this information might "change the way babies are delivered". Even though the author (and common sense) seems to suggest that "normal postnatal care of the newborn can be administered while the infant is still attached". Hmmm. Sounds like the real change needs to be in the mindset of nurses and doctors. They'll have to change where they stand (no pun intended): stay by mom's side instead of going to a warming table! Wow.

    But sarcasm aside, I am actually excited. If they give it a whirl, they may also notice they see fewer depressed newborns, better apgars, and many many happier moms and babies. Who knows, it may catch on eventually.

    Sadly, when I once suggested to a friend that she request delayed clamping, she came back to me from her prenatal to report that the OB thought it a bad idea because the baby would LOSE blood to the placenta! At the very least, obstetricians need to educate their own rank.

  3. Hi Leanne, you just posted your comment the second I posted mine. So here's my question -- I don't know much about extensive resuscitation efforts. What equipment or procedure is required that cannot be brought to the mother's side? Could you explain the logistics? Thanks, Judit

  4. You could do any resuscitation needed right by the mother's side. The equipment used is quite simple and portable. If you're at home, you either do mouth-to-mouth or use a bag & mask (with or without O2 attached). Hospital equipment generally plugs into the wall, rather than relying on portable O2 tanks, at least in the hospitals I've been to. For very serious cases, you might end up doing chest compressions. Most homebirth midwives have a large cutting board or cookie sheet that they wrap in a warmed towel to serve as their resuscitation board.

    It's less convenient to resuscitate on the mother's belly, or in the birth tub, or whatever. But it's entirely doable; the birth attendants just have to be more flexible. Hmmm, imagine that.

    Frankly, if a baby is having difficulties coming around after the birth, the last thing you want to do is sever its lifeline. The logic behind that escapes me.

  5. Less than 1% of all newborns will need chest compressions (CPR) as well as oxygen by bag and mask. In a hospital setting, it is not practically feasible to do these procedures while the baby's cord is still attached as the baby must be on a firm surface for effective chest compressions. If the baby just needs a little oxygen, without bag and mask, it can be given with the baby on the mom's belly. As you said, Rixa, there are ways to do it at home if you are creative.

  6. Thanks R & L, I didn't know about the firm surface for chest compressions; I see the rest is entirely as I imagined, i.e. doable on mom with cord attached.
    The 1% figure is especially encouraging bc many of those moms birth under less than ideal circumstances (augmented, under anesthesia and immobile etc.) and 99% of babies still do okay without chest comression and oxygen!

    Now I'm thinking of midwives schlepping around oxygen tanks and boards possibly for years before they once need them. Yet people have this idea that a midwife is less equipped than hospital, and homebirth is risky? Ugh.

  7. I went to my doctor today for an apt and I am so depressed. I will be 28 weeks on Sunday so I am due in a few months. She had never heard of delayed cord clamping and told me she hasn't ever heard of any "medical research" on it. She also told me that it's hard to put the baby on the mom's belly if the cord is still attached and the placenta is still in the vagina! She told me she would google it and see what she finds. Rixa's post is the 1st I have personally heard of it but it makes total sense to me and I want to do what's best for my baby. I don't want to be told what I am allowed and not allowed to do. I really like my doctor and don't want to switch but how can I change her mindset? Urgh. Birthing centers and home births are looking more enticing to me by the minute.

  8. This paper was included in last week's JAMA, so well-read doctors should be picking up on it soon!

  9. I live in Toronto, and I saw the headline on my way to work on whatever day it was published. I didn't even bother to read the article because I figured it would just depress me. My first reaction to the headline was a big fat "DUH!" with a little eye-rolling and head-shaking.

    I do hope that many more doctors begin incorporating delayed cord clamping/cutting (by MORE than the suggested 2 minutes, please and thank you); it would make such a huge difference, I think.

  10. Hi anonymous who is 28 weeks pregnant (and we really need a better way of telling all you anonymouses apart!):

    I'm a bit surprised your doctor has never "heard" of delayed cord clamping and cutting. It's a routine that's only a few decades old, after all.

    Unless you have an unusually short cord, there is plenty of cord for placing the baby on your stomach. After all, the baby was pretty much in the same place, but just on the inside. I had more than enough cord to snuggle her close to my chest, to kiss her head, etc.

    In theory (but alas, not as often in practice), you should simply say "Do not cut or clamp the cord until the placenta is out" or "until X amount of minutes have passed." Whether or not the doc agrees with it should be a moot point, if you do not consent to it.

    Your doctor should have to PROVE to you that immediate cord clamping is beneficial and without risks, not the other way around. The burden of proof should be on the intervention, not on normal human physiology.

  11. What a beautiful blog, and bringing attention to this is great. I personally believe that nature is perfect, and that the cord can be left attached to the baby until it falls off naturally, this is called lotus birth, just like any other part of birth, this is something that we are all free to choose, or not - I do believe each one of us has our own right way.

    I am 13 weeks pregnant, first pregnancy, and will be having a UC, water birth at home with my husband. Our other plans:
    breastfeeding, lotus birth, elimination communication (diaper-free). There is more, however I choose to write the things we will do, instead of the things we wont.

    I just started to read your blog, looking forward to exploring some more :)

  12. Welcome Lorib and thanks for reading.


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