Cord Clamping

Don’t Cut the Lifeline! Resuscitation, Leaving the Cord Intact, and Advocating for Yourself

by Asheya on December 23, 2011

In my last post on cord amputation I said,

If health care providers and parents feel the need to amputate the cord at all (which some don’t) that amputation should be done with the least harm to the baby. All activities after the birth of the baby should be designed around the concept that it is normal, healthy, and very beneficial for the baby to remain attached to the placenta.

When discussing premature cord amputation (commonly called delayed cord clamping) most care providers will agree with parents’ wishes to cut the cord only after it has stopped pulsing, but only if the baby is in good condition. Care providers usually give the caveat that if the baby requires resuscitation then they will do what they have to do–i.e. cut the cord and take the baby to the warmer so they can do the resuscitation procedure they have been trained in.

Let me say it again.

All activities after the birth of the baby should be designed around the concept that it is normal, healthy, and very beneficial for the baby to remain attached to the placenta.

Especially, any resuscitation efforts should be done while the baby is still connected to the placenta–a flat baby is not an excuse to amputate the cord. In fact, it is in this situation that it is imperative that the baby have the cord as a lifeline to the placenta. (see Midwife Thinking’s blog for a great overview of the science, and links to research.) The reason the cord is a lifeline has to do with the physiology of the placenta and the baby.

All of the baby’s blood is not in the baby at the moment of birth–some of the blood is still in the placenta. The pulsing cord indicates that flow from the placenta to the baby is still happening. This blood is oxygenated. The full volume of blood that belongs to the baby is not only important because it contains oxygen, but also because it provides enough blood so that the body can direct the right amount of blood to the lungs, allowing them to function properly. And the full amount of blood means there are the right number of red blood cells to circulate any oxygen the baby does manage to breathe in through her lungs.

If the cord is amputated so the baby can be resuscitated, the baby not only lacks oxygen from the missing blood still in the placenta, he also lacks enough blood to allow the lungs to work properly and has a decreased number of red blood cells to circulate oxygen. Bad news all around.

Hospitals are not currently designed, either with equipment or the training of personnel, to resuscitate baby with the cord attached. Many homebirth midwives, on the other hand, have designed their resuscitation process with the intent to keep the baby with the mom and attached to the placenta. A large flat surface (such as a plastic board used in the kitchen for chopping vegetables), an electric heating pad, a blue pad or baby blanket, the oxygen mask and tank, and the midwife’s knees are all that are required for a portable resuscitation center. This can be brought to the mom, so that all resuscitation efforts occur immediately beside her. (here is a blog post, with photos, about resuscitation actually being done in the mother’s arms.)

A baby who is still attached to the placenta is still receiving oxygenated blood, buying them time before they need to start breathing and use their lungs to get oxygen instead of getting it from the placenta. Even a cord that has stopped pulsing may still be providing blood to the baby from the placenta–birth is a complex process, and nothing is ever set in stone. The flow of blood from placenta to baby is passive–if you put the baby level with the placenta or under the level of the placenta, blood will flow from placenta to baby. If there’s a chance that a non-breathing baby could be receiving oxygen from a non-pulsing cord, why risk it and amputate the cord when it’s totally unnecessary? Better to change our practices, in order to allow for the unknown and the miracle of physiology to do what it does best: ensure survival.

How to shift practice? I know how hard it is to present to a doctor, midwife, nurse etc. your requests, and have them come back with, “Of course we’ll do what you want IF EVERYTHING IS GOING FINE.” In this case, it is when something is definitely not going fine that leaving the cord intact is of paramount importance, but unfortunately directly in conflict with hospital protocols and procedures.

Here’s where the hard truths come in. Much as I want maternity care to change without individual women having to stand up and make it happen, that’s not the way it works. We shouldn’t have to stand up for ourselves and our babies when we’re pregnant. We shouldn’t have to stand up for ourselves and our babies when we’re giving birth. We should be able to trust that our care providers will do exactly that–provide care that is the most beneficial for ourselves and our babies. But unfortunately, this is not how it is.

Doctors, midwives, nurses–they do care. But most of them are steeped in a medical system that doesn’t have enough time to educate them about physiological birth, and doesn’t have a tradition of following the first rule of medicine, which is: assume that all interventions are harmful and risky until proven otherwise (i.e. first, do no harm). In fact, in obstetrics it’s just the opposite: assume all interventions are helpful and safe until proven otherwise. Which has led to a lot of harm.

So what can you as an individual woman do, when you say you want your baby resuscitated with the cord intact and your doctor or midwife tells you, “That’s just not how we do it.”

First, gather your inner strength. Standing up for yourself to people we see as gods can be really intimidating. Know that if you choose to try to change this, you are not just helping yourself, but all women and babies who see this team of care providers.

Second, gather the research on the benefits of not amputating the cord. Print it out. Highlight relevant points. We will post resources on Mothers of Change so you have something easily accessible.

Third, write down what a homebirth midwife does to resuscitate a baby. Take this and the research to your care provider. Ask them to brainstorm with you what would need to happen to make this possible in the hospital. Emphasize that if your baby needs resuscitating, you want your baby to have a lifeline so that she has the best possible chance of survival and health. This is especially important for premature babies as well, so a premature infant should not be an excuse for immediate cord amputation.

Fourth, if the care provider is resistant, ask them what would be needed for them to change their practice. Do they need to hear from respected physicians? Do they need to look over the research themselves? Do they need multiple women demanding this? Does the Society of Obstetricians and Gynecologists of Canada need to create a guideline (currently this issue is addressed in their more than ten year old guideline on preventing and managing postpartum hemorrhage–and they recommend immediate clamping, even though they admit there is no good evidence to support the practice. Obstetrics continues to assume interventions are safe until proven otherwise. And often even when interventions have been proven to cause harm, obstetrics still continues to do it.)

Fifth, if your care provider pulls out the ‘dead baby card,’ (i.e. okay we can do this, you will have to sign a waiver, your baby might die etc. etc.), examine the validity of their claims. Yes, you are refusing to let them do a medical procedure (amputating the cord). Yes, they are not used to resuscitating babies in these circumstances. Yes, there might be more confusion in the room and people feeling uncertain as to how this untried method will go.

Ask your care provider–will you still have the skills you usually have when you need to resuscitate a baby (obviously, yes). Will you have the same equipment? (yes, but perhaps slightly modified–i.e. board instead of a warmer that a physician can stand at). So what’s the big risk? Is the doctor or midwife going to sit by and let your baby die because they’ve never tried to resuscitate a baby that doesn’t have an amputated cord and isn’t on the warmer? No. They’re going to do everything they can, using all the same skills and training they usually use, and the same equipment. They will just be performing the procedure about three feet from where they normally do, and sitting down instead of standing. And your baby will be getting oxygen from the placenta all the while, giving your baby more time before it becomes imperative that he breathes, and giving the care provider more time to adjust to a new way of doing things.

The benefits of keeping the baby attached to the placenta when needing encouragement to breathe or needing resuscitation are numerous. And there are benefits that don’t have to do with the placenta, but have to do with the mom. The baby’s safe place, the only home the baby has ever known, is her mother. When a baby can feel her mother’s touch and smell her mother’s skin, the baby knows she is safe. When a baby is taken from her mother, even three feet away, the baby feels unsafe. The baby’s response to feeling unsafe is to shut down–which can make it harder for a baby to breathe. (see Dr. Nils Bergman’s websites on Kangaroo Mother Care and Skin to Skin contact).

When I was having premature contractions with my third pregnancy, I had to think about some of this issues.  And I realized that I just wasn’t willing to compromise my baby’s health and best interest just because this way of doing things was unfamiliar to those providing care. So I asked a doula friend if she would be my doula and advocate for me if I my baby was premature. If you have made it clear to your provider that you are refusing the medical intervention of cord amputation, then my next suggestion is to hire a doula. Even if your care provider has been willing to brainstorm with you and find a way to a solution that does not involve amputating the cord, still, hire a doula.

So this is suggestion six. Hire a doula. Not just any doula. Hire a doula who has the same attitude and values about this issue as you do. Hire a doula who is more concerned about the care you are getting than about her place in the hospital hierarchy, or how advocating for you will impact her ability to be a doula in that hospital. Obviously someone who is running around creating unnecessary conflict with hospital staff is not a good person to have on your team. But you do need someone who is willing to stand in the gap for you, when you are exhausted from giving birth and worried about the safety of your baby, someone who will remind the care providers that you do not give consent and that you are refusing cord amputation, and that any resuscitation needs to be performed with the cord intact. Someone to remind you that amputating the cord is a medical intervention, and not a benign one, and that leaving the cord intact. gives your baby the best possible chance of life and health.

Of course, your baby might be born in great health, breathe right away, and not require any help. That’s what we all hope for! Even in this case, however, having a doula present to remind the staff that you refuse cord amputation can be helpful.

If you are successful in creating a plan with your care provider to resuscitate the baby with the cord intact, please let us know! We would love to hear from you if you have any experience with this issue as well. Leave a comment below!

Resuscitation of baby in mother’s arms:
Midwife Thinking overview of science and research
Skin to Skin Contact:
Kangaroo Mother Care: