Delayed Cord Clamping, Neonatal transition, Placental transfusion

Cesarean section & delayed clamping

Cesarean section and delayed cord clamping

“Immediate clamping is routine at cesarean section
but lacks scientific evidence” (Erikson-Owens, 2009).

Delayed clamping of the umbilical cord in cesarean section delivery is possible for many babies.

In fact, delayed clamping in cesarean section is standard for some practitioners – to enhance placental transfusion and increase the baby’s blood volume at birth (closer to a physiological blood volume).

This may involve:

  • the baby’s head is delivered and the surgeon is hands-off as the baby auto-resuscitates while still attached to placental circulation. The baby is allowed time to transition to breathing – and after a few minutes once the baby begins to cry, the baby’s shoulders are eased out.The remaining delivery is a steady process of active movements by the baby and assistance from the obstetrician. The cord is not clamped until after the baby is completely delivered and the baby’s wellbeing is confirmed. (Smith, Plaat, Fisk, 2008)
  • ‘milking’ or ‘stripping’ blood in the umbilical cord toward baby before clamping;
  • and/or holding the baby below the level of the placenta for 30-60secs before clamping;
  • covering the umbilical cord with a towel while stimulating the baby to achieve adequate respiration prior to clamping; (the cord constricts with exposure to cold)
  • the baby is born and then the placenta is removed – keeping the baby, umbilical cord and placenta intact (without clamping). The placenta is kept level or above the baby, and this method can allow a lotus birth if the parents wish.

Parents are encouraged to speak with their clinical care providers about cesarean section and delayed cord clamping. This may be best covered when discussing a birth plan/ birth preferences, since the need for a cesarean section may arise late in pregnancy, during labour or be an emergency situation.

Some practitioners have limited knowledge or experience in delayed clamping with cesarean delivery. Parents may experience strong resistance or issues with lack of support from other key staff involved in the surgery, including anaesthetic, pediatric and nursing staff.

However, it is helpful to know during your discussions with your provider that delayed clamping with cesarean section is standard practice with some providers.

For example:

  • Nicholas Fogelson MD, an American OB/Gyn states on his website: “We delay cord clamping at cesarean routinely in my cases, and a lot of my partners have followed suit.  It isn’t difficult and doesn’t add a great deal of time to the case.  The pediatricians that are routinely at cesarean need to be brought on board, though, as they will be waiting for the baby wondering why it is still on the field!…Most OBs are happy to delay cord clamping if you let them know.  A lot aren’t aware of the data.  Point them to the video and they will probably change their tune.” (March 27, 2011) comment #124
  • The protocol for some studies of delayed versus immediate clamping involves cesarean section with delayed clamping (1).

There are situations where delayed clamping may not be safe or beneficial – for example, where cesarean section for anterior placenta previa involves incising the placenta or the baby is bradycardic (slow heart rate). In these cases, blood in the cord may be “milked” towards the baby before clamping and the residual blood volume in the placenta can be a source of blood for auto-transfusion (Source). Again, please speak to your health care provider about your particular case.

Examples of delayed clamping in cesarean section delivery

BJOG article A Natural Cesarean: A Woman Centred Technique (video embedded below) features a surgical team discussing their approach to delayed clamping with ‘woman centred’ cesareans. An excerpt from the article:
“Fetal safety is paramount, and we immediately resort to routine management if the baby is unexpectedly born in poor condition. The uterine incision-to-delivery interval is prolonged compared with routine practice, but usually still within the 3 minutes formerly recommended for optimal neonatal condition.14 However, during this period with the head out but the trunk still inside, not only is the crying baby establishing a resting lung volume but also the placental circulation remains intact. Experience with the partially exteriorised fetus during EXIT (Ex utero Intrapartum Treatment surgery to establish the neonatal airway) procedures suggests that fetal oxygenation can be maintained over much longer intervals, the largest series showing an average cord pH of 7.20 after a median of 17 minutes on ‘placental bypass’.15 Because birth is timed when the baby is completely expelled from its mother’s womb, natural caesarean babies often achieve a healthy Apgar score before they are actually born.”

Guideline for the management of Caesarean Section deliveries (David Hutchon) 
“The baby is delivered onto the mother’s thighs and time of delivery recorded. The baby is wrapped in the warm towel and held on the right side of the mother’s thigh about 20 cm below the height of the incision. 40 seconds after delivery the cord is clamped and cut and the baby taken for resuscitation if necessary.”

“The time of the delivery of the baby and the interval before clamping the cord must be recorded. This guideline does not apply to Crash Caesarean sections for acute fetal distress, Ceasarean sections for abruption placenta and placenta praevia or vasa praevia.”

‘Milking’ the umbilical cord at term – cesarean section
“New evidence suggests immediate clamping of the umbilical cord may contribute to anemia of infancy. It can deprive a full-term infant of 25% of its blood volume, representing up to 50 mg/kg of iron. Poor iron stores can affect the developing brain. Immediate clamping is routine at cesarean section but lacks scientific evidence. Delayed clamping for two minutes can reduce anemia but is not always feasible at cesarean section.

Cord milking may offer an alternative at cesarean section for the prevention of anemia. Cord milking is easy to implement at cesarean section and may aid in the prevention of anemia in infancy. While some clinicians focus on polycythemia, a parallel concern is the incidence of anemia found in infants with immediate clamping. Cord milking appears to be an effective alternative to delayed clamping with no associated harm. More research is needed to discern causes of hyperbilirubinemia.”

Birth story – ‘woman-centred’ emergency c-section with delayed clamping

Elise is a birth and postnatal doula and has generously shared the birth story of her third baby Dimitri.

Dimitri was born via an emergency c-section, after transferring from a planned homebirth. Elise arrived at the hospital prepared with a birth plan outlining the “natural cesearean ‘woman-centred’ technique”, which includes a delayed ‘incision to delivery’ time and delayed cord clamping.

Cesarean Lotus Birth Story

“The Caesarean section was performed and our son, Jarrah was born at 7.50 am on Friday 2nd July.     He was immediately taken over to a table to have meconium suctioned from his lungs     – Josh was with him at all times –  the placenta was still attached. 8.00am saw a shift change in staff and a new nurse came in who tried to cut the cord saying it was hospital procedure!! Fortunately Josh was with Jarrah and intervened letting her know of our arrangement with the doctor.

Jarrah was having difficulty breathing, so his father requested that the clamps be removed to allow the blood to flow freely from his placenta back into his body. The Paediatrician refused to do this and we again asked to seek higher authority.  He left and then came back and removed the clamps. Once this was done Jarrah’s breath, colour and strength picked up immediately – this amazed the paediatrician!”
Video: The  “natural”  cesarean: a woman- centered technique 

(1) Studies where infants assigned to delayed clamping including cesarean section include Kugelman et al (2007), Mercer et al (2003), Mercer et al (2006)


Smith J, Plaat F, Fisk N. The natural caesarean: a woman-centred technique. BJOG 2008;115:1037–1042.

References cited in Smith, Plaat & Fisk (2008):

14. Bader AM, Datta S, Arthur GR, Benvenuti E, Courtney M, Hauch M. Maternal and fetal catecholamines and uterine incision-to-delivery interval during elective cesarean. Obstet Gynecol. 1990;75:600–3.[PubMed]

15. Bouchard S, Johnson MP, Flake AW, Howell LJ, Myers LB, Adzick NS, et al.  The EXIT procedure: experience and outcome in 31 cases. J Pediatr Surg. 2002;37:418–26.[PubMed]


About Kate Emerson

Kate Emerson is a practitioner with an interest in neonatal transitional physiology and clinical cord clamping practices. Please visit www.cord-clamping.com to read more.


18 thoughts on “Cesarean section & delayed clamping

  1. Unfortunately cord milking wasn’t enough to stop my son becoming anaemic after immediate clamping due to an anterior placenta previa which had to be incised to deliver him.

    Posted by K B | February 1, 2012, 10:20 am
  2. I think that ‘trauma reduced’ is a better term than ‘Natural’ There is nothing natural about major abdominal surgery and normalizing such a high level of intervention is dangerous. Babies have the right to a natural birth unless there are medical indications for otherwise and mothers’ bodies certainly need to give birth.

    The obvious benefit of this practice is a no -brainer and as one who has been advocating it for the past 15years I am pleased to see it finally being implemented.
    The routine injection for the baby is a very traumatic imprint and should be stopped. That baby does not need that injection.
    We have had very successful Lotus Birth Caesareans too. That is leaving the baby intact with the cord and placenta until it comes in the days after the birth. http://www.lotusbirth.net

    Posted by Rachana Shivam | March 4, 2012, 9:23 am
    • Thank you for your response Rachana. I think a ‘woman-centred’ technique is a good term for practitioners trying to improve the experience for mothers and their babies. I agree the term ‘natural’ is often used to describe un-physiologic birth interventions – for this reason, “natural” is only featured in this article in association with the video title. Warm wishes, Kate

      Posted by GiftedBirth | March 4, 2012, 10:03 am
    • I agree 100% – there can never be any such entity as a ‘natural’ caesarean. It is a total contradiction in terms. I wish the effort that is going into ‘humanising’ CS could be equalled in labour and vaginal birth.
      We had many Lotus CS where I used to work – happy mothers and babies 🙂

      Posted by Lynne Staff | April 8, 2012, 12:59 pm
  3. I have seen this video too. Though it is not entirely natural but at least it is still beneficial to the baby. Less traumatize and mom can enjoy the “delivery” process. Obviously not a birth process. Yes, cord clamping should be delay. Best to wait for 3 minutes. Not sure if that’s possible with c-section.

    Posted by Kong Choon Yen | March 8, 2012, 3:30 pm
    • “Birth” is defined as the moment a baby leaves the mothers body. Cesarean sections have always been a natural form of birth to simply get the baby out if there was a reason she couldn’t push it out herself. We now simply have the medical resources to keep the women alive!
      I have a condition where I am unable to dialate. In the past, women with this condition would die during birth. For this any many other conditions it was simply natural for them to proceed to cut the baby out to save it’s life.
      I take offence (and by the way, so does every other woman who has needed a cesarean) when people accuse us of “choosing” this method. If my choice is being alive for my child or bleeding out, I’m obviously going to choose to be here. Even VBACs, although possible are still very dangerous and some hospitals even refuse to do them.
      The methods discussed in this video are intended to make the experience for mom and baby during this difficult time much more managable. Don’t make us feel even worse for having to go this route by degrading our birth experience to a “delivery” experience. You don’t get to change the definition of birth simply because you advocate for the vaginal route.
      Even women who elect cesareans may do so for their psychological reasons that are none of your business and you are in no position to jugde them.

      Posted by alicia | March 13, 2013, 7:10 am
      • Very well stated. The biases I come across when researching various aspects of birth to support my wife are simply stunning. Your comment needs to be written on a sledge hammer and delivered to some self-righteous (almost always) women who refuse to pause and consider that c-sections are sometimes necessary to save lives. Overused? Of course. But necessary nonetheless.

        And here’s another example of blockheadedness I can across yesterday researching ways to encourage cervix ripening: the mantra, “You should be patient. Don’t rush this.” Not helpful when the doctor is the one saying, “If the cervix doesn’t progress, we need to intervene.” It’s not the mother/patient being impatient. The mother would happily wait until 42 weeks–just 7 days beyond the very noisy average of 287 days (from the first day of the last menstrual cycle) for first-time moms. It’s the doctor who insist that the last week–from 280 to the average date–is already “late.”

        Posted by Chad | February 21, 2014, 3:41 am
      • Thank you for your comment Alicia. I am very supportive and interested in improving cesarean section for the benefit of mothers and their babies. My support also extends to women being able to elect a cesarean section, just as I support women’s choice to home birth, water birth, hospital birth, and access safe midwifery and obstetric care. All the best, Kate

        Posted by Kate Emerson | March 6, 2014, 12:15 pm
  4. Wonderful! What is the injection in the baby for? Vitamin K??

    Posted by Sophia | July 19, 2012, 8:12 pm
  5. Thanks for finally writing about >Cesarean section & delayed clamping | Delayed Cord Clamping <Loved it!

    Posted by Tyrell | October 5, 2014, 5:31 pm


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