Background: Babies have an excess of red blood cells over what they will need after they are born because they are extracting oxygen from the mother's blood, where the concentration is much lower than in air. In the days after they are born, they get rid of the excess, a destruction process that occurs in the liver and produces a yellow byproduct called "bilirubin." Because their livers are immature, the bilirubin tends to build up in the bloodstream instead of being passed through into the bile and from there into the intestines for disposal. (Sidenote: Colostrum, what the baby gets before the milk comes in, is a mild laxative that helps this along.)

I haven't looked at this review, but Lisa has hit the nail on the head. The near universal practice of early cord clamping for the past decades has created what Amy Romano and I are calling in the new edition of Obstetric Myths Versus Research Realities, an "iatrogenic" norm. "Iatrogenic" means "caused by doctors" as in "iatrogenic harm." It's like the way it used to be with the newborn weight gain charts. The old ones were based on infants who were formula fed and started on solids within a couple of months of birth. The growth rates of breastfed babies were compared with the formula fed babies, and their moms would be told that their baby's rate of weight gain was inadequate, and they should supplement. (Now they have separate charts for breastfed babies.) In this case, what is considered the "normal" range for bilirubin level is actually lower than what it would be were third stage were allowed to proceed physiologically, and babies got their full blood supply.

As for requiring phototherapy, years ago I was at a conference where a doctor spoke on this issue. He explained that doctors recognized that they were seeing neurologic harm in babies whose bilirubin counts exceeded 30 (Sidenote: that number is not an absolute; the more preterm the baby, the lower the threshold), so the thought was, "We never want to let bilirubin counts get that high, so we had better start treating at 20." After awhile, 20 felt like the threshold, and doctors started treatment at 15. And then, medical model thinking being what it is, it was, "Just to be on the safe side, let's just put the baby under the lights if the count is 12." In other words, the decision to treat with phototherapy is not tied to the risk of clinical harm.

-- Henci

I think that if you cut the cord before the placenta has been born then you potentially interfere in a process that we don't actually fully understand.  There is a two way process of exchange happening.  Maybe Jaundice is  more common when the cord is cut prior to birth of placenta because only one part of the process is complete.  Anecdotally it appears that if the placenta is born before cutting the cord jaundice is far less.   When recording blood results Normal is considered to be the blood result with early intervention.  It is far more likely that the "high" result with a physiological third stage is really a normal result.

Planned home birth is a great option for a woman not anticipating problems at the birth who has a qualified home birth attendant. However, while conventional obstetric management is neither safe nor effective, you can still get good care in the hospital. It's just less likely. You have to know what questions to ask and what answers you want to hear. The Childbirth Connection website has good material on choosing a place of birth and a care provider and the Coalition for Improving Maternity Services has "Having a Baby? Ten Questions to Ask." I also have chapters on place of birth and care provider in my book, the Thinking Woman's Guide to a Better Birth, that include questions to ask. And even if you plan home birth, you will want to think about an obstetrician and a hospital because there is always the possibility of developing a problem in pregnancy or labor.

-- Henci

I have no idea what the original rationale was for treating newborns in this fashion. Perhaps there was some idea that they needed the stimulus. Years ago, a midwife friend showed a bunch of us childbirth educators and doulas an old film from the 1960s (anybody out there remember movie projectors?) she had that was used by the navy to teach about childbirth . That was when women had heavy doses of narcotics during labor whether they wanted them or not. The baby was limp and gray at delivery. We were horrified at the baby's condition, but the delivery room personnel treated it as no big deal, undoubtedly because that was how all the babies looked at delivery, and, yes, they held the baby upside down and spanked it to get it going.

I am also aware that well into the 1980s, medical staff didn't think babies could see, hear, or feel, so it didn't much matter what you did to them. One of the great abuse scandals of those days was that they would operate on infants without giving them anesthesia, just a paralytic drug to keep them from moving. The theory was that an anesthetic was risky, and the baby didn't feel anything anyway. A mother who realized that this is what had happened to her son started a campaign that ultimately resulted in putting an end to the practice--at least I hope it has. I'm not so sure after reading your post that it still wouldn't be wise for a parent whose baby needs surgery to ask if the baby will be receiving anesthesia. Maybe there are some neonatal surgeons and anesthesiologists who haven't gotten the message.

As for why the younger doc would do it, I would guess that he saw it done that way during his training, and because doctors are not questioned or challenged pretty much no matter how egregious their behavior, no one has ever said to him, "What the hell do you think you are doing?!"

-- Henci

Yes, Henci I have seen the baby held upside down by two practitioners-- only once by the feet (which I know is awful for the baby's back) in what seems to be their standard of practice.  One doc is from the 60's, but the other is probably no more than 50 himself. 

Anyway, although it seems absurd, I was just wondering-- what were/ are doctors thinking by doing this?  What was the supposed benefit?   

I'm stunned! You have actually seen this in this day and age? I thought that kind of treatment went out in the 1970s when they stopped doing Twilight Sleep or giving women enough narcotics to drug a horse, let alone a newborn. As for my thoughts on these practices, "child abuse" comes to mind.

-- Henci 

Henci,

LOVED this post.  I'd like to know more about two other practices I am seeing-- holding the baby upside down and delibertately trying to make a newborn in moments old who looks fine repeatedly cry-- seems cruel.  I'd like to know your thoughts.

Thanks,

Shayna

I am working on the chapter on managing third stage, the time between the birth of the baby and the delivery of the placenta, for the new edition of Ob Myths Versus Research Realities. As some of you may have noticed, I almost never make recommendations outright about medical interventions, but immediate cord clamping demands that I make an exception to my rule:*

I strongly recommend that couples INSIST that the cord not be clamped until it has stopped pulsing. Immediate clamping of the umbilical cord deprives the baby of 25% to 40% of its blood volume.

As one reviewer (Mercer 2002) says, "In other circumstances, . . . such a massive restriction in blood volume would result in severe consequences, even death." It is a testament to the resilience of the birth process that most babies do OK despite this, although that may not apply to preemies. Nonetheless, randomized controlled trials clearly show that immediate cord clamping has short- and long-term adverse effects on the baby's hematologic status. More babies will have anemia as much as 6 months later. In addition, Mercer makes a strong case based on physiology and animal studies that initiation of respiration "is based on and driven by adequate blood volume." Specifically, expansion of the alveoli in the lung depends on blood filling and stiffening the capillary networks that surround them.

Mercer JS, Skovgaard RL. Neonatal transitional physiology: a new paradigm. J Perinat Neonatal Nurs 2002;15(4):56-75.

What about the baby who needs resuscitation? The usual practice is to cut the cord, and rush the baby away for treatment. This makes no sense. As long as the cord is pulsing, the baby is still receiving oxygen from the mother, and leaving the cord attached provides a grace period. Equipment should be brought to the baby, not vice versa. 

One might wonder how this practice came about in the first place. It was based on the theory that hypervolemia (getting too much blood) would increase risk of jaundice, polycythemia (too high a red blood cell count), and respiratory difficulties. None of this has been shown to occur. A recent systematic review concluding that clamping should be delayed takes note of what it calls "asymptomatic polycythemia." But the norms for this have been based on values with immediate clamping. This is like setting newborn growth curves based on formula-fed babies and saying breastfed babies don't gain weight fast enough. What we have is not babies with "asymptomatic polycythemia," we really have babies currently considered normal who are actually suffering from hypovolemia and anemia. And leaving aside the research, if you think about it, on logical grounds alone, it is always a bad idea to interfere routinely with a functioning physiologic process.

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;297(11):1241-52.

By the way, allowing the baby to recover its full complement of blood is good for mom too. Emptying the engorged placenta helps it to detach more efficiently and effectively.

-- Henci

*The other exception is to refuse induction with misoprostol (Cytotec).