Well Rounded Birth Prep

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Friday, December 31, 2010

Photo illustration: delayed cord clamping vs. immediate cord clamping

 World Health Organization supports delayed cord clamping. Here's what research shows:
  • 25-50% of baby's blood volume is in the placenta and cord immediately after birth. 
  • In the minutes following birth, baby's circulatory system retrieves exactly the amount of richly oxygenated blood he or she needs. 
  • Premature cord clamping cuts off baby's oxygen supply from the placenta before the lungs begin to function, which is essential for brain function.
  • Babies whose cords are clamped and cut prematurely are more likely to have respiratory problems, need resuscitation, need a blood transfusion, and/or be anemic. 
  • Cord blood provides baby with his or her own essential stem cells when the cord is allowed to continue pulsating until it is physiologically finished. 
Nevertheless, many OBs (and even some midwives) continue to routinely clamp and cut the cord within 30 seconds after the birth. Why? Tradition and convenience.

Research also shows that pushing in upright positions on the mother's cues and instincts is more beneficial for both mother's and baby's health in the majority of instances. Here's an excellent 2 minute video clip on pushing positions. Although many OBs and midwives routinely practice active 3rd stage management (including immediate cord clamping and cutting, cord traction and fundal pressure to assist delivery of the placenta, and routine Pitocin shots), much has been written that suggests that these practices can cause many of the same problems they purport to prevent, such as hemorrhage.

Below are photos which two mothers have graciously given me permission to publish. They illustrate the difference in appearance of placentas after pushing on instinct in an upright position, physiologic 3rd stage management, and delayed cord clamping,  versus placenta after directed pushing in lithotomy position (on her back),  active 3rd stage management, and immediate cord clamping. These educational photos are graphic, therefore I'm giving fair warning to anyone who does NOT want to view photos of placentas.

*please continue to scroll down to see photos of placentas

*please continue to scroll down

*please continue to scroll down

* You can't say I didn't warn you if you haven't closed this page by now.

The first is a placenta after delayed cord clamping and cutting (30 or so minutes after the birth). The mother pushed on her body's cues in an upright position. She had a waterbirth and delivered the placenta into the birth pool on her body's cues about 30 minutes after the birth, then the placenta was transferred into this bowl right away. The amount of blood that was delivered with the placenta was so minimal that it did not even change the color of the water.

The next photo is of a placenta delivered after active third-stage management. The mother pushed in the lithotomy position (on her back) with directed pushing. The cord was clamped and cut within seconds after the birth. While the mother was still on her back, the midwife directed when and how to push the placenta out, while she gave cord traction. (This was not nearly all of the blood that was delivered with the placenta. It came out with a gush of blood, much of which went directly into a biohazard bag at the end of the bed.) I realize that much of this blood was mother's blood, not baby's blood (placental blood), but it still shows an interesting difference between examples of pushing on instinctive cues and directed pushing; between watchful waiting and active third-stage management. 

It is an interesting pictorial of the variations of third stage management, placentas, and cords.

I have a collection of links (including NIH, Cochrane Review, and PubMed research) on delayed cord clamping and the consequences of routine cord clamping here. I continually add to this bookmark site.

Here is Midwife Thinking's blog post on the role of the placenta and cord in the newborn transition.

Edited to add: Even in the case of C-section, moms can request delayed cord clamping (barring unexpected complications). It's being done safely in some major hospitals by OBs who are meeting consumer demands for delayed cord clamping and other options for a family-centered cesarean. You can read more about family-centered cesareans on ICAN's White Papers and here at Preparing For Birth's sample birth plan for family-centered cesarean. Preparing for Birth is owned by Desirre Andrews, who is ICAN's president as well as a childbirth educator and doula. Family-centered cesareans are another post for another day.


  1. thanks for sharing.. I actually have pictures of my placenta after my waterbirth, and delayed clamping. Took almost 30 minutes for me to deliver. It resembles the first picture greatly. I even remember my midwife quoting this is a Healthy Placenta.

  2. Thank you for sharing. I had no idea there was such a thing as delayed clamping until today. Definitely asking for this next time around.

  3. Oddly enough, as someone who had a managed 3rd stage (retained placenta, had to be removed manually after an hour), my placenta did look like the second one. We did delay clamping. I wonder if the delayed clamping alone is enough to properly drain the placenta?

  4. An hour is only a "retained" placenta in the hospital. So long as the mom isn't hemorraging, letting it come on it's own is far less dangerous than cord traction or manual removal.

  5. This is interesting to me... I had planned to have a homebirth with my 3rd, but was induced at the hospital at 42 weeks (midwives cannot legally attend homebirths in my state after 42 weeks). My OB, while hesitant that it would be of any added benefit, "allowed" my cord to remain unclamped until it had stopped pulsating, around 10 minutes, and the only active management for delivering the placenta was a shot of pitocin that I didn't have time to say no to, and hadn't thought to put it into my birth plan.

    So about 20 minutes after my 3rd sons birth, while nursing him, I felt an urge to push and a HUGE gush of blood literally SHOT out of me onto my Dr and splattered ALL over the room. He quickly grabbed one of those pink tub things, and it was good too because a few seconds later the placenta literally SHOT out of me. My husband looked very scared, the OB laughed and said, "well its a good thing you didn't have this baby at home, or your carpets would be ruined!"

    There was no cord traction, no fundal pressure, and I think the only reason I was "allowed" to not have those things was that my OB and husband got along pretty good, so they talked football, (lol!) and that gave me the extra few minutes I needed.

    Anyways... was it the pit (I had been on pit during labor, asked them to turn it off about 2 hours before he was born) that did that?

  6. Trebor, thanks for sharing. I'm so glad you finally had every detail of your birth plan honored.

    PrincessRubi, thank you so much for commenting. It means a lot to me to help moms know all their options.

    ErinKate, did you happen to have a minute to scan the article link I posted on active 3rd stage management by Dr. Sarah Buckley? It goes into greater detail than I did in this blog. There are other factors that contribute to blood loss postpartum, including pushing & delivery position, whether you pushed instinctively or did directed pushing, whether your CP gave routine Pit shot (and when), and whether (as well as when and how) they did fundal massage postpartum. Pit usage is linked to retained placenta, as well. I really don't have enough details to speculate which factors were present. There's also a wide range of normal bleeding that may look excessive but still not be a hemorrhage.

    Anonymous 1, your comment lines up with what I have heard. My midwife says she wants her clients to have delivered their placentas by an hour postpartum but at that point I think changing positions and trying other less invasive measures would be attempted before manual extraction. I guess it depends on the circumstances.

    Anonymous 2, It does sound plausible, doesn't it?

  7. Thanks for this very stunning visual difference between the two!

  8. Just wanted to point out that I'm fairly certain WHO recommends a degree of active mgmt for 3rd stage - the routine use of Pit.

    Now, I know that other factors increase risk of PP-hemorrhage, such as augmenting & inducing labor, so I can see how, with such a large percentage of births being "pushed" (overly managed), PPH risks would be higher and thus - statistically - routine prophylactic pit may be recommended by WHO- even though routine pit is not the best course of action in a physiological birth.

    Based on my own good health & non-pushed births, I'd planned no active mgmt & all the midwives I've seen (hospital for #1, homebirth for #2), have practiced in this manner anyway.

    But I bring this up because I feel like if you're going to quote WHO recommendations with regards to 3rd stage, it weakens your arguments to then ignore those WHO recommendations that you happen to disagree with.


  9. This was so interesting! Thanks for posting.

    I just went back and looked at my son's placenta, which was an actively managed 3rd stage with immediate cord clamping and traction. It looks just like the second picture...so much blood. I wish I had a picture of my daughter's placenta (born at home with delayed cord clamping). Next time I'll be sure to really look at it because now I'm so curious.

    It's amazing to see how much blood could go into the baby if we just left the cord alone for a bit!!

    birth with confidence

  10. Anonymous 2 - You are lucky you did not haemorrhage! IV pitocin doesn't cross the blood-brain barrier and only works on your uterus (no behavioural effects or feedback loop). Oxytocin receptors on your uterus respond to the pitocin = contractions. Your natural oxytocin (produced in the brain) is suppressed and the feedback loop is unable to work. Your uterus relies on the IV pitocin to contract. This is why physiological third stages are not recommended with inductions of labour or augmentation with pitocin... this is not physiological birth and your body is not working physiologically. To stop a pitocin infusion before the birth of the placenta can lead to haemorrhage due to the uterus not being able to contract as there is no natural oxytocin or pitocin in the blood system. I would hope your OBs understands these basics of physiology and the drug pitocin. This would not have happened at home because your body would have been working with physiological oxytocin... your carpets would have been fine.
    Thanks for a great post Sarah (and the link to my blog)

    1. The package insert for Pitocin says that once active labor is established and an "adequate" contraction pattern is observed, the Pitocin can be turned off slowly--so long as contractions remain adequate. There is no mention on the package insert about this option being a dangerous risk of hemmorhage.

      I do know that use of Pitocin in labor can be a risk for hemmorhage simply because it is often given in doses much higher than the amount that would be produced naturally, which results in the oxytocin receptors on the uterus shutting down. But I would think that gradually shutting the Pit off would allow the body to pick back up on producing oxytocin and might allow the oxytocin receptors to become active again.

    2. Hi Knitted in the Womb, Thank you for visiting my blog. I hope Rachel Reed (midwife thinking) can swing by to reply to your comment.

      I thought I'd throw in this AJOG link showing a conclusion that "Women with severe PPH secondary to uterine atony were exposed to significantly more oxytocin during labor compared to matched controls."


  11. I was so starstruck that Midwife Thinking stopped by my blog that I was stuck. I wanted to post a comment thanking you for visiting my blog, Ms. Reed, and I'm honored (floored, really) that you would call my post "great." *swoon* I appreciate your input.

    Kami, that's an interesting observation of the differences with delayed vs. immediate cord clamping. If you do get a chance to photograph the placenta next time, it would make a great blog post to compare your photos from your different births. I'd be happy to post them here, if you would be interested.

    Meg, I realize that both delayed cord clamping *and* active 3rd stage management are recommended by WHO, and truthfully, I find it a bit perplexing/contradictory myself. I wonder if WHO recommendations are based on studies of active 3rd stage management WITH Pit versus active 3rd stage management WITHOUT Pit, instead of active 3rd stage management after self-directed pushing versus physiologic 3rd stage management after self-directed pushing.
    I read a post related to this topic on Birth Sense blog: "8 ways to avoid pitocin in labor (and why you should)"

    In general, interventions are to be used when they are necessary (which should not be routinely, or else something is wrong with whatever procedure is done routinely). If you stop by again, I'd love to hear your thoughts on that.

  12. Ha ha Sarah - I am very un-star like in real life but love that I made you swoon!
    WHO guidelines are generally aimed at countries which do not have a well established health care infrastructure so I am guessing they are attempting to avoid a PPH in settings that are not geared to manage one.
    Hastie and Fahy wrote a great journal article on the context of the third stage and limitations of current research:
    If you don't have access to the full article email me and I'll send it (address on my 'about' page)

  13. I'm a bit confused about this visual. Couldn't the lack of blood from the water birthed placenta be from the dispersion of blood loss in the birth pool? I am not a midwife so I have no idea how placentas normal look but I definitely could see this having an affect on the amount of blood in comparison to the more widely practiced third stage management.

  14. I deleted my previous comment because I'm sleep deprived and typed the same sentence twice, and I'm also Type A.

    MidwifeThinking/Ms. Reed, that article summary pretty much nails the discrepancy we're talking about.

    Anonymous, Thanks for your question. In the delayed cord clamping example, there was a minimal amount of blood delivered with the placenta. It was so minimal that the birth pool water did not change color. It did not look bloody or red; it looked pretty much as clear as bath water, only with some floating vernix. I have seen birth pools that *have* had enough blood to look red, and this was not one of them.

  15. #1, home water birth. Placenta took two hours before finally delivering. Very little bleeding.
    #2, home birth. Would have been a water birth but she came far too quickly while I was in the bathroom! No blood to clean up, to speak of. A towel or two on the floor and a few wipes off my legs and off her and that was that. Placenta delivered almost 2 hours later.
    #3, home water birth. A little more blood but he came quickly. Placenta delivered after 40 minutes.

    #1 was the only one where the cord was clamped and cut at any point before placenta delivered. That was only because it took so long to deliver and I needed to pee and wanted to take a quick shower. It delivered after my shower.

    I researched so much about lotus births that I seriously considered doing it but felt that I wanted to use the placenta for other things and it would be easier fresh than after it had sat for days. I don't see the need for clamping and cutting in most cases. Especially before placenta delivers on it's own. I realize that natural birth is pretty much an anomoly now but if we allowed birth to take place without intervention then we would have much healthier outcomes. Obviously if a birth necessitates intervention for a safe and healthy outcome then this negates the above.


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