Immediate umbilical cord clamping is still a hallmark of medical childbirth. Though opinions are changing, many doctors harshly defend immediate clamping even in the face of peer evidence showing it's not only non-beneficial, it's actually harmful. Perhaps a greater challenge for moms choosing to birth in the hospital is the fact that cord clamping is “routine.”
Even if your care provider agrees to delay clamping, it's done automatically in the moment – with no thought. Once you understand why it's important to leave the cord intact, you can advocate for your baby and insure your wishes that he or she get a full blood supply are respected.
A baby's circulatory system in the womb includes the placenta. The placenta provides oxygen for baby's blood, and is a vital part of fetal circulation.
A baby experiences a much lower oxygen saturation in the womb than he/she will once fully adapted after birth1. An adult or child has a 95-98% oxygen saturation in the blood, but a baby in utero (in the womb) only has about a 60% oxygen saturation because fresh blood from the placenta mixes almost immediately with de-oxygenated blood in the baby's ductus venosus, which then moves towards the heart. You can see this illustrated in the diagram by the purple “mixed” blood – there's only red blood up to the point where it shunts off from baby's liver.
Pressure levels in the baby's circulatory system are also very high because the lungs are quite constricted at this point. The alveoli of the lungs are usually filled with air, but in an unborn baby they're filled with fluid, which forces the restriction of blood through vessels in the lungs. This creates a very high pressure situation within the baby's body.
There is not a lot of pressure in the placenta, however, so much of baby's blood flows back to the placenta very easily (it seeks the path of least resistance.) I've included a great video demonstrating fetal circulation at the end of the article 2 🙂
These facts about circulation in utero are important to understand.
During labor uterine muscle tightens, creating a taut uterus and compression around the baby. In her Neonatal Resuscitation class, Karen Strange quotes Judy Mercer: “the uterus acts like a compression sock.”3 If you've had varicose veins, you know that compression socks create pressure that helps force blood back up out of the legs (where it wants to pool).
The taut uterus acts in a similar way, forcing blood through the path of least resistance during labor. As I showed you above, that's into the placenta. Research by Peter Dunn shows that about 66ml of blood backs into the placenta during this compression stage (some also goes into baby's head)4.
The bottom line is: a significant amount of baby's blood is not inside your baby during birth. It's in the much lower-resistance placenta, which acts as a reservoir for baby.
At birth, everything begins to change.
Your baby goes through a transition that starts with the birth process pushing fluids out of the lungs. If you watch a natural birth you can see fluids pouring from a baby's mouth as the head is born 5.
The lung alveoli transition from being full of fluid, as I described above, to being full of air. This isn't an instantaneous transition. The UK Neonatal Resuscitation Counsel notes that the first 2 -3 breaths your baby takes are merely breaths to push the remaining fluid out of the alveoli. These inflation breaths not providing high levels of oxygen because they're simply acting a mechanical inflation for the alveoli. By the 4th or 5th breath, you'll see deep chest movements as the lungs begin to inflate and oxygen is brought into the blood6.
While this transition is taking place, your baby is getting blood from the umbilical cord. In fact, the high pressure levels within the lungs and fetal circulatory system during birth suddenly begin to change. The blood that's been held in the placenta during birth starts to flow rapidly down the umbilical cord and into your baby.
There your baby's lungs are beginning to work and oxygen-rich blood is starting to make its way through baby, gradually increasing blood-oxygen saturation levels. You can see this transition happen in your baby as you watch his or her chest become very pink, then the arms, legs, hands, and feet.
What happens when that blood is missing? In other words, what happens when baby's cord is clamped and cut immediately, or restricted in another way?
What happens when you lose blood? The baby loses about 66ml of blood if immediate clamping takes place. That's roughly equivalent to 1500-2000ml of blood loss for you (you lose about 500ml of blood when you donate or give birth; 1000ml during a c-section – so this equivalent is quite high!!!). Your body goes into shock.
A baby robbed of cord blood can experience physical shock and psychological shock – baby's systems immediately move into survival mode to compensate. OB/GYN and researcher Dr. Fogelson describes immediate cord clamping as “fetal phlebotomy” that removes somewhere around 40% of the baby's blood7.
Other researchers have pointed out possible “side effects:”
It's also important to understand that the blood is being held in the placenta at high pressures, with no relief of pressure coming, when the cord is clamped right away. This may not make a huge difference but some researchers believe it can possibly force blood out of the placental circulation and into the maternal lake of blood that the placenta has created. This may increase the chances of sensitivity in an RH- mother among other possible issues.
Birth is truly the beginning of a great adventure – and it's very natural for both mom and baby to pause for a moment before it all unfolds.
In her neonatal resuscitation classes, Karen Strange carefully describes the instinctive behavoirs of mother and baby at birth. Mamas left to themselves usually let baby rest for a moment on the bed or mat on the floor – or if mom has caught the baby, she holds the baby between her thighs for a moment. Mama takes a breath in this moment, letting herself fully absorb the enormity of what she just did… and baby's cord blood flows.
The baby is slightly lower than mama, letting gravity assist as the baby's lungs are clearing and pressure is decreasing, resulting in a flow of blood to the baby that assists him or her as the transition to “all systems are go” is happening.
Instinctively mamas then begin to slowly touch baby, feeling him or her with fingertips, then rubbing fully with palms, and finally pulling baby up into her arms and onto her chest, where her body takes over and becomes baby's temperature regulator, respiration regulator, glucose (blood sugar) regulator, and more.
Many moms and babies need this first moment after the work of birth – and nature may have designed it in part to help baby get all the blood he or she needs flowing.
Immediate cord clamping is a very new trend in human history. As Karen Strange says in her workshops “birth is designed to work in case nobody else is there.”
Umbilical cord blood is rich in primitive fetal stem cells, which is why a huge industry has sprung up around cord blood banking.
I'm not saying that banking a baby's blood is a bad idea, especially if you know that cord blood may be critical to your baby or a sibiling surely then a sacrifice on your baby's part may be worth it.
But for most families, I challenge you to consider that those precious cells and that precious blood may be intended to be inside of your baby. You've seen the short-term implications of cutting this blood off from your baby, and those things are not good. What might be the long-term implications of removing these cells and storing them indefinitely, rather than putting them into the person's body they were intended for?
I'm not sure if there are yet answers to that question, but it's worth thinking about. Surely it's true that birth and physiology were designed to work the way that they do for a reason, and we should think very carefully before disturbing that.
There are many “what if's” when it comes to talking about cord clamping. Many things once believed, such as a danger to babies from having “too much blood,” have been proven to be false by modern research.
But some still worry about leaving the cord intact on a “compromised” baby, and others are concerned about maternal hemorrhage if the placenta isn't yanked out right away.
The truth is, most babies do just fine. Even neonatal resuscitation counsels note that 90% of babies will initiate breathing with no issue at all. Of the 10% that may need assistance, 9% need only a few inflation breaths to help them clear fluid from their lungs – these babies are essentially a variation of normal, and these breaths can be delivered easily by a birth worker or even the mother herself while baby is still attached. The 1% who need additional help can also received it while beside their mother and while still attached to the umbilical cord – which indeed may be the baby's only supply of oxygen. Cutting it off may be more devastating than resuscitation at mama's side. This will always be an “in the moment” decision made while looking at each baby's situation, but many, many babies can be safely cared for while still receiving vital blood and oxygen through the placenta13.
Mom and midwife Maya gives her newborn inflation breaths at his birth – cord still intact! She says her training came right back to her and he just needed a little help to start up 🙂
It's also a common worry that a mama may keep bleeding if the placenta is not “delivered” immediately. Again the design of birth is contrary to that assumption. Birth, when left alone, works very well. High (lifetime high) levels of hormones protect both mother and baby at this time. The uninterrupted interaction with mother and baby (as I described above) facilitate and encourage this hormone rush and the safety it brings with it. As hormones, including oxytocin, skyrocket to levels that give everyone in the room a “contact high,” the uterus continues to do its important work of becoming firmer and firmer and shearing the placenta off the uterine wall. Blood is flowing down to baby as this happens. And the contracting uterus clamps and cuts off exposed capillary ends, which stops bleeding. As with above, there are times when an individual mother and baby's situation may warrant intervention by a skilled care provider, but that is the exception and not the rule.
All birth interventions should be looked at critically through the lens of what happens when a well-nourished mother and baby are supported in birthing naturally. I.E. with no outside interventions, from IV poles and forced pushing to bright lights and multiple spectators. What happens in that birth is the gold standard – not what “normally” happens to a mother who has had her labor disturbed from the moment she stepped out her front door (the very first intervention, as noted by OB Michael Rosenthal).
By understanding how carefully birth is orchestrated to work, we can understand how to keep birth in any environment safe for mother and baby. I discuss this extensively in related articles: Will the REAL Oxytocin Please Stand Up, The Case for Bonding at Birth, and What is Physiological Birth? (each opens in a new tab for your convenience).
Cord-Clamping.com also covers cesarean and nuchal cord (cord around the neck) as these issues are often on parents' minds, too (opens in a new tab for your convenience).
The rising trend in cord clamping is for care providers to begrudgingly acknowledge that delayed clamping may be ideal, so they keep the cord clamp on the tray for 3 minutes. Or, if you're lucky, maybe 5 minutes.
Is 3-5 minutes really long enough? Clinical studies have shown that cords can begin to cease pulsation within about 3 minutes, which is where that standard came from. But many care providers and parents have observed that a cord can pulse for much longer than that.
The definition of “delayed” cord clamping varies widely – from a 2-3 minute minimum, to when the placenta is born, even to the extremes of lotus birth where baby is left attached to the placenta until the cord naturally falls off.
Where you decide to fall in that continuum is up to you. Personally I feel that clamping once the placenta is born is very reasonable as you can be assured that the cord will be white and limp by that point, indicating that most of the blood has probably cleared. Sister Morning Star, an experienced midwife, recommends leaving the cord intact for 12 hours if your baby is premature14.
Note the difference between the cords in this photo from the Texas Midwives' Association:
Your baby is born knowing that he or she needs all that cord blood – the blood pulses down the cord and into your baby for a reason. Babies whose cords are left unclamped have a higher blood supply, higher birth weights (~3oz higher), and are less likely to suffer complications both in the immediate postpartum and throughout infancy.
An intact cord creates safety for your baby on many levels, and forces others around you to respect that you and your baby are still, literally, connected. You're more likely to be able to pick up and study your baby in a way that feels right to you. Baby is more likely to be left, undisturbed and skin-to-skin to get to know you. The powerful benefits of this early bonding to both you and baby are physical, psychological, and emotional.
Cord clamping is an experiment that has run its course, and the natural design of birth for both mothers and babies has proven superior. Give your baby the gift of all of his or her blood – and the gift of connection to the person her or she wants to meet above all others – you 🙂
2. Fetal Circulation Video:
3. Integrative Resuscitation of the Newborn & NRP Certification with Karen Strange, Detroit, February 2014
4. http://www.infantgrapevine.co.uk/pdf/inf_027_muc.pdf (retrieved 10/20/2014)
5. http://www.indiebirth.com/the-freebirth-of-true/ – the 47 second – 1 minute mark of this slideshow of True's birth has a nice picture of fluids pouring from baby. It also shows mom Maryn holding her baby low for a moment before lifting him to her chest. Thank you to IndieBirth for sharing!
6. https://www.resus.org.uk/pages/nlsalgo.pdf (retrieved 10/20/1014)
14. Prematurity and Perinatal Neglect, Sister Morning Star. http://www.midwiferytoday.com/magazine/Issue111.asp