Third stage the natural way
By Julie Cottle
Otherwise known as physiological management
Physiological management allows the placenta and membranes to birth without medical intervention. It can also allow for the natural clamping of the cord by the baby’s body which can be extremely advantageous to the baby. This process may take from five minutes to one hour or even longer if there has been some interference in the natural hormonal cascade that causes these events.
The mother may find that using positions that use gravity will help the delivery of the placenta to go smoothly. It can also be helpful to push during contractions as you did during second stage.
If the placenta is not delivered within 30 mins and you in a hospital environment you will most likely be told that active management of third stage should be started. You actually have quite a lot of time before the situation becomes critical and you could start to use the management techniques outlined in the section help with natural therapies instead of using the synthetic hormones and cord traction so long as there are no signs of complications. Just so long as the placenta comes away cleanly and it doesn’t leave fragments behind there should be no need for intervention.
Physiologic clamping
Baby can do it.
As mention above, the cord will be cut as soon as or very soon after the baby is born unless you let your care providers know that you wish otherwise. There are many reasons why it is beneficial to leave the cord unclamped and uncut until the placenta has birthed. The main reason being that at the moment of birth, the placenta holds a portion of the baby’s blood in reserve. Nature designed an amazing system for ensuring a smooth transition from life inside the uterus to the outside world where the new baby needs to breathe on its own. The blood passing between the baby and the placenta carries oxygen to the newborn, possibly even after the placenta has detached and delivered. Thus the natural process protects the brain by providing a continuous oxygen supply from two sources until the second source is functioning well.
While in the uterus, the placenta does the job of lungs, kidney, gut and liver for the baby. Because the baby’s organs are not really needed, blood flow to them is minimal until the baby takes its first breath at delivery triggering huge changes in the organisation of the circulatory system.
Once the baby is born blood is diverted away from the umbilical cord and placenta and as the lungs fill with air, blood is sucked into the lung circulation. The placenta and cord contain the additional blood necessary for the extra blood needed to supply the lungs, kidneys, gut and liver which had previously not needed a blood supply of it’s own. If the baby has to use its own blood supply for these organs it suffers a massive drop in blood volume of anywhere from 1/3rd to ½ of its blood volume.
The transfer of the blood from the placenta to the baby happens during the contractions of third stage, with blood is being pushed into the baby with each contraction, and some blood is returning to the placenta between contractions. It is thought that the baby may be able to regulate the transfusion of the blood depending on its individual need by crying which causes constriction of the blood vessels in the cord which slows the intake of blood.
Gravity will also affect the transfer of blood from the placenta to the baby’s circulation, so it is ideal to have the baby remain at or below the level of the uterus until the cord stops pulsing. This process of “physiological clamping” can take between 1 and 3 minutes.
You will know that natural cord clamping has occurred when:
There are no pulsations in the cord. This tells you that the arteries are closed.
The baby is breathing and is pink. This tells up that the heart and lungs are working.
There is no blood in the cord . This tells us that the transfer of blood from the placenta to the baby is complete.
The arguments for immediate cord clamping
There is much evidence to support delayed cord clamping, so why is it so unusual?
- There is a belief that the oxygen deficit is what causes the baby to start breathing. Yes, the blood passing between the baby and the placenta carries oxygen to the newborn, maybe even after the placenta has detached and delivered. The truth is that we don’t know exactly what causes the newborn to take its first breath; another theory is that it is the change in temperature. If we don’t know, why assume that Mother Nature has it wrong?
- Belief that delayed clamping will cause too much blood to go to the newborn. In fact the baby will receive exactly what it needs as the cord is still able to take excess blood away from the baby and will clamp itself when the time is right.
- Belief that delayed clamping results in a higher incidence of jaundice. In an effort to prevent the possibility of jaundice, obstetric practitioners have reasoned against delayed cord clamping, since it increases the volume of red blood cells which, in breaking down, will produce increased levels of bilirubin possibly resulting in jaundice. True, jaundice may be prevented in premature infants by early clamping; however, for a full-term baby, there are so many advantages to delaying cord clamping until after the placenta has delivered itself. Research I have read on the topic has confirmed that there is a larger number of red blood cells transferred to the baby but not enough to increase the risk of jaundice in healthy full term babies. See special circumstances for more info regarding pre-term babies, resuscitation and Rh incompatibility and donating cord blood.
- Convenience. It is easier when whisking a baby away to be cleaned weighed and ‘checked’. Following most hospital protocols is easier done when the baby is no longer attached to the mother. The alternative is: a baby can be put on the mother’s belly immediately following the birth or wrapped in a blanket and held by the mother providing the cord is long enough, until the placenta is delivered and the cord stops pulsating.
- Potential dangers of immediate cord clamping
For the Mother
- Interference with third stage hormonal systems involving oxytocin and endorphins , these hormones are linked to bonding and are a natural means of preventing haemorrhage
- More difficulty in delivering a bulky placenta due to a higher blood volume than it should
- Increased risk of haemorrhage
- Increased risk of retained placenta
- Increased risk of baby’s blood entering mothers circulation which can cause Rh incompatibility in future pregnancies of susceptible mothers.
For the baby
- Denial of the full ‘placental transfusion’ to the newborn baby for some babies this means it loses up to half of its total blood volume (54 to 160 ml out of 300 to 350 ml)
- Deprivation of oxygen contained in the placental blood
- Loss of ‘life-line’ if breathing is delayed, increasing risk of damage from lack of oxygen
- Not enough blood to adequately supply newly functioning tissue and organs in the time after birth
- There are concerns of possible long-term organ damage
- Brain lesions have been found in primates and human babies who have undergone immediate cord clamping that are absent in those who have delayed cord clamping. This appears to be due to oxygen deprivation and is being investigated as a possible cause of autism and learning difficulties.
- Increased likelihood of anaemia
- Deprivation of stem cells contained in the placental/cord blood. Companies pay big bucks to have this blood collected and whisked away in a cold box to collect stem cells. These cells can be donated to someone who is very sick or used for medical research. Some parents choose to have their children’s cord blood saved for future treatment if it is required. Cord blood is now considered liquid gold and we are only beginning to understand the significance of stem cells. How do we know what we are doing by depriving our children of them?
- Increased need for resuscitation
- Increased risk of respiratory problems, especially in vulnerable babies.
Special circumstances and delayed cord cutting
Premature babies . It seems that this is the most controversial circumstance when considering when to cut the cord. There has been research to show that delayed cord cutting does increase the chance of the baby developing jaundice and other research shows that it has no effect. There does seem to unequivocal evidence to suggest that delayed cord clamping in very premature newborns reduces the need for blood transfusions for these babies and reduces the risk of bleeding into the brain.
My baby requires resuscitation. It is in these emergencies that the baby needs the cord intact to supply it with oxygen and blood. In most circumstances, necessary procedures can be carried out with the baby attached to the cord, either on the bed between its mother’s knees or on its mother’s abdomen. There are occasional cases where the cord is too short for this happen.
Rh incompatibility . For Rh negative women, there is credible evidence to suggest that it is the clamping of a pulsing cord that causes the blood of the baby to enter the blood stream of the mother causing sensitisation problems. In this instance cord cutting should undoubtedly be delayed and if this is not possible then allowing free bleeding from the mothers end of the cord can also reduce the risk of sensitisation occurring
I want to donate or store my babies cord blood . In this instance I think that the benefits have to outweigh the risks and this is up to every couple to determine. It depends on the knowledge and skill of the person collecting the blood as to weather cord blood collection and cord cutting needs to happen immediately or whether it can be delayed at least until the cord has stopped pulsing. There are many midwives who have successfully collected enough cord blood to donate or store after waiting for the placenta to be fully birthed. If there is a dire need for the baby’s stem cells from the cord blood (such as treatment for a family member) the best way to be absolutely sure that there will be enough collected is to collect it immediately following the birth.
What about caesareans? A baby born by caesarean can be lifted out with both the cord and placenta still attached and place on mum’s chest just the same as in a vaginal delivery. A very good study I read recently concludes that it is possible to perform delayed cord clamping at a caesarean birth of premature babies and that it should be performed wherever possible. Whether or not you have this option available to you will have a lot to do with the practices of the obstetrician you have working with you, so it is a good idea to discuss this option with your obstetrician before a caesarean and also to make sure that the rest of the team know of your wishes.
Take a look at this video featuring a surgical team discussing their approach with ‘woman centred’ caesareans in which they routinely delay cord clamping. It most certainly can be done if you want it and has great benefits. It may just require a little chat with the surgeon and paediatrician attending your birth.
A warning- this video does contain graphic surgical procedures but it is a very positive video and worth the watch if you’re not too squeemish.
An amazing fact.
Newborns that have had a completely natural birth, and are simply placed on their mother’s abdomen, will make their way without any assistance to their mother’s nipple and attach themselves.
This is a completely instinctive response and is achieved by the same pushing reflex that has helped the baby out of its mother during the birth process. Another amazing fact, it always results in a 100 per cent correct attachment to the nipple.
This is a wonderful video created by UNICEF demonstrating this amazing instinct known as the breast crawl.
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