Known by midwives as the third stage maze, the third stage of labour is a critical time for the birthing mother and her baby, this article looks at the different ways the third stage of labour can be handled, the consequences of those actions and the crucial lack of informed choice offered to mothers in today’s society regarding this vital stage. We also look at the rising controversial issue of Cord Blood Banking.
As a mammalian species ~ defined by our mammary glands and the milk they produce for our young ~ we share almost all features of labour and birth with our fellow mammals, but of all species the human newborn baby is the most immature and incapable, completely dependent on its mother to meet all their basic but vital needs. The complex orchestration of labour hormones Oxytocin, Endorphines, Epinephrine and Norepinephrine and Prolactin are produced deep in our middle (mammalian) brain, which co-ordinates these processes and ultimately ensures the survival of mother and baby.
These hormones continue to play crucial roles for mother and baby during the third stage of labour, the time between birth of the baby and when the new mother births her baby’s placenta. This stage is often overlooked but is a critical time for mother and baby. For the new mother, the third stage is a time of reaping the rewards of her labour. Mother Nature provides peak levels of oxytocin, the hormone of love, and endorphins, hormones of pleasure, for both mother and baby. Skin~to~skin contact and the baby’s first attempts to breastfeed further increase maternal oxytocin levels, strengthening the uterine contractions that help the baby’s placenta to separate and the mother’s uterus to contract down. It is easy to forget that during the third stage of labour, the new mother is still in labour and in fact, from a hormonal perspective, we could say the mother and baby are more “in labour” than ever at this time. Further, this hormonal situation is unique, and will never again occur for this mother and her baby, representing our best (and most evolved) opportunity to ensure successful attachment and breastfeeding and therefore species survival.
Created from a single cell, baby and placenta function as one unit throughout pregnancy, linked by the tactile umbilical lifeline. The wondrous placenta directly absorbs the nutrients first; leaving anything that may be left over for the mother, which explains why some women find that they are ravenously hungry at times and they may need to look into their diet and be sure that it can provide them with enough nutrients to fulfil the needs for both their baby and themselves. At the same time oxygen rich blood is being circulated, removing carbon dioxide and waste from the baby and passing it back through the maternal side of the placenta and back to the mother. The conventional thinking has been that the placenta ‘ages’ past term, potentially compromising the baby’s growth, well being, and ability to cope with labour. However, placental anatomists have shown that the placenta continues to expand and increase in surface area beyond forty weeks, and that a healthy, well-embedded placenta has a large “functional reserve”.
According to research by world renowned UK paediatrician Peter Dunn, during the second stage of labour, as the baby makes the final descent from the mother’s womb, around 66 ml (2.23 ounces) of blood is transferred from the baby and retained in the placenta, which is just the beginning, probably because the umbilical vein (which returns blood from the placenta to baby) is compressed, and temporarily blocked, as the baby comes through the mother’s vagina. This extra volume makes the placenta fuller and more rigid, which may help it remain attached to the mother’s uterus in the minutes after birth, despite the sudden reduction in uterine size, and so continue to oxygenate the newborn until effective breathing is established. As the baby emerges, this pressure is released, allowing a bolus of warm, oxygenated, pH-balanced, placental blood to perfuse the newborn in the seconds after birth totalling around 100 ml. This 100 ml of blood is called the placental transfusion. The placental transfusion provides the stored oxygen and iron-rich blood necessary for filling the blood vessels in the lungs, kidneys, liver, gut and skin - all the organs that are not used in the womb. Contained within this blood is also a rich store of stem cells which later develop into new blood and immune cells. An average placental transfusion contains 30 to 35 milligrams of additional iron, which is equivalent to the iron contained in 100 litres (26 gallons) of breast milk!
This transfusion is augmented during each of the mother’s third-stage contractions, which are as powerful as those during labour. With each new contraction, the in-utero placenta is compressed, squeezing blood into the newborn’s body. Between contractions the mother’s uterus relaxes and some blood can return from the baby to placenta through the low pressure umbilical vein. Several studies have documented this process graphically by recording newborn weight gain in minutes after birth. According to Gunther’s observations, crying slows the baby’s intake of blood, which is also controlled by constriction of the vessels within the cord, both of which imply that the baby can regulate the transfusion according to individual need.
If the mother’s sacred and intimate time during her labour, birth and the immediate bonding time with her newborn baby are respected, with no drugs being administered and mother and baby left undisturbed after birth, her natural hormonal systems will ensure the strong and healthy uterine contractions necessary to birth her baby’s placenta and to prevent haemorrhage at this critical time. The placental transfusion decreases the size of the placenta enabling the uterus to contract more efficiently around it, further decreasing chances of post-partum haemorrhage.
Early clamping has been widely adopted in western obstetrics as part of the package known as active management of the third stage, designed to reduce the risk of maternal haemorrhage after birth. Active management includes the use of an oxytocic agent – a drug that, like oxytocin, causes the uterus to contract strongly – usually given by injection into the mother’s thigh as the baby is born, early cord clamping; and controlled cord traction, which involves pulling on the cord to deliver the placenta as quickly as possible. It is here that the idea of a ‘third stage maze’ comes into play as the timing of these actions is vital to ensure that they do not cause more harm to the mother and baby. Cord traction has been shown to damage the delicate placental vessels, producing an increased risk of a Feto-Maternal Haemorrhage, when the baby’s blood crosses the barrier into the mother’s bloodstream. Cord traction carries other placental hazards. When the placenta is not yet separated, strong traction can actually pull the cord off, making placental delivery more difficult and surgery for removal more likely. Cord traction is also a painful procedure for the new mother. Strong cord traction can also rarely cause an inversion of the new mother’s uterus, producing a state of profound shock.
Active management proponents have believed that immediate cord clamping is necessary because if the cord is not clamped before the oxytocic effect commences, the baby is at risk of having too much blood pumped from the placenta by the stronger uterine contractions. This area has been poorly studied. One early study using ergot drug methylergometrine (methylergonovine) suggested that the use of an oxytocic will hasten the baby’s placental transfusion from three minutes to one minute; however, in this study, blood and red cell volumes were equivalent for babies with and without oxytocic exposure. In contrast Dunn found that babies whose mothers received the drug combination syntometrine with cord clamping at three minutes, received an average of 40ml (1.35 ounces) in excess of the normal placental transfusion.
A recent review has analyzed maternal and infant outcomes according to the timing of cord clamping relative to oxytocic drug administration (cord clamping before and after oxytocic) and found no differences in any outcomes. This may reflect the newborn’s ability to avoid over perfusion by sending blood back to the placenta, as long as the cord remains unclamped. This is the blueprint among all other mammals, none of whom, obviously clamp the cord before the placenta emerges. This finding is reassuring for recent policies that encourage the use of oxytocic drugs soon after birth along with delayed clamping. However, there may be other negative effects for the newborn when an oxytocic drug is administered to the mother before the cord is clamped. And although the aim of active management is to reduce the risk of haemorrhage for the mother, “it’s widespread acceptance was not preceded by studies evaluating the effects of depriving neonates (newborns) of a significant volume of blood”.
Some experts in this area say that interference with the placental transfusion by the practice of immediate cord clamping may be related to some of our children’s developmental problems, such as cerebral palsy, autism, and learning difficulties. There is strong medical evidence that the early-clamped baby can be at higher risk of anaemia as cord clamping deprives the baby of an estimated 1.8 to 5.1 ounces (54 to 160 ml) of blood, which at the upper limits is almost half of a baby’s total blood volume at birth (300-350ml). Morley comments, “Clamping the cord before the infants first breath results in blood being sacrificed from other organs to establish pulmonary perfusion (blood supply to the lungs). Fatality may result if the child is already hypovolemic (low in blood volume).”
Peltonen recorded on film an early clamped newborn’s heart functions as the baby took a first breath. This film showed that, for several cardiac cycles after the first breath, the baby’s left heart had insufficient blood. Peltonen concludes, “It would seem that the closing of the umbilical circulation (cord clamping) before aeration of the lungs has taken place in highly unphysiological measure and should be avoided.”
Premature babies are likely to lose an even greater proportion of their blood through immediate cord clamping, because the placenta is bigger in relation to the baby’s body and contains more blood. In one randomised trial premature babies who experienced a delay in cord clamping by only thirty seconds showed reduced need for transfusion, less severe breathing problems, better oxygen levels and indications of improving long-term outcomes, compared with those whose cords were clamped immediately. In caesarean babies immediate cord clamping is usually performed as routine practice, the consequence of this may be an increased risk of respiratory distress. Several studies have shown that this can be eliminated when a full placental transfusion is allowed, again allowing gravity to work, by making sure that the placenta is kept level with the mother, which is recommended by Dunn.
In recent years there have been some welcome developments in thinking and practice of the third stage. U.S. authors Morley, Mercer, and others have published papers that have deepened our understanding of neonatal physiology during the third stage and of the risks of early clamping for the baby. Opinion and research on early versus delayed cord clamping in full-term newborns, published recently in major journals, have also sided with delayed clamping. Hutton and Hassan’s systematic review and meta-analysis in the Journal of the American medical Association (JAMA) 2007, concluded that “Delayed cord clamping for a minimum of two minutes following birth is beneficial to the newborn, extending into infancy. In the British Medical Journal (BMJ) in 2007, Weeks states, “There is now considerable evidence that early cord clamping does not benefit mother’s or babies and may even be harmful” and recommend a delay of three minutes, with the baby on the mother’s abdomen.
So how long have we known about the negative consequences of early cord clamping? Obstetrician Charles White wrote in 1773, "The common method of tying and cutting the navel string in the instant the child is born, is likewise one of those errors in practice that has nothing to plead in its favour but custom.” In 1801 Erasmus Darwin (grandfather to Charles Darwin) wrote: “Another thing very injurious to the child is the tying and cutting of the navel string too soon; which should be always left till the child has not only repeatedly breathed but till all pulsations in the cord ceases. As otherwise the child is much weaker than it ought to be, a part of the blood being left in the placenta which ought to have been in the child.”
The recent discovery of the amazing properties of cord blood, and the hematopoietic (blood-making) stem cells contained within it, heightens the need to ensure that a newborn baby gets a full quota. Collecting newborn babies blood is a human rights issue as it involves collecting their placental transfusion and requires early clamping - ideally within thirty seconds of birth - so that the adequate number of stem cells is obtained. Cord blood harvesting by both private and public banks also requires early clamping and they promote it as harmless to the baby. Parents are being emotionally bombarded with information on the potential benefits of cord blood storage and can end up paying out thousands over many years to store their baby’s blood based on an extremely slim chance that the person may need it later in life. So we start to see that there is another ‘richness’ stored within this miraculous organ and this is monetary profit. Umbilical cord blood is now known as liquid gold! All evidence shows that the best bank for the newborns blood is the baby!
The UK Royal College of Obstetricians and Gynaecologists (RCOG) states that, “Cord blood collection could jeopardise the mother’s or the baby’s health.” The European Group on Ethics in Science and New technologies to the European Commission states that, “indications to store cord blood at birth in view of a future autologous graft are for the present time almost nonexistent.” A cord blood collection of 100 ml from a full-term newborn (almost one-third of the 350 ml average newborn blood volume) is equivalent to the loss, in an adult, of 1.7 litres (3.5 pints) of blood, or three to four times the volume of a usual adult blood donation.
It is ironic that cord blood has been recently suggested as treatment for Autism – a condition that, as mentioned earlier, some experts believe may be due, at least in part, to the early cord clamping that would be necessary for collecting cord blood. The American Academy of Pediatrics states, “If cord clamping is done too soon after birth, the infant may be deprived of placental blood transfusion, resulting in lower blood volume and increased risk of anemia in later life....There may be temptation to practice immediate cord clamping aggressively to increase the volume of cord blood that can be harvested for cord blood banking. This practice is unethical and should be discouraged.”
Private, for-profit cord blood banks exist in most European countries, with this “business based on hope” spreading to developed and developing countries around the world. However the European group on ethics in Science and New Technologies states, “the legitimacy of commercial cord blood banks for autologous use should be questioned as they sell a service, which has presently no real use regarding therapeutic options.....The activities of such banks raise serious ethical criticisms”.
The International Federation of Gynaecology and Obstetrics (FIGO) Committee for the Ethical Aspects of Human Reproduction and Women’s Health conclude, in 1998: “The information mother’s currently receive at the time of requesting consent (for the collection of umbilical cord blood) is that blood in the placenta is no longer of use to the baby and this “waste blood” may help to save another person’s life. This information is incomplete and does not permit informed consent.”
Richard Branson recently launched Virgin Health Bank – “Life-saving today. Life-changing tomorrows”. On their website you can find his opening letter which states in the first paragraph that; “We’re all aware that the human body has an amazing capacity to heal itself but there are some illnesses and injuries we need more help to fight. The use of umbilical cord blood stem cells is an area in which I have been personally interested for many years. The thought that a straightforward technique carried out immediately after the baby is born could, in the future, save or enhance lives is incredible”.
Virgin Health Bank charge a fee of £1,500 to take blood samples from the mother, for administration, courier, a cord blood collection kit and 20 years storage of your baby’s blood. The fee is further increased to £1,600 if using the payment plan. On the website under the question ‘What are Stem Cells?’ it states that, “The Stem Cells found in cord blood are particulary versatile, collected using a straightforward technique and, they’re brand new, they’re also at their most vital.” They also state that; “The collection and storage of umbilical cord stem cells is Vatican-approved and raises no ethical or political issues”.
When reading the FAQ’s section of the website, I found this question below.
Is it true that collecting cord blood distracts the midwife from helping with the birth?
“Normally, collecting umbilical cord blood is a straightforward process and shouldn’t interfere with looking after the mother and baby. It usually takes 5-10 minutes and should be undertaken within about 30 minutes of the baby’s birth. However the wellbeing of the mother and baby is always priority, if there was any possibility that the collection could interfere with the care of either, the collection should not take place.”
What this clearly states is that they would not carry out the collection is it would interfere with the health and wellbeing of mother or baby and from what we have learned, we know that this does in fact put the mother and baby at risk. I decided to contact Virgin Health Bank to bring up this very important issue to see what they had to say about it. This was their response; “Thank you for your interest in Virgin Health Bank and for taking the time to e-mail us with your questions regarding the third stage of labour and cord blood banking. As you will have gleaned from our website, we do not prescribe when the cord should be clamped or when the cord blood should be collected. The health care professionals in charge of the delivery make such decisions in accordance with the policies of the respective maternity unit and the wishes of the mother to be. On our website we clearly state that nothing should compromise the attention which mother and baby receive, as their safety and wellbeing is paramount”.
I replied and gave them another opportunity to respond showing that they accept that they should take responsibility for the information they do not include on the website, giving perspective families real FACTS to become informed in making their decision. Most health care providers do not currently discuss the third stage and the negative consequences of ICC (immediate Cord Clamping). I received no further communication from Virgin Health Bank.
So according to Virgin and many others out there, including many care providers, it is up to us to become informed about the decisions surrounding our birth choices. We need to group together globally to inform, inspire and increase the knowledge and the power that each of us hold inside from our own passions and experiences. I am launching a new campaign called The Lotus Birth Campaign for Babies ~ ‘Speaking up for those who can’t speak for themselves’. It acknowledges the spectrum of possible ways of birthing and ultimately the most natural way ~ Lotus Birth.
Lotus Birth is the total non-severance of the umbilical cord, allowing it to detach naturally. The mother births the placenta and keeps it close to her baby until detachment. As the placenta is made to meet the individual needs of the baby, the time the baby takes to ‘let go’ of their life support system varies, but it’s usually around 3-5 days after birth, which is considerably less time than a cut cord. Lotus Birth establishes the baby-placenta relationship and suggests that the mother gives birth to the baby-placenta.
It has been said that Lotus Birth combines the modern values of natural birth with a mind towards facilitating a paradigm of peace and unity for the baby, mother and father, and world family upon birth. Viewing birth as the entry of a holy child into the world, Lotus Birth honours the Yogic value of Ahimsa (non-violence) and throughout labour and birth welcomes the baby as perfect as a full bloom Lotus, coming directly from the divine and born through the heart of the mother/couple down to earth. Lotus Birth incorporates the values of dignity, ecstatic physiology/drug-free labouring, sexual integrity, and respectful, gentle receiving of the baby to the mother's bosom upon birth.
Lotus Birth extends the birth time into the sacred days that follow and enables baby, mother and father and all the family members to pause, reflect and engage in nature’s conduct. Lotus Birth is a call to return to the rhythms of nature, to witness the natural order and to the experience of not doing, just being.
When the placenta remains connected to the baby after birth, the baby internalises a sense of deep connection to its physical being and the knowing that is in the mammalian and reptilian brains. With a Lotus Birth, the baby can draw into itself the deep sense of connection to the fact of embodiment, its composition of blood, bones, muscles and other tissues – it can experience its complete incorporation. This then becomes the knowing on which its sense of being is based. This deep knowing lends it a security, a reassurance of being what it is.
When our connection of our physical being is firm, we are then free to become aware of what lies beyond – the higher levels of existence. We become better able to experience ourselves as light and energy beyond the dense reality of the physical body. We are open to inspiration, to higher guidance, to insight.
Buckley concludes; “The Third stage represents the first meeting between mother and baby, creating a powerful imprint on their relationship. When both are undrugged and quiet, fully present and alert, the potentials for love and trust are invoked for mother, baby, family, and the world we share.”
You can read an article written about Lotus Birth by Dr Sarah J Buckley on her website http://www.sarahbuckley.com/lotus-birth-a-ritual-for-our-times/
Information on third stage is largely derived from the chapter ‘Leaving Well Enough Alone’ in Gentle Birth, Gentle Mothering (Celestial Arts, 2009) used with permission of the author Dr Sarah J Buckley. This chapter includes more information on the third stage and cord blood banking, and all medical references. For more of Sarah's writing and to buy her book, see www.sarahbuckley.com )