Cutting the Umbilical Cord
Cords around the baby’s neck
At a recent ARM meeting, a few of us were discussing the practice of feeling for the cord round the neck immediately following birth of the baby’s head. As students, many of us have seen this done routinely, but are aware of the discomfort that can ensue for the woman. What do you midwives out there do?
If there is an obvious loop this can be slipped over the head. Do tight cords always have to be clamped and cut at this point? Would signs of a short/tight cord (round the neck) have been evident via heart rates and possible deviations re; descent?
I just returned from a night shift and helped a mother birth a lovely big baby…and the cord was fairly tight around the neck, so I explained that I wanted her to push the baby out really gently with the next contraction.. baby appeared easily with both a hand and an elbow coming with the shoulders (he immediately sucked his thumb!).
WhatI now wonder, is WHY did I feel for the cord. There hadn’t been a CTG and hadn’t been any of those telling variable FH decelerations earlier in labour – but, unusually for me, I thought I’d just check. Intuition. Maybe it was the mother’s intuition even – she was very unconfident about the birth itself, waiting for a last-minute problem.
No problem at all in this case, but I felt better being ready to clamp and cut the cord if the baby didn’t easily deliver after the shoulders came through the pelvis. Having seen a few babies with a cord wrapped thrice around the neck, I’m not sure they’d all have the cord length left to be fully born…but I like the suggestions of keeping baby close to the perineum.
At a waterbirth I attended the woman birthed in a semi squat and the cord was 4 times round the neck with like a half loop around the shoulder and going through the legs. Two of these loops were extrememly tight and we all were hands-on with unlooping the baby at the same time as helping the woman to scoop him up. The apgars were really good. We all marvelled at the length of this cord as it must have been at least three times the length of the baby – I wish I had measured it now!
Obviously the cord was not felt as it was a waterbirth but I wonder what the outcome would have been if it had been clamped and cut on the perineum, with such amount around the neck in the first place.
I stopped feeling for the cord round the baby’s neck many years ago, following a tragedy at our unit. A baby with shoulder dystocia had the cord round its neck and it had been clamped and cut. The baby was stuck for many minutes and was a fresh stillbirth when eventually born. If the cord had been left intact, could it have survived fairly unscathed I asked myself?
I have never had a problem with a cord since then and do not check, and as a supervisor advise midwives not to also; I believe it is safe practice. The cord will always untangle during the birth and the baby will always have its lifline intact if there is any difficulty during the birth.
I was taught to feel for cord and either clamp and cut, or loop it over the head. I haven’t done either for years with, touch wood, no snapped cords. It was a lovely midwife called Jan Jennings who helped me learn that I could just hold the baby close to the Mum as has been described and that I could just disentangle the cord after the baby was born.
I am a British trained midwife who has been in New Zealand for eight years. I was taught to feel for the cord and did so until I noticed how uncomfortable it was for the woman, especially those awful sweeps around the tender labia and clitoris following a birth. Now I only feel for the cord if there is no advancement of the shoulders in a land birth.
In a waterbirth, delay of the shoulders may mean a cord or the need for the woman to stand up or turn over. With many babies, one just disentangles the child as s/he emerges. We rarely use a CTG throughout a birth so don’t tend to look for changes there.
I must say that I did feel for a cord just recently–but the baby did turn out to be over five kilos!
If cord loose loop it over head. If in water don’t go investigating at all. Endeavouring to do the same on dry land. I have never clamped and cut a cord before a baby was out; you can never guarentee that those shoulders will definitely come and you may have just removed that baby’s life line. If been having a fetal heart rate drop with contractions I would anticipate that the cord is wrapped around something.
In my experience a loose loop can easily be slipped over, no problems.
If the cord is very tight then i do clamp and cut at this point if there is time, but I have been at births where the mother just carried on pushing and there was no time to cut. Often the baby is shocked at birth and may need a whiff of oxygen.
anecdotally and in my limited experience early decelerations earlier in labour than 2nd stage often indicate a cord involvement, sometimes round the neck, sometimes around the shoulders. If there has been a tracing of this kind in labour then I am more likely to check for a cord around the neck.
A senior midwife said that she had read research which proved that not feeling for the cord and leaving it is just as safe, if not even ‘safer’, than feeling and ‘unlooping’.
She said that if you hold the baby close to the mother’s body and as the baby’s body comes out you keep the baby’s head as close to mum as possible and follow her body upwards toward her front so that the rest of the body ‘slips out’ in a way that baby’s feet end up pointing towards mum’s feet, am I explaining this right? It’s difficult without the aid of a doll/pictures to explain.
She said that it would not matter if the cord was wrapped around baby or was short, if helping baby out in this way there would be no problems for the whole of the baby’s body to come out and then ‘unwrap’ baby from the cord as soon as he/she was born.
From Midwifery Today E-News:
While listening to fetal heart tones late in labor (when heard right above the pubic bone) it seems at times I hear cord sounds. This usually happens when the baby comes with a nuchal cord. I now prepare myself for a nuchal cord when I hear a cord pulsing at a woman’s pubic bone, and I must say, it is nice to anticipate this fairly unexpected event. Have any other midwives found this to be true?
Hearing nuchal cord sounds with hand held Sonicaid is something I’ve never discussed much with other midwives, but yes, it does happened and I’ve anticipated cord around the neck of the baby a few times. Yet it has not changed my practice of the ‘do nothing’ option.
Ever since I went to the first International Waterbirth Conference in London, and heard European midwives and doctors share their practice of over 10000 waterbirths, I have been confident to receive babies without feeling for cord and then simply disentangling them if they are born with cord around their neck.
Sometimes babies end up doing a few somersaults, as in the case of my grandson who had a few loops around his neck (he loves tumbling now!). I’ve received babies with extremely tight-looking cords, but it hasn’t stopped their mother birthing them, and again the cord was easily removed holding baby in a reverse position i.e. head of baby very near perineum and very close to mother’s body.
Every so often you hear of horror stories where there are snapped cords but these are rare and not really associated with nuchal cord and should not make midwives practice in a fearful way. And yes, maybe one day there will be a baby who may need help to be born with an extemely tight and short cord and that will be a practice judgment to cut the cord at that time, but in the meantime I believe there is no need to cut or even slip the cord over before the birth. In fact, the benefits of an intact cord far outweigh the panicky practice I was taught as a student – to be almost frightened of the nuchal cord. The amount of pain that has been inflicted upon women whilst feeling for the cord should not be forgotten either.
I decided some time ago that I do not want to use the normal plastic cord clamp on the baby I’m expecting. Time is kind of running out and I’m still not really sure what to do!
Two parts to this question really – what have any of you seen used (ie parcel string, ribbon, bias binding?) and do you have any reservations about it not being sterile or not?
My midwife raised her eyebrows at it this morning (even though she read my birth plan (all 7 pages!! 🙂 ) ages ago. She is very hung up about it not being the norm and keeps telling me that plastic clamps are sterile. Well they’re only sterile until you open the packet aren’t they – then then get dirtied in all the usual baby stuff like a ribbon would, don’t they? I pointed out that whilst I’m aware of babies getting umbilical cord infections, we’re actually only tying something onto a bit of dying flesh, aren’t we? Whatever happens, I won’t be using a plastic clamp, even it that means we remove it as soon as she’s left, but I’d rather know what you lovely ladies thought or if you have any experience of using an alternative?
We used rubber bands many years ago!
Maragaret Myles (1981) stated:
“Rubber bands, 3.5 cms long by 2mm wide, are wound four times round an average size cord: they are considered to be more efficient than tape which may allow leakage: rubber bands may cut through a thick cord. Rubber bands shrink as the cord shrinks.”
We applied the Spencer Wells forceps 5 cms from the umbilicus and wrapped the elastic band round the cord and forceps 4 times and then providing the elastic seemed tight enough, we removed the clamp.
I have also used silk cord.
I have never known a rubber band to cut a cord!
You may like to read the World Health Organisation information on cord care: WHO, (1999),Care of the Umbilical Cord: A review of the evidence (www.umbicut.com/article1/htm)
We had a mum recently who did not like the idea of plastic cord clamps. The cord was clamped with metal clamp and cut as usual then the metal clamp was just left there for a while (About an hour I think). This was then removed and that was it – no bleeding, no hassle – cord fell off 3 days later.
Dental tape works quite well – and I have no qualms about being sterile. I sterilise my own instruments after use – and store ‘clean’. Birth is not a sterile event.
Have been using non-waxed dental floss for years- it seems to be effective, cheap and socially clean. It caused alot of raised eyebrows from the paediatricans at the hospital which led to us giving up using it for hospital births and going back to clamps, but we do lots of home births where we use dental floss. And in fact, now feel like making a stand against the unneccessary medicalisation of cord tying! Everyone get their dental floss out!
I agree – using dental floss works really well. I also know a couple who chose to make their own cord tie, plaited out of horses hair from their own horse. Boiled up lovely and was a very effective tie!
Many of the women I attend prefer not to use the plastic cord clamps and there really is no problem. Messrs Ethicon sell Umbilical cotton tape in a sterile pack rather like a suture packet. I am looking at one as I type. Or the woman can just get some 1/4 inch cotton tape, cut two lengths of about 10 inches and while in early labour boil them in water for about 20 minutes, take them off the boil and leave to cool. Midwife then has two sterile lengths of tape in sterile water.
(from another post)
If I have a client who does not want me to use the plastic cord clamps, it is likely that a physiological third stage will also be planned, so that the cord will be non-pulsing and flaccid when I eventually get round to cutting it. In such cases I use cord ligature made from 1/4 “wide cotton tape I just cut a couple of pieces of tape about 10” long to give me enough to get hold of and just tie the cord off tightly before it is cut I boil the tape for about 10 minutes. The advantages of the plastic clamps are that they are very quick to apply so if I have a client who chooses active management or in the very few cases where I advise active management I do prefer the clamps. Though I do agree they can get in the way of skin to skin and sometimes feeding.
I have some tape which is produced by ethicon and is intended for tying cords. It’s obviously not sterile once opened and used for the first time, but it is clean as it is like a cotton reel in a tube with a snap lid and you pull out as much as you want and cut off the appropriate length – a bit like you do dental floss but as it’s tape rather than as thin as floss I would think it’s less likely to cut through the cord. I ‘inherited’ it from a midwife friend (looks like there’s enough there to last me and a few midwives after me!) and use it when clients don’t want a plastic clamp.
I only got about halfway through mentioning to a midwife last time that I would like to use dental floss instead of a plastic clamp on my second baby’s cord, when she said “Oh, we’ll just use a cord tie, then” – I think that was what she called it. In the event it was just thin string, just like dental floss. Nobody seemed to find it at all controversial.
I didn’t want that hard plastic clamp scratching my baby’s tummy as it had first time round, and also since I preferred to have skin-to-skin contact, ie not dressing baby at all for most of the time the first few days, just keeping us both under towels etc, I didn’t want it scratching me, either!
You don’t need to use anything – if you are having a physiological third stage the cord will have ligated itself (physiological third stage is not ‘just’ having no ecbolic…but not cutting the cord until the placenta has birthed and then some).
If you do want to use something though braided cross-stitch thread in chosen colours is what many couples planning unassisted birth use. Use it wet as it grips the cord tissue better.
I am hoping to acheive the same and am glad to have you paving the way. I was going to ask about this nearer the birth, once I have written my huge birth plan. I feel a bit embarrassed about asking for this kind of thing from my community team, although they are pretty cool.
I have read previous threads on this and understand that you may need to sterilise your cord (gauze? ribbon? ribbon sounds nice) which you can leave quite long so that tying is easy (trim it after) – in boiling water and keep in a sterile place. You could thoughtfully provide an extra pair of sterile scissors too, as a hb pack may only have a pair or two, although what infection the tie can get ill from I don’t know.
You could ask the mw to make a long stump with a plastic clip in the first instance (might help if they are worried and stressed about all the water and natural third stage etc.) and then put your own tie on later, although I don’t know if there is an optimum distance from your baby.
You don’t need to sterilise anything you use. You’re tying it to dead flesh that needs bacteria to rot and fall off; making it sterile defeats the purpose.
I am afraid I disagree with a little bit of what you are saying. Yes cords do separate by necrosis, and yes I am sure that there are bacteria involved, but they are intrinsic to that baby’s environment. We have to remember that many babies die of infection from their cord stumps where birth attendants do not use clean/sterile instruments to cut the cord. It is such a simple precaution to take, to use a sterile pair of scissors or a new razor blade to cut the cord.
I do agree with you that where there is delayed cutting of the cord bleeding from the stump if left unligated or clamped is unlikely. However I have seen it happen and have been called back at 3am to deal with a bleeding cord and very frightened parents. In the case I remember the baby had been born about lunchtime, the placenta about 45 minutes later, and we didn’t cut the cord for an hour after that. I did leave about 3 inches of cord because we did not ligate, but it started to bleed sometime in the night Because there was a long stump the parents were able to compress it and it had stopped bleeding before I arrived. I estimated the baby had lost about 30 mls – not a significant amount, but enough to make me wary of leaving cords unligated.
(Cord stump infection) is not just a product of hospital birth – neonatal tetanus kills many babies worldwide who were born at home. It is the reason the Nicaraguan midwives cauterised the court stumps with a machete heated in the fire…
Delayed Cord Cutting/Clamping
Why compromised babies should be resuscitated without cutting the cord:
Can Hasty Cord Clamping Injure the Newborn? By George M. Morley, MB., CH. B from July 1998, OBG Management – the whole article, with lots of refs, is at: http://www.birthlove.com/pages/health/cords.html
So what is the rationale for cutting the cord at all? Is it primarily so baby can be removed to heat /recuscitation/ exam?
Not only can it give you the extra oxygen for a shoulder dystocia, but ditto for a baby which has had the cord pinched and comes out “flat”.
OR is the argument that if the cord is not cut, the placenta will not detach or will partially detach? And where does maternal end clamped/not clamped fit into this picture?
I have never understood why a baby which is apneic for whatever reason should be deprived of the extra minutes of oxygenated blood before the placenta separates.
I do not cut unless baby is clearly fine and cord is clearly too short for comfortable movement. Sometimes this means that the baby is attached to the separated placenta for a while while I try to control a bleed or similar (sometimes a couple of hours). I find that once everything is attended to, the cord cutting and clamping can be a ritual enjoyed and by the participating parents .
You do get more jaundice because the baby will get more blood. It takes about 5 days to clear (once mum’s milk is in) and I have not seen it get to levels that are dangerous. You also get less anemia as baby gets more blood which is nice if the mum is exclusively nursing beyond 6 months as these babies have increased stores.
AS long as you do not let the blood pour into the baby by holding him below the placenta befoe it detaches (duh!) I can’t see why the cord gets cut.
The Consultant Neonatologist attached to our obstetric unit always said that once the cord was exposed to colder air – ie, OUTSIDE the mother’s body, its effectiveness in providing the baby with O2 was as good as useless. He recommended cutting the cord (if the baby appeared shocked) so that O2 could be given by bag & mask. His reasoning was that the baby could be given more O2 via bag and mask method rather than “rely” on the cord.
I’m not saying that I agree with him but I’d love to hear thoughts on this rationale.
I bet the consultant neonatologist can’t come up with any evidence to say that the cors stops bringing oxygenated blood to the babe the moment it hits the air. If the placenta is still attached and you cut the cord and leave it unclamped are you willing to wait and see how much blood pumps through that ‘useless’ cord? Not me!
The system does shut down, but I do think there is a good couple of minutes there. You can also bag and even do PPV with cord intact, right there on the bed.
Presumably the consultant believes that the cord will spasm in the cold air, in which case the blood will no longer circulate? Of course all you need to do is feel the cord to find out whether or not blood is circulating. If it is pulsating, then surely blood must be moving along it? If blood is circulating, then common sense says that gaseous exchange is still taking place at the placental site. If that is the case, then the baby will still be obtaining oxygen, and will not need to inflate its lungs at once.
It is true of course that placental exchange provides less oxygen than lung exchange – hence the different colour of the blood, and the baby’s change of colour when it first breathes… But where is the research that says the baby suddenly requires huge amounts more oxygen in the first minutes of life outside its mother: what does it need such huge new amounts for?
At least if you leave the cord alone there will still be gaseous exchange going on while the baby’s physiology makes the decision to change over to lung-breathing mode, and during those first breaths which are such a big effort. How does the consultant know that the cord in cold air is no longer functional? Where are the figures on gaseous exchange through the cord post-birth? Is this perhaps theoretical knowledge only?
In my experience the cord stops pulsating around the time the placenta separates (obviously no point in blood circulating through it after that). If the cord is not pulsating, the placenta has probably separated, even if only partially.
If you give syntometrine with the anterior shoulder and clamp and cut immediately you miss all this fascinating process.
If the baby is shocked it will usually respond nicely if given time to recover and kept warm and snuggled close. Homeopathic aconite is brilliant for shock, and can be given crushed in a teaspoon and gently rubbed inside the baby’s cheek with the tip of your finger.
Can’t see any of that happening on a resuscitaire though, which is possibly all the neonatologist ever sees.
Have you witnessed a cord which continued to pulsate after the placenta had definitely completely separated?
I have! But only once 4 years ago as a student at a home waterbirth.
Shortly after birthing her baby and still in the pool, whilst snuggling her baby with one hand, this magnificent woman calmly remarked ‘this is for you’ then passed her placent to me with her free hand! Both the placenta and cord continued to pulsate for a further few minutes, we all laughed at how the placenta was like a little creature throbbing away. No one had ever seen anything like it before.
Maybe the warmth of the water was a factor at first, but it kept going even after it was removed from the pool ………any ideas?
Some midwives believe that it facilitates a physiological third stage if the cord is not cut until the placenta has actually been delivered. See the US Midwife Archives atwww.gentlebirth.org/archives/cordIssues.html .
They speculate that cutting the cord can slow the delivery of the placenta and increase maternal blood loss because somehow the body’s natural feedback system is interrupted. Sounded sensible to me though – after all, from an evolutionary point of view, I thought it unlikely that our ancestors would have been biting through the cord before the placenta was delivered.
I decided to try this fully physiological third stage, on the grounds that, no matter how antisocial I felt after the birth, I would be tied to my baby and would be forced to spend that time cuddled up to him. It worked wonderfully, and I was somewhat disappointed when the placenta duly turned up after only 10-15 minutes and a quick push! When you do this, no-one can come between you and your baby. He can’t be passed around, or cleaned up, or weighed or measured. You might have written in your birth plan that you don’t want any of these things done until you’re ready, but sometimes people forget, or don’t want to make a fuss, and will just go along with the flow. It’s a great way of protecting those precious moments.
At this birth, I had a 3rd stage of 10-15 mins and estimated blood loss of < 100ml, compared to a third stage of an hour and blood loss of over 500mls last time. Of course, there's no way of knowing how much the delayed cord cutting contributed to that improved outcome - I was at lower risk of blood loss anyway as it was my second baby and he was a lot smaller - but certainly psychologically it was vastly preferable. Angela
Just surfacing after a run of wonderful homebirths, the last this morning, a beautiful underwater birth of a boy to a first time mum, totally fantastic!!!
The reason for this posting is to ask some advice about others’ experience regarding cord cutting. I am totally OK about leaving all alone until the placenta is birthed and then normally clamp and get the parents to cut, if they want to.
I have a client at present who does not understand why I need to clamp the cord in the first place. I have heard that some midwives in America just leave the placenta attached to the cord for a couple of hours and then separate without need to leave a clamp on. has anyone had experience of this?
I must admit I always put a clamp on before finally cutting, I don’t feel comfortable to just leave it. Am I being over cautious? I am always happy to be challenged and I find this an interesting area. We have intefered with the physiological process so much that some basic functions become forgotten or misinterpreted. What did they do before clamps? What do animals do? I am sure they don’t clamp the cords of their young.
Susan , independent midwife
Animals chew the cord off I believe. Rather you than me :0)
‘Lotus birth’ is the term used to describe the practice of leaving the placenta attached to the baby until the cord falls off.
We keep sheep and the cord always breaks as the lamb is born. I understand this is so for horses and cows as well, but dogs and cats bite through the cord. We also spray the cord stump as otherwise there is a fair chance that the lamb will pick up an infection and die.
You have to understand that it is a sheep’s sole ambition to die in as inconvenient and, preferably rare, way as possible (thus making a place for itself in esoteric veterinary manuals) so we take infection risks seriously.
I’m wondering whether it would be better to clamp the cord, but I expect if we did, the ewe would, in attempting to clean her lamb, bite it off and swallow it thus ensuring not only that she dies, but the lamb does too – a major achievement for a ewe.
Rats, mice and all other rodents I’ve kept, bite through the cord after the placenta is born, and usually eat the placenta too. Occasionally they leave some if they have a large litter. There is rarely any bleeding from the cord stump.
I understand that contact with air causes the blood vessels in the cord to constrict, which presumably minimises bleeding. One thing’s for sure – (cue for me to repeat favourite saying) – 220 million years of mammalian evolution will not have got it consistently wrong, so there will be some physiological mechanism for this. All mammals have cords and they all have to be severed at some point. To my knowledge, ours is the only species which, in some cultures, routinely ties the cord.
Angela, mother and rodent breeder!
I sometimes don’t clamp the cord – I use ligatures made from tape. I think in a “natural” animal environment cords are not constricted and are bitten by the mother which will sort of seal the baby end. And of course the fetal/placental vessels are going out of use as the post-natal pulmonary circulation picks up, but it takes time and there may be enough pressure still in the umbilical vessels for the baby to bleed too much, before the vessels seal off if left unconstricted by either a clamp or a ligature.
In many cultures the cord is sealed with cow dung – a sort of early tetanus immunisation which, like many immunisations, has side-effects; in this case, often fatal ones!
You don’t always need to clamp the cord at either end if you wait for it to go white. It does make most parents feel better if the baby’s end is clamped though. My midwife did not clamp for any of her four babies but has only had a couple of parents choose not to in all the years she has been practising.
I have recently come across something called a lotus birth – this is where the cord is not cut and the baby is kept with the placenta attached until the cord separates from the baby. There is a website about this with lots of information about how to mask smells and advice about salting the placenta to dry it out and stop it oozing over the baby clothes!
Some of the birth stories on this melbourne Midwifery page mentions lotus birth:
“The placenta was birthed about 10 minutes after Hailey. We salted and placed the placenta in a bag and wrapped it in a bunny rug along side Hailey. Over the next four days Hailey just slept and drank, after the cord broke away Hailey really awoke her second birth. ”
“We got out of the pool to get the baby girl warm, wrapping her in a blanket. Shortly after the placenta birthed. We never cut the cord. The placenta was salted and wrapped in a few nappies and put in a plastic bag which was placed in a very small pillow slip and carried with the baby for the next four days until the cord came away from her belly button of it’s own accord. I believe much of the baby’s peace in the first four days was due to allowing the placenta and cord to stay intact beside her until they were ready to come away. The placenta is an amazing organ originating not directly from the mother but from the cell division of the fertilised egg; it is truly a part of the baby. The placenta is not something to be cut off the baby, treated as dirty and smelly and thrown in the bin.”
“commenced breastfeeding, placenta birthed naturally 12 minutes later, cord and placenta remained attached until natural separation occurred on the 4th day (Lotus Birth).”
In my culture, the placenta is seen as the baby’s guardian spirit, I can see the point of allowing the placenta and the baby to make the their own separation rather than abruptly end it ourselves.
Without wishing to offend anyone, what is the intention behind the Lotus Birth? How does the baby benefit?
Surely as an evolutionary thing, we would not have wanted to keep our babies attached to something that attracted predators for any longer than necessary, and I always assume that nature has evolved to give us the best chance of surviving.
I believe that the benefits to the mother and baby are thought to be emotional and spiritual in nature, in addition to an earlier cord separation time.
I have a copy of ‘Lotus Birth’ by Shivam Rachana which I’m yet to find a quiet moment to read, but I think that leaving the cord uncut so that the baby remains attached to its placenta is seen as period of transition, connectedness, security, sacredness and is seen as a less traumatic experience.
Some people who have undergone primal therapy have relived the pain and trauma of having their cords cut, amongst other things. Shivam Rachana has looked at babies’ reactions to having their cords cut and children’s interest in placentas. Our own birth traumas are thought to influence how we birth and support others in birth.
Michel Odent’s work in primal health research looks at the effects of early experiences, particularly those surrounding the birth experience and their long term consequences on our wellbeing and personality. His book ‘The Scientification of Love’ is very thought provoking as is ‘Lotus Birth’.
There are some interesting photos of a mother caring for her baby with the placenta still being attached (lotus birth) here: http://www.body-mind-spirit.com/gentlebirth/newbaby.htm
I was fortunate enought to attend to a woman who had a lovely waterbirth. After (the woman) birthed her baby we asked her if she would like a physiological thrid stage or the Syntometrine, to which she adamantly said she wanted Syntometrine. The syntometrine was given and she got out and got on the bed. I waited to the cord lengthening and the trickling of blood (all the signs of separation) then palpated and made sure that the uterus was well contracted. I went to apply cord controlled traction and, lo and behold, it snapped on me. I actually took a look at the cord and discovered that the cord started off quite fat and thick but tapered off quite thinly where it snapped.
We got her on her knees and breastfeeding and decided to wait an hour before putting IV syntocinon up. The syntocinon was put up at 8am and the Registrar on call was eager to get started with manual removal, ranting about if she doesn’t do it now, it will be 9am before she could come back to the woman to do it. The Reg also informed her Consultant on the phone who ranted and raved about getting the placenta out NOW because he was going to have to come in to do later anyway.
It was wonderful to see all THREE midwives there stand their ground and said NO to her, actually using the policy to defend their case. The policy was to wait for one hour after the administration of syntometrine, then IV syntocinon for an hour, and if that doesn’t work, finally a manual removal. The Reg wasn’t aware of this policy and said that normally she doesn’t even bother to wait. She also playfully/lightly accused my mentor who was present of the birth for the snapped cord, to which I said ‘She didn’t facilitate the birth, I did, and I applied the cord traction’. Her response to this (which was not directed at me, funnily enough I don’t think she even acknowledged me) was ‘Well, she must be stronger than you (my mentor) plus she is younger as well. Plus you are the supervisor it is always your fault’. She was convinced that the woman would need manual removal and the midwives told her that it would probably be unnecessary. Her response was ‘Well, we are the doctors’. Dunno what she meant by that but it was marvellous to see midwives stand up to a Reg..it was just the right combination of midwives. Well anyway, my mentor assured me that it was not my fault and that it has happened to her many a times.
I called today to find out what happened and apparently, the woman pushed it out at about an hour after the syntocinon went up and when they inspected the placenta, the midwife on the phone said … the cord was inserted on the side and there were two bits to the placenta and the cord snapped at the insertion point. I was so pleased that the woman didn’t need manual removal.
Well done to you and your colleagues for standing your ground. A friend of mine had a manual removal of the placenta some years ago, and it really traumatised her. She could not forget this man rummaging about so deep inside her, she said (a long time after, I might add, as the memory refused to fade) and found the whole thing violating and horrible. Understatement. I’m not saying manual removal is a no-no, ever, but it looks like you saved this woman from one which was unnecessary, using midwifery skills, and her experience of that lovely waterbirth will not have been ruined. Hooray.
What a fuss about a snapped cord!!! Certainly keep the doctors at bay unless they can present some evidence to show that any of this is necessary.
I certainly have been laid-back about snapped cords ever since my very first delivery when, as a student of course, I grabbed this cord and attempted Controlled Cord Traction having no real idea how hard to pull. Of course it had to be a thin one and came off at insertion.
The midwife was not in the least bit worried. Suggested attempting maternal effort and out the placenta came. And thus has been my practice ever since. I have no great objection to active management of the third stage but I hate pulling against resistance, so if it doesnt come quite easily my instinct takes over and I merely let go, wait a while, and once I am positive the fundus has risen and the placenta separated I ask the mum to give a wee push. And, surprise surprise, out it pops.
Too much hurry scurry nowadays….
‘Snapped Cord’ is when the cord breaks off after baby has been born, usually as a result of ‘active management’ of the 3rd stage ie somebody attempting to pull the placenta out, the cord ‘snaps’ somewhere in the vagina so you can no longer see it or get hold of it! It really isn’t nasty at all and can be dealt with quite safetly by the mother being upright (on a loo is good) so she can try pushing it out, breast feeding, or if no joy an IV of syntocinon. Immediate manual removal is appalling practice in my view and exposes a woman to far more risk of infection, damage to uterus, even rupture, and the trauma of this horrid procedure.
We take cord blood for rhesus negative mothers. We have taken cord blood after an active 3rd stage and the cord has been clamped and cut. We draw the blood off above the clamp (maternal side) whilst waiting for placenta to deliver.
Lorraine 3rd year student
If you wait more than 15 mins post placental detachment then it can be hard to get enough blood out of the cord..you can insert a needle and aspirate it out of placental veins.
Whenever you cut, you need to clamp the cord end if there is going to be a period of time before you drain the cord.You’ll have to ask the lab if ‘milking’ the cord’ is ok.
Do not know about syntocinon but I’d second a guess that becasue most women receive it in 3rd stage in a hospital setting, then it will have no effect on the storage and viability of the sample.
The registry will certainly be able to answer any other questions. Do uk practices not take any cord blood after the birth? in Texas we had to to check for syphilis and babies RH if mum negative
MIDIRS have a atandard search on cord blood banking (PN106). There will also be a short article on whether or not this should be a private matter in the maternity services section of the March 2001 edition of the Digest.
There is now a commercial company providing banking services in the UK. Their website is www.cordbloodbank.co.uk
London Cord Blood Bank, Deansbrook road, Edcgware, London, HA8 9BD. Tel: 020-8732-5440
MIDIRS (Midwives Information and Resource Service)
My one and only time that I pulled a cord off was as a student at a home birth. The look on the midwife’s face was sufficient to ensure I was unlikely to repeat the event. What she taught me was:- empty bladder, baby to breast, placenta had separated and on examination was found to be in the cervix and upper vagina. Combined uterine massage with assisting descent manually – being mindful of the potential for uterine inversion – sponge holders proved useful to start the descent. Mum was great as I recall.
I still work with the midwife, who doesn’t recall the event – it was just using her midwifery skills and passing them on. Recently some one wanted to reduce the equipment we carry – and although it hasn’t been necessary I take comfort from knowing the sponge holders are available if necessary – rarely use syntometrine now so even less likely.
If the cord snaps why can’t you just use maternal effort – my preferred choice given half a chance.
Links to other sources of information:
Cord Blood Banking/Samples
AH updated 15 December 2002