Episode 191- Optimal Cord Management
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD, and each episode I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey.
[0:25] Hello and welcome to today's episode of the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson, and today I'm talking about optimal cord management, the umbilical cord. Is that what we're talking about?
[0:38] And this is including delayed cord clamping, but it's going to be even more than that. And I'm talking about how to fully respect and use the umbilical cord to its full benefit and function because an intact cord is such a gift to your baby and I'm going to explain why. And I'm going to explain why you should be fighting hard to keep your baby's cord intact, especially in those more complex situations like preterm birth and during an emergency. As you listen to this episode, you may be shocked to realize how much I can actually say about this topic, or maybe not if you've been listening to the podcast a while, you know that I like to chat. And it's actually really hard to get this into one short episode, but I'm going to do my best to explain to you why the umbilical cord is the gift that just keeps on giving even after the birth of your baby. And by the end of this episode, you will understand why. And if you are getting ready to have your baby soon, I just want to ask you if you feel ready. If you feel ready to labour and birth calmly.
[1:53] And confidently. And if you have a shadow of a doubt, I want to recommend two things to you. Firstly, The Birth Box by Poppy Child. And this episode is sponsored by my dear friend and birth prep extraordinaire, Poppy Child from Pop That Mama. She's a doula and hypnobirthing practitioner and her online hypnobirthing course called The Birth Box has already helped thousands of women get ready for labor. Listen to this recent review of the birth box. The woman says, I'm a first time mom and I gave birth to my beautiful baby boy yesterday. I've been listening to the birth box on repeat for the past few months, including the day in which I went into labor. And I had the most empowering birth experience. And I can honestly say that listening to the birth box was a huge part of this success.
[2:45] Reframing the pain that you experienced during labor can be a purposeful pain instead of a harmful pain. And that really helped me to know that. And just being able to surrender to the wild ride that birth is and let my body take over was the most incredible thing. And this is coming from a pelvic floor physiotherapist based here in Australia. She says, I will recommend it to all my patients. And you know me, I'm so picky about what I will endorse but I do get behind the work that Poppy is doing and in the birth box you'll learn tools to help you manage pain and how to stay steady when labor gets intense. It's all about giving you knowledge, confidence and a mindset that actually works when the big day comes and for the big days that will follow.
[3:35] Birth Box is rated five stars across the board. And with my code, Melanie, you'll get 25% off. So if you're preparing for birth, go to the checkout. You'll be so glad you did. The link is in the show notes. Use the code Melanie to get your 25% off. And the second thing I want to recommend to you is my guide to giving birth without pain medication. It's an all-facts, no-fluff guide that gives you the strategies that you need in order to work through labor and birth without pain medication. It prepares you beautifully along with the birth box in order to facilitate the normal process of labor and birth by not interrupting it with pain medication.
[4:21] It contains two sections. One is comprehensive and practical lists that you can do to manage labour pain without medication. And the second part is for your partner and support people so they know how to support you to give birth without medication. I actually released this about 12 weeks ago and already 550 women have purchased and used the course.
[4:46] I mean, they purchased it because it's super cheap, really high value. It's only $27. That is cheaper than lunch. And the course works. Women have already been flooding me with feedback about how the strategies help them to get through labor without pain medication. And they're telling me how helpful it was. And I know they work. I already knew they worked because everything that's in there is what I already tell my clients when they are planning on having their babies at home. And I've been watching them use those strategies for the last 18 years. The link to purchase the guide is in the show notes below. So if you don't yet have a solid plan for how you're going to manage the pain of contractions or you feel like maybe your support people are not prepared,
[5:31] you need this guide. It's only $27. You can pause this episode now if you want, scroll down to the show notes, purchase the guide so that you can be fully prepared to give birth without pain medication. Okay, let's get into this episode. I'm discussing this topic partly as a warning both to parents and care providers.
[5:53] Partly, I want to warn you that this archaic and old medical practice of rapid cord clamping seems to be clawing its way back from the grave. I thought we had buried this practice, but there's been a number of occasions recently where I have audibly gasped at the audacity of what some care providers are saying about cord management and optimal cord clamping. And the first scenario is when I was in hospital with a client not too long ago.
[6:28] She told the care providers there to keep the cord attached to the placenta for a while to wait till after the placenta was born. And this prompted, so the baby hadn't been born yet, but this prompted multiple visits from the pediatric team who strongly advised against it. And they even handed her a leaflet about all the risks of keeping the cord intact. And then they asked if the woman wouldn't mind them sending another pediatrician in to counsel her about her decision. The woman declined that opportunity to have another person come in to talk to her about not cutting the cord. And they respected that. But they said, if you don't mind, if you could please, when the baby's born, just keep the placenta lower than the baby, okay?
[7:17] And, you know, I had a little smirk on my face when that was the suggestion. And we'll talk about firstly why they suggested keeping the placenta lower than the baby, but also why that's absurd. We'll talk about that as we go. And there was another time that I transferred a client to hospital after her baby had been born. The baby had a shoulder dystocia at home and we managed it well, we're skilled to do that as midwives. And although the baby did need some resuscitation, which we also did before the ambulance got there. By the time the ambulance arrived, the baby's in really good condition. It was skin to skin with its mother, but I still felt it would be a good idea to have the baby checked by a pediatrician considering how dramatic the events were of her birth. And we got to the hospital, they checked over the baby. Everyone said, yep, great. Baby looks well, no problems. There's been no side effects to the fact that the baby had shoulder dystrophy and a resuscitation, no injuries, all checks were normal and they said you can return home except we want to do a blood test on the baby and I was curious as to why they just gave the baby a clear bill of health and the pediatrician said it's because the cord wasn't cut and clamped and so probably the baby got too much blood and so they have to check that.
[8:35] The baby's blood to see if it's got too much. And I had to hold in my laugh because I thought this was some kind of weird joke. So I will also talk about the science behind an intact cord and why this is ludicrous. But I've also recently had a number of midwives reach out to tell me that the hospitals they work in and that they've recently told staff that they must cut the umbilical cord within a minute of the baby being born. And I've since heard this a few more times because I talk to midwives all the time. They're once again being told to quickly cut the cord after birth. I don't know how it came back, but these situations I'm encountering tell me that there is a rotting zombie corpse of information that has clawed its way back. And I am now very keen to reignite the debate about optimal cord clamping. I thought it was settled, but it turns Turns out that rapid cord clamping is
[9:36] making a comeback. So I'm here to speak about that. And what we'll do is we'll start with a quick anatomy lesson, which will be super important if it's going to make sense why delayed cord clamping or cutting the cord in an optimal way, not delaying it, optimal cord clamping. So I'll explain the anatomy so you understand why that's important.
[9:58] But today we're talking about what happens to the cord after your baby's born, not while it's still inside. The focus is on the period of time after birth. But just quickly, first, before we do that, in order to keep this podcast free to you, the listener, we have a very few carefully selected supporters who generously sponsor this podcast. And if you are a woman and family learning about care options, I want to introduce you to the Birth Time documentary.
[10:28] If you've been listening to this podcast for a while, you'll know how passionate I am about women having great births. And this documentary puts into a neat 90-minute package so much of what I've been trying to tell you over the last three and a half years.
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[12:25] Okay, so let's get into the anatomy. So your baby comes out and it's got an umbilical cord at its belly button. We all know that. That cord is attached to your placenta, which is still inside you. And during pregnancy, this is the way that your baby is supplied with blood, oxygen, nutrients, all the way through your pregnancy. It's their lifeline. And as we'll talk about, it's also their lifeline as a transition to becoming air breathers after birth. There's this transitional period between intrauterine life, life inside the uterus, and extrauterine life, life outside the uterus. But there's this transition point immediately after birth. The baby has to immediately transition from intrauterine life to extrauterine life. And today my purpose is to explain how to optimize this short transitional moment so that the baby is as healthy as possible. I'll describe the umbilical cord's role in this and how precious this transition time is and the things that can happen if we interrupt it by cutting and clamping the cord too early.
[13:33] So if you're having mainstream maternity care and most of you people listening, this is what you'll be getting. What you can expect is that your baby comes out and your care provider will be very interested in the timing of when to detach your baby from its placenta by clamping and cutting the cord. Often in hospitals, they will use the little plastic clamps and it sits a few centimeters away from your baby's abdomen, attach the cord. They clamp it, cut the cord, and then that stays in place until the cord dries and falls off. And if you're specifically interested in cord clamping, and then there's another option of tying the cord, I've actually done this full episode, believe it or not, there's a full episode of cord clamping versus cord tying versus burning, all the little different things you can do with the cord afterwards, episode 96. And I'll link that in the show notes so you can easily click below.
[14:32] But clamping and cutting the cord used to be part of the process of what we call active management of the placenta, which is basically the medical way of managing placental birth is to give you an injection of artificial oxytocin very soon after your baby's born. That's followed by cutting and clamping the cord and then putting pressure or what we called traction, controlled cord traction, on the cord until the placenta detaches and comes out. That whole process takes usually no more than five minutes, but within that active management of your placental birth is embedded in there is cord cutting and clamping.
[15:17] And if you're interested in understanding the details about different placental birth options, so that's one placental birth option is active management, but there's other ways to give birth to your placenta. Again, there's a whole episode on that, episode 129. Again, it's linked in the show notes, so you can just click on through and have a listen to that. But today I'm going to focus on how to provide optimal care to the baby's cord
[15:41] so that it can do its job of sustaining the baby through that transition. So it has a healthful and completed transition from intrauterine life to extra uterine life.
[15:55] And there's no denying that the research is in support of not immediately cutting and clamping the cord. That used to be the practice of immediate cutting and clamping and now though in this day and age with the amount of research that we had somebody or anybody who suggests that immediate or rapid cord clamping and cutting is is appropriate, is not up to date with the research and is choosing to be ill-informed. This is not hard information to come by because almost everyone agrees now that optimal clamping practices means you wait for white. That's how we know. It's until the cord is empty of blood because that means the baby is finished with it. A full plump cord full of blood, you should see that as blood the baby's blood is filling the cord that's the baby's blood and until that cord is empty and is white the baby's not finished with it yet so we also another thing we don't call it delayed cord clamping anymore this used to be the way that we described it so not clamping and cutting the cord immediately we used to call it delayed cord clamping but now we use the term optimal cord clamping rather than delayed cord clamping because it reminds us that it is optimal in most scenarios to wait until the cord is finished.
[17:19] So the opposite to optimal cord clamping is rapid cord clamping and I'll work through the research on this throughout the episode but if you're looking at older research we used to call it delayed cord clamping. So if you're looking at research on this and using a search term of optimal cord clamping that's kind of a newer terminology. So you'd be better off finding data and.
[17:43] If you use the search term delayed cord clamping. Okay, so we'll look now at the physiology of how the cord functions after the birth of the baby and what happens to the baby's blood volume. And I'll also talk about how to assess the baby for readiness for cord clamping. We'll talk about that in a minute so that you know when you're looking at it if it's time or not. There's no questions about, do you think we can cut the cord now?
[18:09] There's a few little assessments you can do to discover if it's time. But first, I want everyone to understand what the baby's using its cord for after it's born and why it's important that we're all focused on optimal cord clamping.
[18:22] So from the beginning of its life, the baby makes its own placenta and inside the placenta is the baby's blood and only the baby's blood. There's no maternal blood in the placenta. So at any one time, approximately two thirds of the baby's blood that it made itself, And it made its own placenta. About two thirds of the baby's blood is circulating in the baby's body. And the other third is circulating through the placenta. So it's constantly replenishing itself, coming back and forth from the mother's blood supply, which it's aligned with, but not mixing with. And it's collecting oxygen, nutrients, and everything it needs. So the baby's sending blood up and down through the arteries and veins in the cord. There's two arteries, one vein in the cord, and it's sending it back and forth to the placenta to collect nutrients, nourishment, oxygen, all kinds of things from the maternal blood supply, which is then, again, not connected, but they are aligned. They don't touch, but that's where all the action happens, in the placenta. And then the blood gets oxygenated, nourished, and sent back to the baby. The baby uses it to grow and thrive.
[19:33] That is the very basics. The science of placentation is way more complex than that. But your baby's placenta is attached to the uterine wall from approximately three to four weeks gestation. And the function of the placenta changes through the time of your pregnancy, as does the blood volume and all kinds of things. But it's attached from three to four weeks of gestation. So then when the baby comes out, it needs to transition from relying on the placenta for nourishment and oxygen to all of that happening without the placenta. So there's a transition period whereby the baby stops using its placenta and then starts relying on the external environment and on its parents and the world's atmosphere to survive. So now it uses its lungs, whereas in utero, while it was in the uterus.
[20:28] The lungs are compressed and the space is filled with fluid, not air. So when the baby comes out, the lungs have to completely change their function to now being the center of oxygen transfer into the baby, whereas it used to be the umbilical cord. So as the baby is being squished out, the lungs are kind of, they're also squished. And then when the baby comes out, they expand open like it's what I say is kind of like they pop open and there's a substance called surfactant, which coats the inside of the baby's lungs, which is a later development in pregnancy. This is also why we should keep our babies in as long as they need to be because surfactant, it coats the inside of the lungs in the later term of pregnancy. But the baby's lungs get coated with this surfactant, which kind of makes the lungs a bit bouncy and able to ping open when the baby is born. And so simultaneously, as the baby gets pushed out, its lungs expand to receive or almost suck in air. And I kind of describe it to people like a sponge. It's a bit like a vacuum. So when the baby takes its first breath, that's its diaphragm and its lungs expanding to receive oxygen into the baby's body.
[21:50] Kind of like if you pick a sponge up and you squish it and then you plunge it into some water and you let it go, then the sponge just sucks up the water a little bit. That's part of the physiology of a baby filling its lungs with air for the first time. Now, you might be thinking, what about if the baby's born in water? I'd encourage you to listen to the water birth episode, which was a few episodes ago. The baby has other mechanisms for taking its first breath. This is just one of them. but the transition to breathing air after having virtually no air in its lungs is almost instantaneous so when the baby comes out we give it a minute or so to transition to be able to adequately transfer air through their lungs like this is incredible that previously like a minute ago the baby was receiving oxygen through the umbilical cord into its body and now its lungs of fully functioning as the site for oxygen transfer.
[22:49] So you want that initial expansion of the lungs to be efficient and functioning perfectly before considering cutting the other source of oxygen. I know as I say this, people are like, well, of course, you want the lungs to fully take over before you cut off the oxygen supply of the umbilical cord. That kind of makes sense, right? I mean, as you think about it, but there's this transition period where the baby has to transition from receiving oxygen from its umbilical cord to now receiving it all from the oxygen transfer in their lungs. So you want that initial expansion to be efficient because how much surface area is available in the lungs determines how much oxygen can be transferred. And the other thing that happens is previous to this in utero, the lung tissue was receiving enough blood to keep the tissues alive, thriving and developing, but they didn't need a large, large blood volume for the purpose of oxygen transfer, whereas now they do. And so there's this thing that happens in the baby's body that shunts way more blood to the lungs for the purpose of collecting oxygen. And what we know is that when a baby is in utero, its circulation, the journey that the blood takes around the baby's body is a completely different route to when you're born.
[24:18] And the baby's circulation is different to yours and ours. Our circulation is wired completely differently to a baby in utero. So during your intrauterine life, your circulation has all these different doors that are open that create a different route through the baby's body. And then once it's born, there's these gates open.
[24:41] And a good first effective breath, and usually within the first minute of life or few minutes of life, all these gates close within the baby's blood circulation.
[24:54] And once the baby takes a big, full, effective breath, the baby's body recognizes that it may actually no longer need to rely on the placenta for life. And once the baby's body is convinced that it's fully and properly transitioned, the baby's circulation will close all the gates in their blood supply that were previously requiring it to have intrauterine blood flow. And this completely reroutes the baby's blood circulation. I'm not going to explain exactly all the details because obviously that's a bit more complicated. There's a whole anatomy textbook related to these kinds of things. But one of the gates that closes is access to the umbilical cord and then the other redirects blood through the heart and lungs differently to how they would now function for us when we're on the outside and so basically the change this changes the way that the baby's blood circulates and where it collects oxygen from used to collect oxygen from the umbilical cord now it collects oxygen from the lungs so we can expect this transition to occur in the first one to five minutes but if you immediately or rapidly cut and clamp the cord, then you interrupt that circulation adaptation. So let's talk about that.
[26:12] What happens if you interrupt the baby while it's working out their transition to life outside the uterus? Because there is this precious short interval between being born and the placenta detaching from its mother for the baby to pack its last and final items from the placenta and the uterus and its mother and check it's got its full blood supply and all its oxygen and nutrient needs are met before it then says farewell to its intrauterine circulation and is ready for life on the outside fully prepared with what they've taken from the placenta while they could in that transition period and I want to talk about what happens there's so much to talk about but okay I don't I hope they've got the right order and it all makes sense but let's talk about we'll talk about equilibrium what happens through the placenta so as the baby is closing all the circulation gates it's actually taking and giving blood back to the placenta the baby is aiming to find a blood volume equilibrium and while it's doing this transition while it's doing the transition between air breathing or using its cord it's considering how much blood do i need It doesn't recheck. No, that's too much. It puts some back.
[27:37] So the taking of its first breath, it starts to oxygenate differently. And its whole circulation is deciding when is the right time to close the gates. Are my lungs functioning properly yet? Do I have my proper and full blood supply? And once those two things can be answered, where the baby has adequately transitioned to air breathing and it has its full blood volume, the baby's body will make the decision as to when to fully close the circulation gates and stop using the umbilical cords.
[28:12] So the baby actually will physiologically extract some of its blood from the placenta to add to its own blood volume. And remembering the blood in the placenta and in the cord is the baby's blood. It's not cord blood. It's the baby's blood. Rachel Reid has a great statement about this. She's like, it's like if you say, use the term cord blood, assuming that the blood belongs to the cord, It's like saying when you go and give blood or get pathology blood tests done that you're saying they're going to take my arm blood. It's your blood. It's all circulating. The umbilical cord is an extension of the baby's circulation. So any blood in there is the baby's. It's not the mother's. It doesn't just belong to the placenta or the cord. It's actually the baby's blood. Okay. And so there is this feedback system where it will take some, put some back, and they'll be back and forth until the baby is confident that they've reached a blood volume equilibrium and now it's good to close the gates. So this process has been studied. We know that this is the basic physiology and function of the umbilical blood flow in the moments following birth. And they have studied this blood flow and how much blood is going back and forth and for how long. And what they've actually noticed is if the baby's crying.
[29:33] There's a different blood volume going through to if the baby's not crying. And so crying determines how much blood comes back and forth from the placenta. So while they have noticed that when a baby's not crying, there's a change in blood flow compared to when it is crying. So let's talk about that. Because some people say, oh, it's important for the baby to cry for lung function. And to set their respiration at birth. And that does kind of helps set the initial breathing, initial respiration. But a baby's cry also helps set their circulation.
[30:12] So while the cry sets their respiration, also think as they're crying, that is a technique for adding or taking some blood supply from the placenta. Crying is a physiological function to help set the baby's circulation. And this is what they found from these studies. And actually, all the studies are in the resource folder. So if you're super keen to read these things, if you're a total physiological nerd like me, and you want to read and understand this physiology in the resource folder for this podcast, they're all there in full text and you just click the link. You get access to that resource folder by being on the podcast mailing list so go to melanethemidwife.com or you can scroll down into the show notes just click the button to join the mailing list and all the resources are just sent straight to you it's a big list today actually there was a lot.
[31:05] So earlier on, we talked about veins and arteries that come in and out of the, from the back and forth from the placenta. And in these research papers, they studied how much venous blood flow from the vein and how much arterial blood flow happens and for how long. So the initial research that a lot of people are going off for delayed cord clamping, sorry, delayed cord clamping in inverted commas, it says anything more than a minute or so seems to be enough for the baby to transition that's what people are saying.
[31:38] And if you want to cut and clamp the cord after a minute they're saying look most of the transition has happened but there's actually research that says no.
[31:48] That's not the case. And this is some research that was done in 2014, and they studied the venous flow at birth through the vein and at five minutes. And at five minutes on average, still 33% of the babies showed continued venous blood flow through the cord. So one third of the babies at five minutes were still using their umbilical cord for blood flow. and in 43% of the babies at about five minutes there was still arterial blood flow. So what this study is saying is that actually we don't really properly understand how long every single baby needs before we can't clamp and cut their cord because in this study they found that at at least five minutes nearly half or a third still had venous and arterial blood flow through the cord. What that's saying is, is that the baby is still using it to transition, might not be using it to transition for respiration, but it's possibly using it to get that circulatory equilibrium, the blood volume equilibrium. It might be able to breathe just fine, but it hasn't quite yet got its full blood volume. That equilibrium is still happening, and the baby's cry is an important element in that. And maybe babies who cry more are working at that cord equilibrium.
[33:13] Maybe it's the ones who aren't crying anymore think, no, I've nailed it. I don't need to work on that. It's all working just fine. So crying is potentially a physiological process that the baby is trying to use to balance its blood supply. And it appears that what this study is saying, that the baby is still using the cord to transition and that transitional period is probably longer than we've been previously told. And at least, at least five minutes, according to this study, but probably even more because, 33% of venous blood was still pumping at five minutes and 43 arterial blood by five minutes. So then they also assessed how much flow, how much blood flow was happening during large breaths and when the baby was crying. And they found dramatic differences. So if the baby was taking big, huge breaths, they show that the venous flow increased significantly.
[34:09] And they can stop or reverse the venous flow during crying. And so it's thought that actually the baby's rate of breathing, the time of crying influences how much blood flow comes back and forth for the placenta.
[34:25] I'm sure it's way more complex than that and also way more complex than we've been actually taught. So crying isn't the only element. Obviously, breathing impacts this as well. And this isn't to say that if your baby's not crying that it's somehow unwell. It's just saying crying has a part in the equilibrium of this. If your baby didn't have a huge cry, maybe its transition was perfectly managed without it and that's fine. But it does highlight the complexity of this process and it gives us a reason to consider not interrupting this process so the baby can finish. There is a physiological process that has to unfold, a transitional process for the baby to efficiently and effectively transition to extra uterine life. They don't get to do this again. This is their one chance to set themselves up for the early part of their life with a full and functioning respiratory and circulatory system. And if you interrupt that process and deprive the baby of some of its blood volume and its transitional time, it's interrupted for good. They can't go back and do that again.
[35:40] So when you get one shot at something, you want to do it in the most optimal way possible. And that's what this episode is about. How can we optimize a baby's transition to life?
[35:52] So let's talk about optimal care of the cord because it's the avenue to the placenta and the baby's using its placenta even though it's born. So how can we efficiently nurture this part in these few minutes that this baby has to get itself ready for extra uterine life? And this is why we call it optimal cord clamping because we've acknowledged that at some point in birthing history, we've started to intervene in the process and we're not letting babies finish transition. We're not letting them transition efficiently. We're deciding when they're done and cutting and clamping their cord. And by cutting and clamping the cord early, you don't let the baby finish transitioning to life and you've completely interrupted that. And that's on us. That's on you. That's on the whole maternity care system because we know better now that all the research that's there, and I yet am yet to come across a paper that suggests that early clamping is a good idea. So we all know that clamping immediately is not a good idea but what we don't know yet is how long do we leave it intact and there is some research around the length some hospitals or clinicians will say oh doesn't need more than 60 seconds some people say it doesn't need more than three minutes others will say you know there's some research that talks about 180 seconds.
[37:09] And for those not seeing that at home, that's three minutes. But I want to say that it's just like everybody's labor and body. And just like everybody's pregnancy and everybody's height and weight, and there's all these individual factors to each individual person, I would like to suggest that each baby has an individual amount of time that they need to transition from intrauterine life to extrauterine life. It could depend on the circumstances around their birth. It could depend on their body type. We've done a whole lot of things in the environment. Each baby, I don't think we can put a specific time on each baby and say, you should have been able to transition within this period of time. It's absurd. We don't even say that about labor. We don't say, oh, that's, you know, this is the time in which you should labor. This is a normal, I mean, we do, but we shouldn't. I'm just saying, not every baby is going to conform to the exact amount of seconds. So.
[38:10] Optimal cord clamping, I'm not going to give it a number because I think that's poor practice to assume that every baby will transition within 60 or 180 seconds or 5 minutes or 10 minutes. I believe, like with all other elements of maternity care, we need to have the clinical skill to be able to assess each single individual baby to determine if it's fully transitioned yet and if it's no longer using its cord. So if you're looking at a baby, you should have, And your healthcare provider should have the clinical skill to go, yep, baby's done with the cord, we can cut it. Or even if it's 15 minutes down the track and you're like, I don't think this baby's finished with its cord yet. Now we've got to start asking questions. Why is this baby having trouble transitioning?
[38:57] And also, gosh, if it's still transitioning, the worst thing I can do is cut its cord. So only until you can individually assess every baby can you decide how long is long enough for that baby to be attached to its cord. So optimal cord clamping means recognizing the signs that the baby has finished using its placenta and then you know you're in the window where you can cut it. So let's talk about how you can know if the baby's finished with its cord and if it's already effectively transitioned and you know if in your mind you said well the research says that after five minutes the baby's not using any anymore but you're looking at this baby's umbilical cord and it's huge and it's plump and it's full of blood that baby may not have fully transitioned properly and it's quite possibly not functioning properly yet if the cord is still full of blood the baby's still using it and there is that campaign that's been knocking around you know the wait for white campaign it's really helpful because it's a really objective way of working out has the baby finished using its cord.
[40:09] So if you're looking at the cord and it's completely white and flaccid and you can see very little blood flow through it, then the baby's done. If there's no blood flowing through the cord, it's finished. And we used to say that if the cord's no longer pulsating, then you can cut it. But there is some research to say, well, actually, the cord can pulse for a lot longer than there's actually blood in it. So cessation of pulsation, it needs to be on a shirt or something. Cessation of pulsation is not a good clinical indicator of if the baby's finished or not. But waiting for white is a good indicator. So it's actually really easy. Anyone can look and go, oh, look, that cord's empty. You don't even need to touch it. So if the cord's white and flaccid,
[40:57] no blood flowing through it, it's good to go. You can cut it. There's no problem with that.
[41:03] And again, there's heaps of research. you can look through the papers in the resource folder, which also tells us what happens if you cut and clamp a cord too early. I mean, you could already make assumptions based on what I've already told you. If the baby hasn't fully transitioned yet, you're going to cut off its oxygen supply. And now you have to take over respirations for the baby in the form of some kind of resuscitation because you didn't wait for the baby to be able to use its own lungs effectively yet so now we've got to take over but the other thing that it misses out on is its blood volume, And we know that one third of its blood volume is in the placenta while two
[41:43] thirds is circulating around the baby. And so with rapid cord clamping, this is actually linked to childhood anemia where the baby, because it missed out on a percentage of its blood supply, it hasn't got an adequate amount of blood or nutrients for its first year of life.
[42:03] Now there's so much more than that so much more than just missing out on one third of your blood volume and it carries more than just oxygen and nutrients it's got a whole other function, but if you took a third of a mother's blood supply she'd be so compromised so yeah I mean missing out on a third of your blood volume is a problem okay now I want to briefly address that story that I mentioned at the beginning of the podcast, where the pediatrician asked the woman to keep the placenta lower than the baby if she did have a plan to do optimal cord clamping. And, you know, the woman wanted to keep the cord attached for an extended amount of time. And I want to just clarify the process of the baby receiving its final blood volume. It's not a passive process determined by the position of the baby. It's not like The placenta is like a drink bottle full of blood. And if you tip it upside down or if the baby's lower than the placenta, the blood's just going to flow freely through the umbilical vein and arteries of the umbilical cord. And in the same way, if the baby's at the top, it's not going to flow out of the baby. It's not this passive straw. So you don't have to put the baby in any special positions for better or worse. There is an operating pump.
[43:29] That allows the blood back and forth to and from the placenta in the baby's circulatory system. And so what we know is there's no too long, there's no time that's too long to leave the baby attached to its cord, but there is a too short. So if in doubt, if you don't know if the baby's effectively transitioned, just leave the cord attached. There's no danger. It's not like the blood's going to pour in and out just inadvertently based on the position of the baby versus the placenta. There's no danger in doing that. I know that because I've been a home birth midwife for 18 years and cutting the cord is almost always an afterthought. And I can tell you that there is not a huge percentage of babies in my care who are suddenly unwell because all of the placental blood volumes ended up inside its body. It's not how it works.
[44:20] So the only thing that the research has found is a slightly increased chance in the risk of the baby becoming jaundice if the cord is left to completely finish. But maybe this is just normal jaundice levels because the baby's getting its full blood volume and our measurement of jaundice levels have come from immediate and rapid cord clamping. And so we're thinking that that's the normal level of jaundice, but actually the normal level of jaundice is whatever happens to a baby who's had optimal cord clamping. That's the normal level of jaundice, by the way. So, but anyway, that's different to the dialogue that's going on. So let's talk about jaundice. And there is some research. It talks about, there's other research that talks about jaundice actually being a protective mechanism. Again, another day. Wasn't going to go in that direction. But the physiology of why babies might have more chance of jaundice if they're allowed to have their whole blood volume is that when a baby's in utero, its hemoglobin is a little bit different. There's less percentage oxygen in utero than out here in the earth.
[45:35] So a baby's hemoglobin can receive more oxytocin. Sorry, not oxytocin. A baby's hemoglobin can receive more oxygen than the hemoglobin that we've got on our red blood cells now that you're out. In breathing air on land. So it's a lower oxygen environment in utero. So the hemoglobin needs to be way more efficient at capturing and transporting whatever oxygen there is. But when the baby's born, their body realizes pretty quick that this type of hemoglobin is not necessary in this atmosphere on earth. And so that hemoglobin breaks down and it's replaced by a more appropriate hemoglobin. And I know I'm kind of dumbing this down a little bit. There might be hematologists out there going, oh my gosh she's explaining it all wrong but essentially that breakdown of red blood cells creates an excess of a substance called bilirubin and the liver processes the excess bilirubin and it breaks it down and it shunts it out of the liver through the gallbladder and into the digestive system and the baby poos it out as a waste product. The problem is is that if the baby's liver can't keep up with the red blood cell breakdown and the amount of excess bilirubin and it can't be cleared properly by the liver there's a bit of a backlog it stores it in the skin it's like i'll just put it here for a second and then when we've dealt with it we can we can deal with it later i'll process it later.
[47:04] But the bilirubin makes the baby look a little bit yellow. And there's what we call physiological jaundice, which is considered just like a normal type of jaundice. It usually happens around day three. It's got various levels of seriousness, but most babies that are feeding well and pooing, and if they're exposed to natural light, they will just naturally deal with this jaundice itself. And it's not a problem. And I know, you know, again, home birth midwife, so I care for women at home and we very rarely, I can count on one hand the number of times I've had to transfer a baby into hospital for management of jaundice. Really physiological jaundice just passes with good feeding, exposure to light and if the baby's pooing.
[47:54] But if you're in hospital and the baby's got jaundice, bilirubin actually breaks down under UV lights. And so that's why I, you know, if a woman in my cares, her baby's a little bit yellow, a few minutes back and front in the sun, full exposure.
[48:11] Obviously not in the heat, heat of the day, can help break it down. But if you're in hospital and your baby's got jaundice, they'll put them under UV lights and they call it a bilibed or they've got bilib blankets. And the UV light can break down the bilirubin inside the baby's skin. So it's not a very serious thing for most babies. It's very rare to have serious jaundice just as a result of optimal cord clamping. Sometimes there are pathological reasons for jaundice and that's not related to cord clamping. If we think about it, if that's the only argument, oh, look, we shouldn't be doing optimal cord clamping because the babies are at risk of jaundice, I'd say you're introducing far more risk and danger to the baby by doing rapid cord clamping than the baby would be under being exposed to low levels of jaundice. So it's not the same level of risk if we're like, oh, you can't have all of your blood supply or your adequate transitioning time because I'm a bit worried you'll get yellow in the first three days or after of your life. It's a bit of a poor excuse for why we would not do optimal cord clamping if you ask me if I'm being polite about it.
[49:26] All right, so I feel like maybe I've, if you weren't convinced already, maybe you're convinced, yeah, okay, let's start doing optimal cord clamping. Let's start waiting for white. Let's give all the babies adequate transition time between intrauterine and extrauterine life so they can make a full and healthy transition.
[49:44] However, now people are all asking, but what about if there's a medical emergency? Don't they need to immediately cut and clamp the cord so that the baby can be taken to get extra medical care? So let's have a chat about these circumstances, about when you or your baby might require additional medical care. So how does optimal cord management work under these conditions? And we'll also talk about things such as collecting blood from the cord if you've got a negative blood group. Also, a lot of hospitals have a practice of collecting cord gases. We'll talk about that too. We'll talk about cord management during a resuscitation and how do we manage placental birth with an intact cord and also this issue of blood banking, cord, newborn, like cord blood blanking or baby blood banking, not cord blood blanking, blood blanking. Say that 10 times. All right. So I'll start talking about placental management with an intact, unclamped cord because there is research on this, thankfully. I mean, it's what I do too, but that's not the point.
[50:52] So this is sometimes where midwives don't know what to do. They're like, should I cut and clear up the cord before I administer the oxytocin for the placental birth? And if you're in hospital, chances are 99% of you are going to be either practicing or receiving active management of the placenta. So, There is enough research on this active management and optimal cord clamping to be able to say that you don't need to cut and clamp the cord in order to do active placental birth management, which is great. So this paper, you can read it, you can read the paper in full. It's called Optimal Timing of Oxytocin Administration for Active Management of Placental Birth with Optimal Cord Clamping. Perfect. So what they're asking is, when can we give the oxytocin?
[51:42] So have a look at the resource folder if you're on the mailing list. And if you want to join the mailing list, the link's in the show notes. It's easy. So if you read this paper, Optimal Timing of Oxytocin Administration for Active Management of Procental Birth with Optimal Cord Clamping, you'll see that what they found was that you can give oxytocin at any time with the cord intact, and it won't impact on the level of blood loss for the mother or on the transition for the baby. So what they did is they checked, if I gave oxytocin sometime after the birth, would the mum bleed more if I waited? And would the transition of the baby be compromised with the addition of the oxytocin? Because some people say that if you give the oxytocin injection and then the uterus contracts a lot, maybe sometimes that can cause shunting of more blood than the baby needs from the placenta into the baby. This study said no, that's not true. It doesn't work like that. And the concern that this study also wanted to address is that if they wait longer to administer the oxytocin until after the.
[52:54] Cord is cut and clamped, like after you've waited for optimal cord clamping, you waited the time, would that lead to higher blood loss? And again, the answer is no. So the research found that if you wait three, four or five minutes and you wanted to wait to do optimal cord clamping for four or five minutes, however long you wait, cut and clamp the cord, then administer the oxytocin to do active management, there wasn't an increase in blood loss for the woman. So actually what this research paper said is, wait till the baby's born, wait till it's fully transitioned. When it's fully transitioned, cut the cord. Then if you want to administer the oxytocin for placental birth, you don't get an increase in blood loss for the mother. So you don't put a woman at increased risk of a postpartum hemorrhage by waiting till the cord is white, then cutting and clamping, then doing active management. This paper actually showed that it's an appropriate clinical strategy for actively managed placental birth.
[53:59] That would be a beautiful way of just slowing down because you all know that after the birth, there's this rapid fire intervention, cutting and clamping, injection of oxytocin, control cord traction on the placenta, rubbing the baby. Ah, it's chaos. There's arms everywhere. What this paper is saying is there was no increase in postpartum hemorrhage in the group where they just waited for the cord to be white cut and then did placental birth. So it did not lead to an increase in blood loss for the woman or postpartum hemorrhage and you can confidently do that based on the research. So have a look at that paper. We can no longer argue that we need to cut and clamp in order to give oxytocin or to do active management. You can actually wait.
[54:49] All right, now I'm going to talk about optimal cord management in unique situations. And so I think we can all agree that yes, we should be waiting for white before we cut and clamp. But what happens in these special circumstances where more needs to be done for the baby?
[55:05] And there, you know, when there's this question of when is it appropriate to intervene and cut short that transition process and cut the cord? Because maybe the intervention of early cord clotting might have a perceived higher benefit than leaving the cord intact. I mean, I can't think of many scenarios, but the research has been done on this. So let's talk about preterm births. And often in preterm births, there's this propensity to want to quickly remove the baby from its mother so that it can be assessed by a pediatrician. And, you know, they can go, oh yeah, your baby transitioned fine or no, your baby needs more care. So there is a Cochrane review, which if you've been around long enough, you'll know that Cochrane is one of the higher level research methods and databases that you can find. They're all available full text. They do systematic reviews. So essentially, they gather together as many randomized control trials as they can find on a topic and they review them together and they give us the findings. Now, fortunately, cutting and clamping the cord is a studiable intervention. And so there's been some research on this, enough to do a Cochrane review. And they did a paper on optimal cord clamping for preterm infants between 24 and 36 weeks.
[56:28] Now, obviously, babies who are much, much younger might need more rapid intervention than those who are older. So, you know, if you've got a 35-weeker that's born, you might have a lot more leeway for optimal clamping than if you've got a 24, 28-weeker. So I don't want to make blanket assumptions of or give you recommendations of what you should do in your unique situation.
[56:51] But the Cochrane paper did show that the longer you can leave the cord pulsating for preterm babies, the better the outcomes for the baby in the long term. There are fewer deaths and better transitions. So overall, still practicing optimal cord clamping and giving as much time as you possibly can for these preterm infants does have an impact on long-term outcomes. And now that I've already explained to you the physiology of the baby equalizing its blood supply and getting its respirations established, it makes so much sense that vulnerable babies would also, just like healthy babies, benefit from optimal cord management.
[57:38] So this might involve though, altering the physical layout of the room so that the pediatric team can provide care to the baby near to the mother so that they can give medical care while the baby's attached to the placenta. It's not, and I've seen this done. So when people say, oh no, you can't, you can't, you actually can. The problem is, is that you've been trained to do everything at this one single location and it benefits the clinicians. It doesn't benefit the baby for it to be rapidly detached from its mother and then removed to be cared for a whole team of medical people who cannot replace the baby's blood volume in the same way as its own cord can. So when anybody says no, we can't.
[58:27] I often think, no, no, you won't. It's likely, you need to know that it's likely that the pediatric team won't facilitate this because a risk of barriers that they personally perceive. But we are so clever as a human race and I just can't believe that people, clever, wise medical people would say, we can't. We don't know how to give care to your baby with it still attached to its cord. It's absurd.
[58:57] So, with regards to how long does the baby need to stay attached in order to receive the benefits? So, this study was the Cochrane Review. It was systematic review and they bundled together lots of different studies.
[59:10] 30 seconds was one of the minimum times and anything more is amazing.
[59:15] So if you don't absolutely need to cut the cord, the longer you can give it, the better. But there was some talk of 30 seconds. You know, they often detach these babies for the purpose of resuscitation. But if we see attachment to the cord and to the placenta as resuscitation, as a resuscitation technique, You know, the baby's still using its cord and placenta as a resuscitation tool. So if you actually consider the placenta, one of the team members, the placenta is doing a job and it's doing a job that nobody else can do. It's a tool to help the baby still get enough oxygen and blood volume while you're resuscitating. So you could be helping the baby to set its respirations, to start breathing, especially for those early babies who don't have that surfactant yet.
[1:00:14] And then the placenta and the cord is a tool for the baby to still get its adequate blood supply, to equilibrium in circulation, and still be getting enough oxygen. So if the baby's still using it, why not take advantage that the baby still has an alternative oxygen and nutrient supply while you're trying to help the baby get started, particularly if it's preterm.
[1:00:40] These vulnerable babies can use all the help they can get in the form of additional blood supply and oxygen. So keeping the cord intact for these compromised babies, it seems just like an insurance policy and an overall makes sense to do. If you're trying to resuscitate a baby that's still attached to its placenta, it's that extra element of resus.
[1:01:06] And so you can do all the stuff you're doing, but with the placenta attached. So the placenta is like your first responder in a resuscitation. They're actually your best friend in a resuscitation. And the babies respond positively to the feel, smell, and warmth of their mother. So we could also consider that the placenta, along with its mother, are integral elements in the resuscitation process. Because the baby is a person. It's not just a little machine that you're trying to get started and keep alive. And, you know, I also wonder if when we're doing a resuscitation while the baby is still attached to the cord and if the cord's still pulsing and the mother is witnessing you working on her baby, you know, and I haven't researched this, this is just me speculating, that when the woman's seeing this, that there's possibly an increase in the adrenaline of her body. And for anybody who's involved in the resuscitation of babies, you'll know that for babies who really have trouble getting started, they will sometimes use adrenaline as a tool to get the baby going. But if the baby's still attached to a placenta and the placenta's still attached to a smother and the mom's experienced some heightened adrenaline because they're witnessing what's happening to their baby, maybe, maybe she could transfer some of that adrenaline to the baby and that could also be like a resuscitation tool.
[1:02:29] If the baby has not fully transitioned yet and it hasn't shut all of those little doors off. So again, I'm just speculating. But, you know, it could still be a mechanism and it makes no sense to detach the baby. Maybe it's got all these other things, beneficial elements that we don't know about yet. Now, I know I was just talking about the placenta and the cord being resuscitation tools. It's not just me making that up. There's actually research papers on this. Thankfully, we've got them in the resource folder and they use, they talk about the use of the placenta for resuscitation. So it's okay. If you are working in a hospital, you can approach the heads of the paediatric team or your midwifery unit managers and policymakers and say, hey...
[1:03:20] We can get better outcomes for babies, all babies born here, whether they're well or born with some complexity. We can get better outcomes for them and also save the hospital money by reducing the number of care days and the acuity of care that unwell babies need. If we just allow a few more minutes a bit more time for the baby to transition if we use our intellect to solve some of the problems that are that occur when you've got to work on a baby with an attached cord you can actually go into the resource folder take those papers show them to the people that you work with and say actually we could save the hospital cost but also improve our outcomes.
[1:04:05] You're actually going to have babies in better condition doing it this way and you're likely to reduce the cost of things like high acuity care for babies. And so if you look at it practically, actually the outcomes, not only are they going to be better for the babies, but possibly going to have shorter stays in your facilities. It's very expensive to look after an unwell baby. So the easiest thing you can do is to not do something. Don't cut the record. Give it a bit of extra time. The research is on your side. Look at the resource folder. Make some small little changes in your own practice and then maybe let it filter out into the place that you work. So every day that a baby is not in a hospital is saving the hospital money. So by not intervening and by actually just waiting, it could be a minute or two and still giving all of the care that you need to do and you can actually do it. You can really improve baby's outcomes, not just.
[1:05:00] Then but in the long term and also reduce the reliance that it has on your service so, and people thinking you're in an emergency you can't do it well I can't keep mentioning I'm a home birth midwife and I have been involved in some emergencies at home resuscitations as a midwife and we always do them with the cord attached and in some really challenging places and I'm coming at it from experience to tell you that it is possible to get two midwives, oxygen, resus supplies, ambulance officers into small tight spaces and we can resus on a towel on the floor, using a floating kickboard in a pool, on the side of the pool, on the mother's lap. It's possible. Practitioners just have to be willing and think a little bit. Okay, that's all I'll say about that, about not clamping the cord as a part of resuscitation. Now, the other reason that they might give you for wanting to clamp the cord early, this is a bugbear of mine, and it's becoming more routine, is to routinely clamp and cut the cord to collect what we call cord blood gases.
[1:06:14] Now, to women, I want to say that this blood collection is a collection of your baby's blood from the cord. You can decline this. You don't have to accept this routine. Routinely, the baby comes out and they put two clamps on in some facilities, and then they try and capture the blood and get routine blood gases, even on well, healthy babies. But you can opt out of this. You can ask them, does your facility do routine blood gases on all babies? And you can say, I'd like to opt out of that. Do not clamp my baby's cord for the purpose of routine blood gases. You've got to remember that you still need to get consent from women. You cannot take the baby's blood from, even though it's from the cord, you can't take it without the consent of the woman if you're listening as a care provider. Again, we've got to stop calling it cord blood. It's not cord blood. It's the baby's blood.
[1:07:11] The flip side of this is that some hospitals would do this if your baby has been in what they call to be perceived to be in distress. Maybe the labor has been complex and sometimes the cord glasses are done to determine if the baby was in distress, if there's been hypoxia, and maybe that determines the level of care that they'll give the baby.
[1:07:34] And again, there's reasons for that, but certainly if it's been a complex birth, they'll want to do blood gases. And I'm not saying that they shouldn't, and I think it's a little bit controversial, especially when you talk to Dr. Kirsten Small, who's been on the podcast before about evidence-based monitoring of babies. But I won't go into the research, but using cord gases as a diagnostic process, it isn't an exact science, but some hospitals are doing them routinely on well babies, but usually on unwell babies. And in order to do it, they're often clamping and cutting the cord for the purpose of getting blood gases, which is insane. If you've got an unwell baby and you're worried that they were in distress, you're worried that they were hypoxic during the labor and birth, and you're trying to work out how hypoxic, and you're like, oh, okay, the next thing that we'll do to this very distressed baby who needs medical care is cut short its transition to extra uterine life and its access to umbilical cord blood and its full blood volume just so we can check how distressed it was come on i'm so frustrated with this lack of clinical reasoning i'm gonna stop now because i'm gonna go overboard but what i want to say is there's some research pitch.
[1:08:59] And it was about collecting of cord blood gases without cutting and clamping the cord. So although I know I'm not going to change the practice around the acquisition of cord blood gases for distressed babies, we could definitely decline them for well babies. 100% I would stand by that. I would die on that hill. But of course, I'm not going to say don't get cord gases on an unwell baby. But I did find you some research.
[1:09:29] That says you can do cord blood gases on an intact cord. So let's have a look at that. So there's two papers in the resource folder on this and you can collect cord gases while the cord is still pulsing without clamping it and get very similar results compared to if you clamped it or not. So you can do cord gases on an intact cord while it's still attached to the baby, while the placenta is still in its mother. So there was a 2014 study done that basically found no difference whether or not they clamped or cut the cord and did it with the blood still actually flowing. So it's still flowing through the umbilical vein and arteries. You do the blood sampling without clamping or cutting. And there was a bigger one done in 2021, which showed some slight differences, but then they said it was not of clinical significance as to whether or not it was clamped or not. So if you're a midwife and you're working in a facility that's requiring this to be done routinely and you just absolutely can't get out of that, you can do it with the cord attached. And I know people are thinking, oh Mel, this is an OH&S issue. Do you be trying to take blood from an intact cord with a baby on one end and a mother on the other?
[1:10:49] Well mate, you guys are the ones who decided you wanted to do this routinely so maybe you can solve that problem yourselves but it can be done on an intact cord which is also incredibly frustrating to think that we're going to burst someone's you know bubble skin to skin bubble by trying to get access to the baby's cord I'm going to stop going on about this because it's so infuriating anyway, For an unwell baby, nonetheless, you could do this without clamping, cutting the cord. It could still have all this blood flowing that it needs. Now, another reason why clinicians are sometimes cutting or clamping the cord is to collect blood for a baby whose mother is a rhesus negative blood group. So if you've got a negative blood group as a mother, then after birth, your clinician will collect the baby's blood to find out what blood type the baby is. And they'll also do a blood test to determine if there's been any mixing of maternal blood with the newborn blood. So they'll check the baby and they'll check you. So if you've got a negative blood group, it's about 10% of the population.
[1:11:52] That's what they're going to want to do. But there's another way of getting the baby's blood. You don't have to poke the baby. You also don't have to cut and clamp the cord. And it could be collected hours after the birth, after the placenta's already born. So if you go to my Instagram page at Melanie the Migwife or at the Great Birth Rebellion, you can watch me do a full tutorial on how to collect blood from the placenta for blood typing and checking if there's been any blood mixing. So you will see in the video that instead of collecting blood from the cord, which is now empty because I always do optimal cord clamping, The cord's empty. Can't get any blood out of that. But if you trace that back to the placenta, and as we know now, all the blood in the placenta is the babies, it's not the mothers. Find any plump blood vessel and take some of the baby's blood out of that. You will get enough to do blood typing and adapt for the babies.
[1:12:59] So if you've got a client who's a negative blood group and you've got to do that blood test, get it from the placenta, go to my social media page at Melanie the Midwife or at The Great Birth Rebellion and there's an exact tutorial. This is not a complex skill. You've already got heaps of skills if you're getting blood out of a cord. You can do it out of a placenta. Now, the final reason why people are not allowing the baby to get their full blood volume through the cord is that some families are opting for blood banking with the idea of collecting and storing the baby's blood that was left in the placenta
[1:13:37] for potential future use. Potential future use so if you ask me though it doesn't make sense to it doesn't make medical sense to be depriving a baby of its full blood volume and stem cells in the interest of storing a baby's blood for the potential of using stem cells later in life because actually your baby needs its blood now it doesn't need it later so anyway okay I'm not going to go on too long but I'm not on board with cord blood banking or cord blood collection.
[1:14:14] Baby's blood collection for later storage and now briefly I want to talk about optimal cord clamping during cesarean section and I have already spoken about this on the podcast before but I will give it give it to you briefly this can be done again it's an it's an issue of some clinicians won't rather than can't so I've had clients who have had to transition from giving birth at home to giving birth in hospital and then have ended up requiring a cesarean section for one reason or another.
[1:14:44] And we've still wanted to do optimal cord clamping. And when you've got an obstetrician who's willing to work with you, this can be done. And I know because I've seen it done. And that means it can be done. Anybody who chooses not to do it, won't do it. It's not that they can't do it. They're very clever people. All of these things can be worked out. So what we did when we worked with the family and the obstetrician to make this plan for optimal cord clamping is when you lie down for a cesarean section you're positioned flat and what you can do is before they start the surgery just ask that they separate your legs a little bit to create a big enough space that they could slide the baby between your legs over the top of the sterile drapes after the baby's born and so what I've seen an obstetrician do is baby comes out and you can lay a warm, sterile blanket in there. Some of the theatres have got warming stations for the baby's blanket.
[1:15:47] That are sterile and you can put the baby in that and on that. And so there's an element of warmth that the baby gets to maintain while it's waiting to do that transition. The issue is, is that theaters are really cold. They keep them really cold and babies can get cold quickly. But by putting the baby in between the woman's legs, it creates a bit of a barrier. The baby's not going to fall, but it can also stay attached to the cord for a bit longer. And so in this birth that I'm particularly thinking about, the obstetrician said to the woman, how long do you want to keep the cord attached for?
[1:16:24] And the woman said, can you leave it attached for two minutes? And they were very gracious, but very vigilant. And they put the baby between the woman's legs and they literally watched the clock for two whole minutes. And then when the two whole minutes were over, the obstetrician shot eyes at me as a kind of a, is it okay to cut the cord now? And I gave a little nod, approving that, yes, I also believe it's been two minutes. And then they cut the cord and the placenta was born. Now that woman was so grateful. It was a very beautiful experience to be part of because I witnessed how, when we think outside the box a little bit and have
[1:17:04] a little bit of willingness, these things can be done. It's not that they can't be, it's that some clinicians won't do them for some reason or another. And sometimes it's because the baby actually needs help. And of course, the pediatrician can't care for the baby while it's still attached to its mother during a cesarean section. So of course, these situations are going to always be unique.
[1:17:27] But we were in another scenario where an obstetrician said they won't do that. We won't do delayed or optimal cord clamping in the scenario of a cesarean section. And the woman said, well, that's fine, but I want a lotus birth. And a lotus birth means that the baby stays attached to the placenta even when it's born. And the parents wait days and days before detaching the placenta. However you feel about that, it's irrelevant. it. She wasn't actually planning a lotus birth, but to her, if she was planning a lotus birth, the key element was that they didn't cut the cord. And so what the obstetrician ended up having to do reluctantly was put the baby again between the woman's legs at my suggestion because they said, look, we can't. And I said, we actually, you can. What I've seen in the past is an obstetrician place the baby here while they extracted the placenta and the obstetrician sort of went okay we probably could do that. So the baby was positioned between the woman's legs while the obstetrician detached the placenta from the woman's uterus which is the usual process for a cesarean section but it gave that baby just a few more precious seconds attached to the placenta and transitioning.
[1:18:46] So these are a few scenarios under which you could advocate for yourself for optimal cord clamping even in more complex situations and I'm calling on you clinicians and the facilities that assist these babies to consider how you can keep providing top quality medical care but just right close to the mum so the baby can stay close to the placenta and be attached to its cord.
[1:19:16] Okay, that's the end of today's episode and I just want to remind you about the Guide to Giving Birth Without Pain Medication. For optimal birth outcomes, avoiding medication is where it's at and I've made this all killer, no filler guide to how to give birth without pain medication. It's got all the strategies you need.
[1:19:35] Just click the link in the show notes, get the Guide to Giving Birth Without Pain Medication. That has been today's episode of The Great Birth Rebellion and I will see you in the next episode. To get access to the resources for each podcast episode, join the mailing list at MelanieTheMidwife.com. And to support the work of this podcast, wear The Rebellion in the form of clothing and other merch at TheGreatBirthRebellion.com. Follow me, Mel, @MelanieTheMidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
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