Archive for the ‘Third Stage’ Category

New Cochrane Review: Delayed Cord Clamping Likely Beneficial for Healthy Term Newborns

July 25th, 2013 by avatar

By Mark Sloan, M.D.

Last fall, Dr. Mark Sloan wrote an extremely well-received post on Science & Sensibility, Common Objections to Delayed Cord Clamping; What’s the Evidence Say? that both professionals and consumers could use to understand and discuss the benefits of delayed cord clamping. From that post, we read that early cord clamping is an intervention that needs to change.  Yet, early cord clamping is still observed in L&D rooms across the United States, despite the mounting evidence for waiting at least 1-3 minutes before clamping occurs.  A new Cochrane review was just released in July, 2013, and I am grateful to Dr. Sloan for summarizing this review and sharing the  new information on this topic. – Sharon Muza, Community Manager, Science & Sensibility



A new Cochrane review of the timing of cord clamping in healthy term neonates was released earlier this month: Effect of timing of umbilical cord clamping of term infants on mother and baby outcomes. It’s an update of a 2009 review on the subject, and the language is more pro-delayed cord clamping (ie, clamping the cord at 1-3 minutes after birth) this time around. Here’s an excerpt from the Author’s Conclusions:

 “A more liberal approach to delaying clamping of the umbilical cord in healthy term infants appears to be warranted, particularly in light of growing evidence that delayed cord clamping increases early haemoglobin concentrations and iron stores in infants. Delayed cord clamping is likely to be beneficial as long as access to treatment for jaundice requiring phototherapy is available.”

To understand why this change in emphasis since the 2009 Cochrane review is important, let’s first look at why the timing of cord clamping is important to newborns, how current obstetric practice came to be, and what the Cochrane review did (and didn’t) find. 

A brief physiology review

At term, roughly 1/3 of a fetus’s blood supply resides in the placenta. In the course of labor and delivery, much of that blood is transfused from the placenta into the fetus/newborn, driven by the force of uterine contractions. That transfusion continues beyond the moment of birth; if left undisturbed for 1 to 3 minutes, the placenta will deliver about three additional ounces of blood to the newborn.

That may not sound like much, but three ounces of blood is equivalent to a three month supply of iron for the newborn. Iron is critical to brain growth and development; iron deficiency is a known cause of cognitive and social-emotional deficits in infants, which may be permanent. As breast milk alone may not supply a baby with all the iron he or she needs, it’s that additional iron that makes delayed cord clamping (DCC) so important. 

A brief history of cord clamping

Until the relatively recent past, the umbilical cord was generally allowed to stop pulsating before it was cut and tied off. Aristotle and Hippocrates, among many other medical and science writers, wrote approvingly of the practice. The first mention of early cord clamping (ECC)—cutting the cord before pulsation has ceased—is found in the 1600s, when management of the third stage of labor changed with the rise of male midwives, flat-on-the-back birthing practices, and forceps. 

Though ECC gained in popularity, controversy dogged the practice from the beginning. To give just one example, the prominent British physician Erasmus Darwin (Charles’s grandfather) condemned the practice, declaring in 1801 that early cord clamping was “a very injurious thing” that left babies “much weaker than [they] ought to be.” 

Despite ongoing objections, ECC became the obstetrical standard of care in the mid-1960s, promoted primarily as a tool to prevent maternal postpartum hemorrhage (PPH). Though subsequent research has shown that ECC is of no benefit in postpartum hemorrhage (PPH) prevention, the practice remains a firmly entrenched part of obstetrical care in the U.S. 

What did the 2013 Cochrane review find?

The review found that DCC babies had significantly higher body iron stores than ECC babies, an increase that persisted for months.

What didn’t the Cochrane review find?

Maternal adverse outcomes: The review found no significant ECC-versus-DCC differences in any maternal outcomes, including postpartum hemorrhage, length of the third stage of labor, need for blood transfusion, and need for manual removal of the placenta.

Neonatal adverse outcomes: Similarly, with the single exception of a slight increase in the need for phototherapy to treat hyperbilirubinemia (discussed below), there were no significant differences between ECC and DCC babies in neonatal outcomes such as mortality, Apgar scores < 7 at five minutes, need for resuscitation, NICU admission, respiratory distress, polycythemia, and clinical jaundice.

The apparent association between DCC and an increased need for phototherapy is a bit controversial. As pointed out by Dr. Judith Mercer, an expert on the benefits of delayed clamping, this concern is based largely on a single unpublished 1996 study performed by one of the Cochrane review’s authors (McDonald).  McDonald’s study is one of only two of the nearly forty studies considered for inclusion in the current review that includes unpublished data; when that data is removed, the difference between groups loses significance.   

Of note, the two studies added since the 2009 review found no association between delayed clamping and hyperbilirubinemia requiring phototherapy (Al-Tawil 2012, Andersson 2011). It should also be pointed out that none of the babies in these studies was harmed by hyperbilirubinemia. All recovered completely; there were no cases of kernicterus—brain damage caused by severe neonatal jaundice.

Whatever the case regarding delayed clamping and phototherapy, there’s no doubt that iron deficiency in infancy can lead to permanent cognitive and social-emotional deficits. The global benefits of increased iron stores during a critical period of brain development would seem to outweigh that concern.

The bottom line

For healthy term babies, a delay of 1-3 minutes before cord clamping has been shown to increase neonatal iron stores at a critical period of brain development, with virtually no risk of harm to mother and baby. Conversely, there is no convincing argument in support of clamping the umbilical cord before a minute of age.

Given that ECC has been shown to have no impact on maternal PPH, and that it offers no demonstrable benefit to healthy term newborns (and may in fact be harmful, by reducing body iron stores during a critical period of brain development), the question isn’t “Why switch to delayed cord clamping?” It’s this: “Why continue to intervene?”

Will obstetric practice change? Not immediately, if the recent Huffington Post comments of Dr. Jeffrey Ecker, ACOG chair of obstetric practice, are any indication: 

“Over time, I believe we’ll see an evolution in practice with appropriate women and babies — babies that don’t otherwise need immediate attention,” Ecker said. “I don’t think it is all going to change in a year. But in five, 10 years, we’ll look back and say, ‘Boy, this is different.'”

The best way to speed up that process is for pregnant women and providers of maternity care services to press their local hospitals for change now.


Al-Tawil, M. M., Abdel-Aal, M. R., & Kaddah, M. A. (2012). A randomized controlled trial on delayed cord clamping and iron status at 3–5 months in term neonates held at the level of maternal pelvis. Journal of Neonatal-Perinatal Medicine5(4), 319-326.

Andersson, O., Hellström-Westas, L., Andersson, D., & Domellöf, M. (2011). Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. BMJ: British Medical Journal343.

California WIC Association and the UC Davis Human Lactation Center. (2012) Maternity Care Matters; Overcoming Barriers to Breastfeeding. A Policy Update on California Breastfeeding and Hospital Performance. Retrieved from http://calwic.org/storage/restricted/hospitalreport/Maternity%20Care%20Matters_2012.pdf

McDonald, S. J., Middleton, P., Dowswell, T., & Morris, P. S. (2013). Effect of timing of umbilical cord clamping of term infants on mother and baby outcomes. Health.

Pearson, Catherine. “Cord Clamping: How Delaying Helps Babies.” The Huffington Post. TheHuffingtonPost.com, 11 July 2013. Web. 24 July 2013.

About Mark Sloan, MD

Mark Sloan has been a pediatrician and a Fellow of the American Academy of Pediatrics for more than 25 years. Since 1982, he has practiced with the Permanente Medical Group in Sacramento and Santa Rosa, California, where he was Chief of Pediatrics from 1997 to 2002. He is an Assistant Clinical Professor in the Department of Community and Family Medicine at the University of California, San Francisco. Dr. Sloan’s first book, Birth Day: A Pediatrician Explores the Science, the History and the Wonder of Childbirth was published in 2009 by Ballantine BooksHis writing has appeared in the Chicago Tribune, the San Francisco Chronicle, the San Francisco Examiner, and Notre Dame Magazine, among other publications.  Dr. Sloan can be reached through his blog.


Babies, Childbirth Education, Delayed Cord Clamping, Do No Harm, Evidence Based Medicine, Guest Posts, informed Consent, Medical Interventions, New Research, Newborns, Practice Guidelines, Research, Third Stage , , , , , , , , ,

Common Objections to Delayed Cord Clamping – What’s The Evidence Say?

November 13th, 2012 by avatar

by Mark Sloan M.D.

Today’s guest post is written by Dr. Mark Sloan, pediatrician and author of Birth Day: A Pediatrician Explores the Science, the History and the Wonder of Childbirth.  Dr. Sloan shares information and current research on delayed cord clamping after birth, in a helpful Q&A style format that consumers and professionals can use to discuss this important topic.


photo credit pattiramos.com

Many maternity care providers continue to clamp the umbilical cord immediately after an uncomplicated vaginal birth, even though the significant neonatal benefits of delayed cord clamping (usually defined as 2 to 3 minutes after birth) are now well known.

In some cases this continued practice is due to a misunderstanding of placental physiology in the first few minutes after birth. In others, human nature plays a role: We are often reluctant to change the way we were taught to do things, even in the face of clear evidence that contradicts that teaching.

Though there is no strong scientific support for immediate cord clamping (ICC), entrenched medical habits can be glacially slow in changing. Here are some often-heard objections to delayed cord clamping (DCC), and how an advocate for delayed clamping might respond to them:

1) I have a very busy practice. DCC takes too much time!

Not really, especially when you consider the benefits. Nearly one-third of a baby’s total blood volume resides in the placenta at birth. Half of that blood is transfused into the baby by 1 minute of age. By 3 minutes, more than 90% of the transfusion is complete. (1)

 2) Immediate clamping helps prevent severe postpartum hemorrhage.

There is no convincing evidence to support this view. Several large studies, including a 2009 Cochrane review of 5 trials involving more than 2,200 women, have found no significant difference between ICC and DCC in terms of postpartum hemorrhage or severe postpartum hemorrhage. (2-6, 10)

 3) A healthy, term baby doesn’t get much benefit from delayed clamping.

Though this is a commonly held belief, it’s definitely untrue.

Whether a fetus is premature or full term, approximately one-third of its total blood volume resides in the placenta. This is equal to the volume of blood that will be needed to fully perfuse the fetal lungs, liver, and kidneys at birth.

In addition to the benefits that come with adequate iron stores (see below), babies whose cords are clamped at 2 to 3 minutes—and thus, who have an increased total blood volume compared with their immediately-clamped peers—have a smoother cardiopulmonary transition at birth.

A third benefit: stem cells, which play an essential role in the development of the immune, respiratory, cardiovascular, and central nervous systems, among many other functions. The concentration of stem cells in fetal blood is higher than at any other time of life. ICC leaves nearly one-third of these critical cells in the placenta. (1,3,4,6-10)

Unclamped cord over the course of 15 minutes.
photo nurturingheartsbirthservices.com

 4) Okay, so delayed clamping means a baby gets more blood and more iron. But iron deficiency isn’t really a problem in first-world countries, right?

Wrong. At least 10% of the general U.S. toddler population (1-3 years of age) is iron deficient, with the prevalence rising well above 20% in selected ethnic and socioeconomic populations.

Immediate cord clamping is only one of many factors that contribute to iron deficiency in early childhood. But babies who start out life low on iron have a very difficult time catching up. Delayed cord clamping provides a baby with as much as a 4- to 6-month supply of iron. (1,3,6-10)

 5) Doesn’t iron deficiency just make kids tired?

Iron deficiency does much more damage than that. Early infancy is a time of rapid brain growth and development, and iron is essential to that process. Studies of infants with iron deficiency have found specific deficits in cognitive processing (including attention and memory) which may lead to permanently decreased intellectual functioning. Making matters even worse, children with severe iron deficiency often exhibit “emotional dulling”—difficulty engaging with caretakers and their environment—which can lead to long-lasting social-emotional deficits. For many reasons, early infancy is a particularly bad time to be low on iron. (1,11)

 6) Don’t babies get plenty of iron from breast milk? 

Unfortunately, no. While breast milk contains a remarkable array of healthful components, a high concentration of iron isn’t one of them. This most likely has to do with maternal recovery from childbirth. A recuperating mother has her own urgent iron needs; replacing the blood typically lost in childbirth takes a lot of it. Nature intends babies to get most of the iron they’ll need for their early development from the placental blood reservoir, rather than from mother, and so comparatively little iron goes into breast milk.  (3,7)

 7) But the baby can lose significant blood volume back into the placenta (aka “backflow bleeding”) if clamping is delayed.

This is extremely unlikely in an uncomplicated birth. With some brief exceptions (e.g., between uterine contractions, or when a baby bears down during crying), blood flow immediately after birth is primarily one-way, from placenta to baby. Here’s a brief explanation of why this is true:

In a process that begins during labor and accelerates as the newborn begins to cry, the pulmonary blood vessels, which receive very little blood flow during pregnancy, open and fill. This relatively sudden change causes the newborn’s blood pressure to fall below the pressure in the placenta. Placental blood, driven by strong uterine contractions, follows the pressure gradient and flows through the umbilical vein into the baby.

As the newborn’s oxygen saturation increases, the umbilical arteries close, which stops nearly all blood flow from baby to placenta. The umbilical vein, which isn’t sensitive to oxygen, remains open somewhat longer, allowing a final bit of blood to flow from placenta to baby before it, too, closes.

The lack of significant “backflow bleeding” is confirmed by the fact that DCC results in ~ 30% greater neonatal blood volume than does ICC.  (1,12)

8) DCC can lead to dangerously high levels of neonatal jaundice.

Since bilirubin, the source of neonatal jaundice, originates in red blood cells, it seems logical that the increased blood volume associated with delayed clamping could lead to severe hyperbilirubinemia.

Yet while some studies have demonstrated mildly increased bilirubin levels in DCC babies in the first few days postpartum, most have found no significant difference between DCC and ICC.

This seeming paradox—relatively stable bilirubin levels in the face of substantially increased blood volume—may have to do with increased blood flow to the neonatal liver that comes with the higher total blood volume associated with DCC. Yes, more blood means more bilirubin, which in turn could mean more jaundice, but better blood flow allows the liver to process bilirubin more efficiently.  (3,4,6,7,9,10)

 9) Delayed clamping can lead to neonatal hyperviscocity—“thick blood” that can cause kidney damage and strokes.

DCC can lead to a somewhat higher neonatal hematocrit than ICC, which isn’t surprising given the additional blood volume. Yet, despite fears of thicker blood “sludging” in organs like the brain and kidneys, no studies have demonstrated this to be the case from DCC alone. (4,6,9,10)

 10) You can’t have both the benefits of DCC and immediate skin-to-skin contact. If you place a newborn on his mother’s abdomen (i.e., above the level of the placenta), gravity will reduce the flow of blood from placenta to baby.

Gravity does matter, but mainly in terms of the speed of the placental transfusion. A baby held below the level of the placenta will receive a full transfusion in about 3 minutes; one held above the placenta (e.g., a baby in immediate skin-to-skin contact) will also receive a full transfusion—it just takes a little longer (about 5 minutes). (1,13)

 11) But what if the baby needs resuscitation? Isn’t it best to hand her over to the pediatrician immediately?

One of the first things a truly sick baby in the NICU is going to receive is fluid support—often as a 20 to 40 ml/kg bolus of normal saline or blood. Yet that is exactly what’s left behind in the placenta with ICC—about 30 ml/kg of whole blood. There is considerable evidence that sick babies, both term and preterm, have better outcomes with DCC. It’s better to let nature do its own transfusing. (14-16)


Delayed cord clamping promotes a healthy neonatal cardiopulmonary transition, prevents iron deficiency at a critical time in brain development, provides the newborn with a rich supply of stem cells, and helps sick neonates achieve better outcomes—all with little apparent risk to mother or baby. The evidence of benefit from DCC is so compelling that the burden of proof must now lie with those who wish to continue the practice of immediate clamping, rather than with those who prefer—as nature intended—to wait.

What do you tell your patients, students and clients about delayed cord clamping?  Do you have a favorite resource or two that you like to share?  What are the community standards around delayed cord clamping in your community?  Are health care providers discussing this with their patients?  Do they have recommendations one way or another that you are hearing?  Please join in the discussion.- SM


1) Mercer JS, Erickson-Owens DA. Rethinking placental transfusion and cord clamping issues. Journal of Perinatal & Neonatal Nursing. July/September 2012 26:3; 202–217 doi: 10.1097/JPN.0b013e31825d2d9a

2) Andersson O, Hellstrom-Westas L, Andersson D, et al. Effects of delayed compared with early umbilical cord clamping on maternal postpartum hemorrhage and cord blood gas sampling: a randomized trial. Acta Obstetricia et Gynecologica Scandinavica. Article first published online: 17 Oct, 2012. DOI: 10.1111/j.1600-0412.2012.01530.x

3) Chaparro, CM. Timing of umbilical cord clamping: effect on iron endowment of the newborn and later iron status. Nutrition Reviews. Volume 69, Issue Supplement s1, pages S30–S36, November 2011.

4) Ceriani Cernadas JM, Carroli G, Pellegrini L, et.al. The Effect of Timing of Cord Clamping on Neonatal Venous Hematocrit Values and Clinical Outcome at Term: A Randomized, Controlled Trial. Pediatrics. Vol. 117 No. 4 April 1, 2006 pp. e779 -e786 (2,3 8,9(doi: 10.1542/peds.2005-1156). Published online March 27, 2006.

5) WHO. Department of Making Pregnancy Safer. WHO recommendations for the prevention of postpartum haemorrhage. Geneva: World Health Organization, 2007.

6) McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD004074. DOI:10.1002/14651858.CD004074.pub2.

7) Andersson O, Hellstrom-Westas L, Andersson D, Domellof M. Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. British Medical Journal. 2011; 343: d7157. Published online 2011 November 15. doi:  10.1136/bmj.d7157

8) Ceriani Cernadas JM, Carroli G, Pellegrini L, et.al. The effect of early and delayed umbilical cord clamping on ferritin levels in term infants at six months of life: a randomized, control trial. Arch Argent Pediatr. 2010; 108:201-208.

9) Hutton EK, Hassan ES. Late vs early clamping of the umbilical cord in full-term neonates: systematic review and meta-analysis of controlled trials. JAMA. 2007 Mar 21;297(11):1241-52.

10) McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD004074. DOI:10.1002/14651858.CD004074.pub2.

11) Carter RC, Jacobson JL, Burden MJ, et al. Iron deficiency anemia and cognitive function in infancy. Pediatrics. 2010; 126:2 pp e427-e434 (doi: 10.1542/peds.2009-2097).

12) Mercer JS, Skovgaard R. Neonatal Transitional Physiology: A New Paradigm. J Perinat Neonat Nursing 2002; 15(4) 56-75

13) Yao AC, Lind J. Effect of gravity on placental transfusion. Lancet. 1969; 2:505-508.

14) Mercer JS, Vohr BR, Erickson-Owens DA, et al. Seven-month developmental outcomes of very low-birth-weight infants enrolled in a randomized controlled trial of delayed versus immediate cord clamping. J Perinatol. 2010; 30:11-16.

15) Kinmond S, Aitchison TC, Holland BM, et al. Umbilical cord clamping and preterm infants: a randomized trial. British Medical Journal. 1993; 306:172-175.

16) Rabe H, Wacker, A, Hulskamp G, et al. A randomized controlled trial of delayed cord-clamping in very low-birth-weight preterm infants Eur J Pediatr. 2000; 159:775-777.

About Mark Sloan, M.D.

Mark Sloan has been a pediatrician and a Fellow of the American Academy of Pediatrics for more than 25 years. Since 1982, he has practiced with the Permanente Medical Group in Sacramento and Santa Rosa, California, where he was Chief of Pediatrics from 1997 to 2002. He is an Assistant Clinical Professor in the Department of Community and Family Medicine at the University of California, San Francisco. Dr. Sloan’s first book, Birth Day: A Pediatrician Explores the Science, the History and the Wonder of Childbirth was published in 2009 by Ballantine BooksHis writing has appeared in the Chicago Tribune, the San Francisco Chronicle, the San Francisco Examiner, and Notre Dame Magazine, among other publications.  Dr. Sloan can be reached through his blog.


American Academy of Pediatrics, Delayed Cord Clamping, Do No Harm, Evidence Based Medicine, Healthy Birth Practices, Healthy Care Practices, informed Consent, Medical Interventions, Newborns, Research, Third Stage, Uncategorized , , , , , , , , , ,

“Should We Private Bank Our Baby’s Cord Blood?” Information That Can Help You Answer That Question

September 21st, 2012 by avatar


I was recently asked my thoughts on private cord blood banking by a couple expecting their first child.  This was something that they were considering and wanted to know what information was out there.  I had read various articles and commentaries on private cord blood banking in recent years, but I viewed this as an opportunity to refresh my knowledge before I provided an answer to them.  I wanted to share this information with Science & Sensibility readers, so that you may use it with your classes, clients and patients as well, if you wish.

Kimmelin Hull wrote a very comprehensive post on Science and Sensibility in April, 2011, discussing “Should we, or should we not retrieve Umbilical Cord blood at all?” along with providing information on delayed cord clamping current research, and referring readers to a fantastic Journal of Perinatal Education article, Umbilical Cord Blood: Information for Childbirth Educators, written by Renece Waller-Wise, MSN, CNS, CLC, CNL, LCCE.  Kimmelin Hull’s post and Renece Waller-Wise’s JPE article were great places for me to start my exploration to be able to answer this couple.

Today’s post is not about the benefits and/or risks of delayed cord clamping.  Information on that topic has been provided previously on this site.  What I was really looking for was more information on the likelihood that private banked cord blood might be used for that child or other relatives in the future.

Research indicates that pregnant women frequently do not have adequate information to make an informed decision about cord blood banking. (Fox, et al, 2007).   Additionally, the information sources for childbirth birth educators are frequently the private blood banks or their designated representatives, adding in the potential for bias. (Cord Blood Registry, 2009; Wolf, 1998, 1999) Interestingly, in the state of Washington, where I live, the state requires practitioners to provide information on cord blood donation and banking. (but not on delayed clamping.)

Revised Code of Washington (RCW) 70.54.220  All persons licensed or certified by the state of Washington to provide prenatal care or to practice medicine shall provide information to all pregnant women in their care regarding:

(1) The use and availability of prenatal tests; and

(2) Using objective and standardized information: (a) The differences between and potential benefits and risks involved in public and private cord blood banking that is sufficient to allow a pregnant woman to make an informed decision before her third trimester of pregnancy on whether to participate in a private or public cord blood banking program; and (b) the opportunity to donate, to a public cord blood bank, blood and tissue extracted from the placenta and umbilical cord following delivery of a newborn child.

Nationwide, 26 states have legislation on providing cord blood information. This legislation is intended to guide health care providers and inform parents about their options concerning donation and banking.  You can access this information on a state by state basis here. In Washington, exactly what information should be provided is not spelled out.

Stem cells are available from a variety of sources, but umbilical cord stem cells are the easiest to collect, collection is painless, and according to studies can be done before or after the placenta is delivered. (Gonzalez-Ryan, VanSyckle, Coyne, & Glover, 2000; Percer, 2009). The stem cells are quickly available to be used. But, according to one study, approximately 50% of all cord blood collection samples contain an insufficient volume of blood.  (Drew, 2005).

Private cord blood banking is often marketed as “biological insurance” for potential problems with that child in the future. “Autologous transplant” is where the cord blood is given back to the child it was taken from.  The chance that a child will need its own cord blood is extremely small; a 1:400 to a 1:200,000 chance over the child’s lifetime (Sullivan, 2008). In the case of some illnesses, it would be unwise to transfer the same cord blood cells as they are considered “contaminated” with the very disease that is hoping to be cured.

There is not a lot of research on the period of time that a collected cord blood sample would be viable after storage, and no research on viability over the course of the average human lifespan.

Private cord blood banking is not without significant expense and cost.  Collection and initial processing can run approximately $3000, and then there is an annual fee that can run several hundred dollars for storage each year after that.

Private cord banking services are not regulated, either on the federal level or by the state, so without oversight, regulations and a quality assurance program managed by a third party, consumers may find themselves dealing with programs that could not be financially viable over the long term or may not be handling or storing stem cell products appropriately.

What do various organizations say about private cord blood banking?

 American Congress of Obstetricians and Gynecologists (ACOG)

ACOG has a statement on Umbilical Cord Blood Banking and in their recommendations and conclusions they state:

  • If a patient requests information on umbilical cord banking, balanced and accurate information regarding the advantages and disadvantages of public versus private umbilical cord blood banking should be provided. The remote chance of an autologous unit being used for a child or a family member (approximately 1 in 2,700 individuals) should be disclosed.
  • Discussion may include information regarding maternal infectious disease and genetic testing, the ultimate outcome of use of poor quality units of umbilical cord blood, and a disclosure that demographic data will be maintained on the patient.
  • Some states have passed legislation requiring physicians to inform their patients about umbilical cord blood banking options. Clinicians should consult their state medical associations for more information regarding state laws.
  • Directed donation of umbilical cord blood should be considered when there is a specific diagnosis of a disease known to be treatable by hematopoietic transplant for an immediate family member.
  • Obstetric providers are not obligated to obtain consent for private umbilical cord blood banking.
  • The collection should not alter routine practice for the timing of umbilical cord clamping.
  • Physicians or other professionals who recruit pregnant women and their families for for-profit umbilical cord blood banking should disclose any financial interests or other potential conflicts of interest.

American Academy of Pediatrics

The American Academy of Pediatrics also has a policy statement out on cord blood banking.  Their recommendations are similiar to ACOG.

  • Cord blood donation should be discouraged when cord blood stored in a bank is to be directed for later personal or family use, because most conditions that might be helped by cord blood stem cells already exist in the infant’s cord blood (ie, premalignant changes in stem cells). Physicians should be aware of the unsubstantiated claims of private cord blood banks made to future parents that promise to insure infants or family members against serious illnesses in the future by use of the stem cells contained in cord blood. Although not standard of care, directed cord blood banking should be encouraged when there is knowledge of a full sibling in the family with a medical condition (malignant or genetic) that could potentially benefit from cord blood transplantation.
  • Cord blood donation should be encouraged when the cord blood is stored in a bank for public use. Parents should recognize that genetic (eg, chromosomal abnormalities) and infectious disease testing is performed on the cord blood and that if abnormalities are identified, they will be notified. Parents should also be informed that the cord blood banked in a public program may not be accessible for future private use.
  • Because there are no scientific data at the present time to support autologous cord blood banking and given the difficulty of making an accurate estimate of the need for autologous transplantation and the ready availability of allogeneic transplantation, private storage of cord blood as “biological insurance” should be discouraged. Cord blood banks should comply with national accreditation standards developed by the Foundation for the Accreditation of Cellular Therapy (FACT), the US Food and Drug Administration (FDA), the Federal Trade Commission, and similar state agencies.
Online Resources on Cord Blood Banking to Share with FamiliesParents Guide to Cord Blood Foundation

American College of Nurse–Midwives—“Cord Blood Banking—What It’s All About” (from 2008 Journal of Midwifery & Women’s Health53[2], 161–162)

National Marrow Donor Program—“Cord Blood Donation: Frequently Asked Questions”

compiled by Renece Waller-Wise

I will provide this information to the family who asked me.  I will encourage them to talk to their doctor or midwife, and determine if it is appropriate for them to consult with a genetic counselor, to address family history and other information that may make it more likely for this child or another family member to need collected cord blood.

I would also provide information on the timing of umbilical cord clamping and suggest they discuss with knowledgable providers and the potential bank, the likelihood of an adequate collection when cord clamping is delayed.

After receiving this information from a variety of sources, I trust the parents will be able to make a decision that feels appropriate to them and I will feel that I have provided evidenced based sources that they found useful in their decision-making process.

How do you answer the question “Should we private bank our baby’s cord blood?” What do you say?  What have been your favorite resources on this topic?  Please share information that you feel we can all benefit from.  I welcome your discussion.


American Academy of Pediatrics:Policy Statement: Cord blood banking for potential future transplantation.  PEDIATRICS Vol. 119 No. 1 January 1, 2007 pp. 165 -170 (doi: 10.1542/peds.2006-2901)

American Congress of Obstetricians and Gynecologists. (2008) Umbilical Cord Blood Banking. ACOG Committee Opinion No. 399. Obstet Gynecol 2008;111:475–7.

Cord Blood Registry. (2009). Cord blood spotlight: Childbirth educator’s guide, 1(2), 1–4.

Drew, D. (2005). Umbilical cord blood banking: A rich source of stem cells for transplant. Advance for Nurse Practitioners, 13(Suppl. 4), S2–S7.

Fox, N. S., Stevens, C., Cuibotariu, R., Rubinstein, P., McCullough, L. B., & Chervenak, F. A. (2007). Umbilical cord blood collection: Do patients really understand? Journal of Perinatal Medicine, 35, 314–321.

Gonzalez-Ryan, L., VanSyckle, K., Coyne, K. D., & Glover, N. (2000). Umbilical cord blood banking: Procedural and ethical concerns for this new birth option. Pediatric Nursing, 26(1), 105–110.

Percer, B. (2009). Umbilical cord blood banking: Helping parents make informed choices. Nursing for Women’s Health, 13(3), 216–223

Sullivan, M. J. (2008). Banking on cord blood stem cells. Nature Reviews Cancer, 8, 554–563

Waller-Wise, Renece. (2011) Umbilical cord blood: information for childbirth educators. Journal of Perinatal Education, 20(1), 54–60, doi: 10.1891/1058-1243.20.1.54

Washington State Legislature, Revised Code of Washington 70.54.220 Practitioners to provide information on prenatal testing and cord blood banking. http://apps.leg.wa.gov/rcw/default.aspx?cite=70.54.220  Accessed September 21, 2012.

Wolf, S. (1998). Cord blood banking: A promising new technology. Neonatal Network, 17(4), 5–6.Wolf, S. (1999). Storing lifeblood: Cord blood stem cell banking. American Journal of Nursing, 99(8), 60–68.


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On Birth and Bleeding – Part 2

February 21st, 2012 by avatar

A Guest post by Lucy Juedes LCCE

Third Stage Components for Discussing with Caregivers

It will be important for the caregiver to share his/her perspectives and usual care of the third stage with expectant parents, as well as what the parent might expect from colleagues and the policies of the birth site.  This helps the mothers/parents to better understand the suggested practices.  Perhaps the caregiver might be strongly leaning towards an active approach to placenta delivery even if the mom wants a more expectant approach.  The mom does not have to agree with the caregiver’s reasoning, but she will understand more as she advocates for what she feels is best for herself and her baby.

So, in an effort to help parents understand the third stage, here are the possible components of third stage management.  Moms and birth partners can use these components to ask about specifics, particularly if the caregiver uses the general terms of “active” or “expectant management” of the third stage of labor.  Here are some specifics to assist in asking your questions.

Oxytocin:  In hospitals in theUS, oxytocin (via IV drip or intramuscular shot) is generally administered after the placenta is expelled.  Ergotamines and prostaglandins are often second- and third-tier uterotonic choices, based on the need and characteristics of the situation.  If a mom is planning a homebirth, ask if the midwife has these medications for emergencies or as back-up.  A uterotonic could also be used proactively to decrease the amount of bleeding, as described earlier in current research.  If the mom does not use a uterotonic, the caregiver and mother will have to be more vigilant so that her uterus does not get soft and she bleeds.

Breastfeeding & skin to-skin contact:  Immediate, baby-led breastfeeding has already been shown to be the best care practice in terms of infant feeding.  The physiological approach allows the mom more undivided attention to get to know her baby and begin observing for feeding cues.  It is also very helpful in terms of placental expulsion and uterine contraction.  If the baby is not breastfeeding, manual or oral nipple stimulation can help bring about oxytocin and contractions, helping to get the uterus back down to size from a more physiological perspective.

Cord clamping:  There is evidence, and the WHO recommends, to wait until the umbilical cord stops pulsing before it is clamped and cut.  This usually means waiting 3 – 5 minutes (WHO recommends 2 – 3 minutes), after which time the partner can tell that the cord has stopped pulsing and slackens.  In these first few minutes, the baby receives the last 20% or more of his or her blood volume, which helps with iron levels.  There might be an increased chance for jaundice later, which can be treated by taking the baby outside in the sun, without sunscreen on, or taking the baby to the hospital for exposure to phototherapy.

Controlled cord traction and counter traction:  When this is done, it must be done carefully, and the caregiver should never pull on the cord without pushing the uterus up with the other hand.  The mom could also bear down during this process, or might practice her focusing and relaxation strategies for these last few contractions.  The caregiver will examine the placenta to make sure all of it and its membrane has been expelled.  This is a more active approach.

Uterine massage:  This is done after the placenta is out.  The caregiver or the mom rubs or kneads the mother’s abdomen until the uterus hardens, then the massage is ended.  This massage is done regardless of approach and is a part of good postpartum care.  The uterus must become and remain smaller and hard so that the blood vessels close to the appropriate degree.  Afterpains are associated with placenta expulsion and uterine shrinking, particularly with experienced mothers.  The mom might prefer to do this massage herself and can ask the caregiver to show her how.

The above information has been combined from a variety of sources:  ACOG, Armbruster, Burke, Gaskin, Goer, ICM/FIGO, Lothan & DeVries, Simkin et al., Walsh, and WHO.

Additional Thoughts – Risk Factors?  Too Much Bleeding? 

Risk Factors

One of the most important things for parents to know is that there are risk factors for a postpartum hemorrhage.  Some of these risk factors are associated with the interventions used and the outcomes of stages one and two of labor.  In class, when we discuss third stage management, we can refer back to interventions that increase the likelihood of postpartum bleeding:  inducing or augmenting contractions with oxytocin, prolonged induction, episiotomy, forceps/vacuum, and cesarean surgery.  (Goer)

Other pregnancy, labor, maternal, or fetal characteristics are associated with increased bleeding as well:  rapid labor, use of magnesium sulfate, previous postpartum hemorrhage, preeclampsia, intra-amniotic infection, overdistended uterus (twins, macrosomia, hydramnios), Asian or Hispanic ethnicity, and chorioamniotis.  (ACOG; Burke)  Many of these risk factors the mother can do nothing to change.  Others, she might have some ability to influence – this knowledge might help her focus even more on strategies to keep labor physiological from the start.

Begley et al. shared something to be noted. “Anecdotally, midwives experienced in expectant management say that only women who have had a normal, physiological labor should have expectant management of the third stage.”  (25)  The natural oxytocin levels of these women will be high throughout, and these high levels would help with uterine contraction in the third stage.  The moms can weigh the risks of any blood loss, possible transfusions, and additional uterotonics.

Conversely, it could be that the most appropriate candidates for active management of the third stage are those who have already experienced active management of the earlier stages of labor.  The Prendiville study was the only study that included both women who seemed to receive a more expectant care in the first two stages of labor and those who received a more active approach.  Some of these actively managed first/second stage mothers were induced with pitocin, had epidurals, had a previous postpartum hemorrhage, etc.  All of these mothers were randomly assigned to active versus expectant care groups for the third stage of labor.  However, after five months the protocol was modified due to higher than expected blood loss by the expectantly managed group.  Some of these women needed at least some active management and were switched to fully active management.  Then, the trial was halted early because of potential harm due to too much blood loss in the expectant arm:  the sample size was meant to be 3,900 and the researchers stopped after 1,695 participants.  In the hospital where women with a variety of risk were served, there was a significant difference of more third stage blood loss in expectantly managed mothers as compared to those actively managed.

Lastly, regarding risk, the above factors are ones that we are aware of.  However, most of the time a postpartum hemorrhage cannot be predicted — some analysts suggest up to 90% of the time.  Hence, public health experts prefer a focus on prevention among a wide range of women.  (POPPHI/USAID)

And for all moms, how much blood is too much blood to lose?

Our body has built up a large store of blood during pregnancy, called by some a vascular reserve.  It is physiologically necessary for us to expel some of it during the time period from right birth into the next few weeks.  If the mother loses around 500 mL, she is likely to feel similarly to how she might feel when giving blood, and will need to sit or lie down, eat, and rest.  If a mother has one or more of the risk factors shared above, though, she might lose closer to between 1,000 – 2,499 mL of blood at birth.  Many experts use a threshold of 1,000 mL for healthy women in affluent societies, noting that they can tolerate blood loss of around 1,000 mL without decompensating.  (Walsh)  Goer shares that, According to William’s Obstetrics, the obstetric bible, healthy postpartum women don’t begin to show actual symptoms of excessive blood loss until they have lost around 1500mL.”

Another factor is that a mother might have other responsibilities in addition to caring for her newborn.  Is this her first child or does she have others at home?  Is she caring for an older adult?  Is she married, engaged, dating, or single?  Will she be going back or seeking paid work and if so, is that sooner or later?  Breastfeeding also requires a lot of physiological resources from the mother.  It is important to help expectant mothers and their birth partners situate their ideal birth into their daily lives.  All of these considerations can help mothers be more prepared both for birth and for life with their newborn.

Active Management and Lamaze’s 6 Healthy Birth Practices


Lamaze’s Healthy Birth Practice 4 is “Avoid interventions that are not medically necessary”.  It will be important to know both non-labor risk factors and take into account how the labor and delivery of the baby was managed.  If there was moderate to high intervention in the birth of the baby or if there are other risk factors present, she is more likely to bleed more.  If this is a concern for her, active management techniques are likely to help lessen any bleeding.  If there was no to low intervention in the birth of the baby and there are no other risk factors present, the mom and baby may benefit more from an expectant approach to expelling the placenta.  In all of this the mother is the person to consent to or refuse any interventions.


Lamaze’s Healthy Birth Practice 6 is “Keep mother and baby together – It’s best for mother, baby and breastfeeding”.  Here, according to the research, the benefits of the active approach is a decrease in bleeding; with some mothers severe bleeding is prevented.  Less bleeding means more energy that the mom can devote to recuperating and breastfeeding.  And according to one study there was no difference between the two approaches in breastfeeding rates upon leaving the hospital.  The benefits of the expectant approach is less disturbance and distraction of the mother from her baby in that key time right after birth, as well as increased natural oxytocin that helps with bonding.

Three Bigger Picture Thoughts

For mothers planning birth center births or homebirths in the US, in accord with the ICM/FIGO joint statement, they, too, should be offered active management of the third stage of labor.  The key word here is offered.  This is not regimented, but it is also not to be overlooked.  It also means that the homebirth or birth center caregiver should be able to purchase, store, carry, and administer uterotonics as part of their standards of practice.

I began this topic with the stated goal of preventing postpartum hemorrhage.  It seems clear that, from a public health/greater good perspective, data supports the standard offering of active management to prevent excessive bleeding in situations when the mom’s labor has already been managed using an active approach or where there are other known risk factors.  It also is somewhat supportive of the offering of active management of the third stage of labor even when there are no risk factors present.

However, if the overall goal is preventing postpartum hemorrhage, then the leaders who set hospital policies could also reconsider the use of several other practices that are known risk factors of increasing postpartum hemorrhage.  One such practice is induction rather than waiting the 42 weeks.  Recent efforts to limit births to at least the 39 week mark has probably helped.  Another practice is a focus on providing pain medication and continuous monitoring/IVs rather than encouraging doulas or providing continuous staffing who could provide natural comfort help.  Other routine practices at hospitals probably have an effect, such as routine use of continuous electronic monitoring, IV, and withholding of food.

Lastly, I am positive that evidence-based Lamaze Certified Childbirth Educators can be pretty helpful for many expectant moms and birth partners.  We have the time to answer questions, and to answer the questions behind the questions.  We understand the background behind specific practices.  We know the alternatives, and there is always an alternative.  We can help the moms and birth partners figure out what they want and how to make it most likely.  Though Lamaze childbirth classes, they are already getting used to parenthood, and the baby hasn’t even made it topside yet.



Lucy Juedes is an LCCE and created Birth Prep Basics, serving the needs of growing
families in Southeastern Ohio. She is also the mother of three young children.
Prior to this she worked in public relations and marketing.

Childbirth Education, Delayed Cord Clamping, Evidence Based Medicine, Guest Posts, Third Stage, Uncategorized , , , , , , , , , , , , , ,

On Birth and Bleeding – Part 1

February 20th, 2012 by avatar

A guest posting by Lucy Juedes LCCE

Active, Expectant, and Mixed Management for Placenta Delivery, Hospital Births

Postpartum hemorrhage is a major cause of maternal death worldwide.  International health experts are successfully using a specific combination of protocols, called active management of the third stage of labor, to lower the number of mothers dying in resource-poor countries.

Although not nearly on the scale of resource-poor countries, the US lags behind many other resource-rich countries in terms of maternal death.  Postpartum hemorrhage is also a major cause of maternal death in the US.  From 1991-1999, hemorrhage was at 17.2% of causes for maternal mortality, behind embolism (19.6%).  (Chang et al.)

Recent Science & Sensibility blogs have discussed other specifics of reducing maternal mortality in the US.  In this blog I will share information specifically about the use of the Active Management of the Third Stage of labor.  Specifically:

  • Definition of terms
  • November, 2011 Cochrane Collaboration Review, third stage management, resource-rich countries, hospital-based
  • Key points from this research
  • Third stage components for discussing with caregivers
  • Additional thoughts:  risk factors, too much bleeding?
  • Active management and Lamaze’s 6 Healthy Birth Practices
  • Three bigger picture thoughts

Defining Terms:  Third Stage of Labor, Expectant Management, Active Management, Postpartum Hemorrhage

There were key variations among my sources with regards to definitions of term.  So for the purposes of this article, here is how I’m defining the terms.

The third stage of labor is from right after the baby’s birth through when the placenta and membranes (sometimes called the “afterbirth”) are expelled.  After the baby is born there is a brief lull, then contractions resume.  While the mom’s uterus is contracting and the placenta is shrinking and being expelled, the mom and baby are getting to know each other by sight, sound, smell, touch, and taste.  (Simkin et al.)

There are generally two ways of approaching the management of the third stage of labor:  expectant management and active management.  These are the standard components but there can be marked variation among caregivers.

In expectant management, the baby is put on the mom’s belly for sustained skin-to-skin contact.  At the earliest, the cord is clamped only after pulsation has stopped.  Sometimes it is clamped later, after placenta delivery.  The caregiver observes the mom, checking for any excessive bleeding, and baby, checking for basic health.  However generally the caregiver tries to provide privacy so the mom and baby can get to know each other.   This focus on each other also increases the feelings of love and levels of oxytocin in the mom, which stimulate contractions.   The baby’s movements physically massage the mom’s abdomen, helping with contractions and maintaining warmth.  Breastfeeding or nipple stimulation also brings contractions.  After about 20 minutes, the cord might get longer and there will often be a gush of blood, indicating that the placenta has separated from the uterine wall.  The mom then sits up, kneels, or squats, using gravity and/or her own bearing down to bring out the placenta.  This process usually takes 30 minutes.  (Burke, Gaskin, Lothian & DeVries)

The active management of the third stage of labor is comprised of three parts.  It begins with the caregiver giving a uterotonic, either as an intromuscular shot or via IV, within one minute of the baby’s birth.  Next, after the cord has stopped pulsing and is clamped, the caregiver delivers the placenta by controlled cord traction.  This is generally within 5 – 30 minutes after the baby’s birth.  Lastly, the caregiver massages the uterus to ensure that it becomes firm.  During this process the caregiver also provides comfort and assurance to the mom, who is probably getting to know her baby.  As with expectant management, the baby has been put skin-to-skin on the mom’s chest.  Breastfeeding can also begin now, but the focus of the caregiver is expelling the placenta as soon as possible.  (Burke, Gaskin, Lothian & DeVries, ICM & FIGO, WHO)

It is important to note that uterine massage is an integral part of both expectant and active care.  After the placenta and membranes are out in-full, the caregiver feels the mother’s uterus, which needs to be hard.  If it is soft, the caregiver massages it until it is hard, and checks back every 15 minutes to make sure it remains hard.

It is helpful to remember here that we are talking about the routine use of one or the other type of third stage labor management.  At any point if the caregiver notices too much bleeding, she or he would change procedures.  We are not talking about the best ways to manage a hemorrhage, but the most effective practices to prevent a severe hemorrhage after the birth of the baby.

Postpartum hemorrhage refers to the bleeding that a mother experiences after giving birth.  The time window I am referring to is primary postpartum hemorrhage, which is within 24 hours after the baby’s birth.  Here are the standard levels:

  • 500 – 999 mL           Postpartum hemorrhage, vaginal birth
  • 1,000 – 2,499 mL     Severe postpartum hemorrhage
  • 2,500 + mL              Very severe postpartum hemorrhage

If the mother had cesarean surgery, postpartum hemorrhage is defined as beginning at 1,000 mL.  (Begley et al.)

Recent Review & Analysis from Resource-rich Countries, Hospital Based

There is no question that, in resource-poor countries, increased use of active management of the third stage of labor has prevented postpartum hemorrhaging and saved both mothers’ — and consequently babies’ — lives.  In 2004, the International Confederation of Midwives (ICM) and the International Federation of Gynaecologists and Obstetricians (FIGO) signed a joint statement agreeing that, “Active management of the third stage of labour should be offered to women since it reduces the incidence of postpartum haemorrhage due to uterine atony.” (ICM & FIGO)  Training all birthworkers in active management has been a major focus of global Safe Motherhood efforts to reduce maternal death and disability in resource-poor countries.   (Armbruster)

Research conducted in resource-rich countries has indicated similar results, although not on a similar scale to results seen in resource poor-countries.  A recent Cochrane Pregnancy and Childbirth Group Intervention Review was completed in November, 2011 on “Active versus expectant management for women in the third stage of labour”.  This protocol was first completed in 2008, and this is the most recent review.  (Begley et al.)

The analysts looked at seven trials, all in hospitals, in five countries (6 in high-income countries/UK, Ireland, Sweden, Abu-Dhabi; 1 in a low-income country/Tunisia), involving 8,247 women.  Four of these trials looked at active compared to expectant management (4,829 women).  Three trials looked at active versus a mix of active and expectant management components (3,418 women).  There were no maternal or fetal deaths reported, and no very severe postpartum hemorrhage (>2,500 mL).  Three trials included only women at low risk of bleeding; four included women irrespective of their risk of bleeding.  All the mothers were healthy and expected to give birth vaginally.

The authors looked at a range of variables.  They noted, however, that the following results are the more clinically important effects, so these are what will be examined here:

  • reduced average severe primary postpartum hemorrhage (1,000 – 2,499 mL within the first 24 hours of birth)
  • reduced average need for transfusions
  • reduced average need for uterotonic therapy during the third stage or within the first 24 hours

Active Compared to Expectant Management

Hospital studies that included expectant mothers who had a wide range of risk factors for bleeding.

The primary outcomes of this analysis were these:  (1) in resource-rich countries, (2) in hospitals, and (3) in situations where expectant mothers at mixed levels of risk for postpartum hemorrhage are served, active management:

  • reduced average severe primary postpartum hemorrhage (4,636 women, three studies);
  • reduced average maternal blood transfusions (4,829 women, four studies); and
  • reduced average therapeutic uterotonics (4,829 women, four studies).

In terms of reducing severe postpartum hemorrhage, this result was found in three studies totaling 4,636 women.  Two of these studies included only women with no risk factors whatsoever and are described below (Begley and Rogers).  One study (Prendiville, 1988, United Kingdom, 1,695 women) included mothers who had one or more risk factor:  who were of any age, had more than five children, had a prior postpartum hemorrhage, had an epidural, had a long labor, or who required an operative delivery.  The study only excluded mothers who had a larger medical issue or any condition needing a particular management of the third stage.

Hospital studies that included only women who were at low risk of bleeding

Compared with expectant management, low risk women who received active management showed a statistically significant average reduction in:

  • maternal blood transfusions (3 studies, 3,134 women) and
  • therapeutic uterotonics (3 studies, 3,134 women).

There was no statistical difference between the low-risk mothers whose third stage was actively or expectantly managed in terms of severe primary postpartum hemorrhage.

This research was done on three studies, totaling 3,134 mothers, and contained only low risk women:  one in Ireland (Begley, 1990, 1,429 births) and two in the United Kingdom (Rogers, 1998, 1,512 births and Thilaganathan, 1993, 193 births).  Women were risked out if they had any predisposition to hemorrhaging:  labor induced or augmented with oxytocin, had an epidural, had a first stage longer than 15 hours, had a previous postpartum hemorrhage, intended an instrumental birth, or had more than five children.  If the investigator felt there was any predisposition to bleeding or any other possible participation contraindication, the mother’s data was not included in the study.  Midwives were the professional in charge of the third stage for the Irish study, and waterbirths were a component of birth with the other, large UK study.

Active Compared to Mixed Management

Begley et al. also looked at active compared to mixed management.  Two studies, described below, show a significant reduction in one or two of the three characteristics of concern to clinicians.

Khan, 1997, looked at a final sample of 1,648 births in Abu-Dhabi, a resource-rich country.  Comparing active to mixed management, Begley et al. found a statistically significant reduction in:

  • severe primary postpartum hemorrhage and
  • therapeutic uterotonics.

There was no significant difference regarding blood transfusions.

This study included women at all risk levels.  Similar to the US, oxytocin was administered after the placenta was out.  Begley et al. were concerned with the adequacy of the midwifery training and the overall quality of the study due to uncertain sequence generation.

The second study that Begley et al. reviewed was by Jangsten, 2011, which followed 1,631 births at a university hospital in Sweden.

  • There was a significant reduction in therapeutic uterotonics.

There was no significant difference regarding:

  • severe primary postpartum hemorrhage or
  • blood transfusions

Midwives were responsible for third stage management.  Both high and low risk women were included.  The analysts considered this study to be of good quality.

Other notes from the analysis:

The trials included in this analysis met high standards.  Several other trials were not included in this review due to questions or issues with data quality.  However, when analyzed together the evidence was not high-quality.  The authors noted considerable differences in the specific protocols for active and expectant management used in the included trials.  The authors suggested that more data are necessary to be more confident of the findings.

The authors also noted that there were adverse effects or harms of the active management (when not practiced according to WHO/ICM/FIGO guidelines):  hypertension, afterpains, and return to the hospital due to bleeding.  Active management also resulted in lower birth-weight infants who had lower iron levels.  The authors suggested that these side effects might be reduced by modifications to the active care techniques, and that more research would help identify this.  Specifically, the high blood pressure and afterpains seemed to be related to the use of ergometrine and IV oxytocin.  Controlled cord traction might have led to retained pieces of membrane or placenta, requiring a return to the hospital due to bleeding.  Early cord clamping is related to a 20% or greater reduction of infant blood volume, as compared to the physiological approach of waiting until the cord has stopped pulsing.

Regarding the health of the babies from both women who were low risk and women at varying levels of risk for postpartum bleeding, there was no statistical difference between active and expectant management in the number of admissions to NICUs or in neonatal jaundice requiring phototherapy or exchange transfusions.

The Prendiville, 1988 study was the only study that looked at the effect of active versus expectant management on breastfeeding at discharge, and it found no statistical difference.  However, this study  involved women at a range of bleeding risks.  Even on the expectant side, 20% were considered to need a uterotonic prophylacticly and another 30% received it for actual treatment.  Because half of the mothers in the expectant arm received a uterotonic, perhaps there was not such a big difference between the two groups in terms of experience of birth and its effect on establishing breastfeeding.

The authors suggested that it would be important to investigate if the reduced bleeding due to active management were due to the uterotonic component alone, and if so, what would be the ideal timing.  An earlier analysis (Enkin, 2000) addressed this, which showed that routine use of an oxytoxic alone, without the other two components of active management, cuts the risk of postpartum hemorrhage by 50% and reduces the therapeutic use of oxytoxics by 70%.  New research accepted for publication in The Lancet found that, of the three parts of active management, the uterotonic plays the most important role in preventing postpartum hemorrhage.  (Armbruster)

Key Points from this Research

First, a note about choice of birth site.  The previously described research, which meets the highest standard possible, was done on hospital births.  When specifically asked about if they thought that the routine use on the active management of the third stage of labor should be applied to home births or midwifery-led birth centers, the lead author stated there were no trials at other sites that fit their criteria for inclusion so the authors could not provide evidence-based information for other settings.  The authors noted that there is other research available with pertinent information to home and birth center births, such as these studies:  

  • Bais, 2004, Holland, 3,464 women, descriptive study;
  • New Zealand College of Medicine, 2009, New Zealand, 33,752 women, population-based, retrospective cohort study; and
  • Begley, 2009, Ireland, 446 women, observational study.

One of the things that the Begley et al. research might encourage is that more hospitals use a more active approach to third stage management.  For example, a large tertiary hospital in Illinois recently adopted an active management protocol similar to the WHO guidelines.  This protocol resulted in a decrease in postpartum hemorrhage rates (from 4.52% in the 6 months prior to the protocols to 4.21% in the first 6 months after implementation, totaling 10,582 births) and a decreased use of additional uterotonics.  (Burke)

In situations where a specific protocol for a preventative measure is adopted, consent could become an issue.  Regarding the above hospital and of note to parents who prefer a less active approach to third stage management:  “Once the protocol was announced and clarified to all medical and nursing providers, it became the standard practice for management of the third stage of labor, and deviation from the protocol is not acceptable unless the woman is adamantly opposed to it and adequate counseling has occurred.”  (Burke, 222)  The question here is what does “adamantly opposed” mean in the above context?  Where does consent fit into this?

Parents who prefer an expectant approach to childbirth and who are planning to birth in a hospital that routinely uses a more active approach will need to understand even more about labor and delivery to more effectively advocate for themselves.  This has always been the case, but it might be more so if hospitals adopt routine active management of the third stage of labor.



Lucy Juedes is an LCCE and created Birth Prep Basics, serving the needs of growing
families in Southeastern Ohio. She is also the mother of three young children.
Prior to this she worked in public relations and marketing.

Delayed Cord Clamping, Evidence Based Medicine, Guest Posts, Healthy Birth Practices, Maternal Mortality, Research, Third Stage , , , , , , , , , , , , , ,

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