from Women and Birth, Journal of the Australian College of Midwives (March 2009)
Third stage management has typically focused on women and postpartum haemorrhage. Clamping and cutting the umbilical cord following the birth of the baby has continued to be a routine part of this focus. Active versus physiological management of third stage is generally accepted as an evidence-based plan for women to avoid excessive blood loss. Other considerations around this decision are rarely considered, including the baby's perspective. This paper provides a review of the literature regarding timing of clamping and cutting of the umbilical cord and related issues, and discusses the consequences for babies and in particular Aboriginal babies. Iron stores in babies are improved (among other important advantages) if the cord is left to stop pulsating for 3min before being clamped. Such a simple measure of patience and informed practice can make a long lasting difference to a baby's health and for Aboriginal babies this advantage can be critical in the short and the long term for their development and wellbeing. To achieve much needed reductions in infancy anaemia and essential increases in infant survival, delayed cord clamping and cutting is recommended for all Aboriginal babies.
At birth each baby is separated from their mother and placenta by clamping and cutting the umbilical cord – usually straight after the birth in line with active management of the third stage. This separation has been a routine task focused on prompt efficiency in most situations and referred to by Hutton and Hassan (p. 1241) as “by far the oldest and most prevalent intervention in humans”.1 The absence of evidence for the timing of this ritual is perplexing given there is no proof that delayed cord clamping is harmful.2 For the baby, timing of clamping and cutting of the umbilical cord is a significant transitional event.3
Traditionally and typically in most hospitals cutting of the umbilical cord occurs within seconds of the birth of the baby. This prompt or early (as it has become known) clamping of the cord was originally advised (without evidence) to avoid the baby becoming hypothermic.4 Haste was believed to be best for the baby so leaving the cord to finish pulsating was not a consideration.
Busy Maternity Units can have persisting habit-based practices to reduce staff workload and be paced to ensure efficient throughput of women rather than facilitate woman centred and baby advantaged care. A woman can have a literal ‘stop watch’ applied to her on hospital admission in labour requiring the birth process to run smoothly and in a timely manner; if she has a birth plan staff may find it difficult to practise outside the confines of their ‘busyness’ and the routine of the maternity unit to allow for ‘alternatives’ such as leaving the cord to stop pulsating before it is clamped. One reason for women to choose to birth in a birthing centre or at home for example, is if delayed cord clamping and unimpeded skin-to-skin contact are important to them and their baby.
This paper provides a review of the literature regarding timing of clamping and cutting the umbilical cord from the baby's perspective, discussing the consequences in particular for Aboriginal babies. Midwives and doctors are urged to rethink routine third stage management and apply evidence that benefits the health and wellbeing of babies (as well as their mothers), especially Aboriginal babies.
To view literature review, review findings, discussion and references, click here.
Clamping and cutting of the umbilical cord at 3min following birth (including the need for resuscitation which can be conducted with the baby between the mother's legs while the cord is still patent and attached) is a safe option for optimal placental transfusion regardless of the baby's weight. This practice is completely cost effective (in the immediate and longer term) non-intervening and not harmful for mother or baby. An oxytocic could be administered if necessary to decrease maternal blood loss without needing to clamp and cut the cord. Every baby, and most importantly every Aboriginal baby, regardless of their gestation should have the right and significant advantages of their cord being clamped and cut 3min after their birth to achieve much needed reductions in infancy anaemia and essential increases in infant survival. Such a simple measure of patience and informed practice with such life enhancing advantages for all babies, especially Aboriginal babies, is vital. Keeping the cord patent and extending the time before cord clamping and cutting for at least several minutes after the birth of the baby, or preferably until cord pulsations cease, is recommended for all Aboriginal babies as an effective primary health strategy by midwives and doctors.