Category Archives: Research

how are umbilical cords severed?

Comments please!  You do not need to be a midwife to comment, just someone who knows what the local practices are for babies born outside of a facility. If you would prefer to email, send your response to . 

I am interested in gathering data regarding practices around severing the baby’s umbilical cord.  I would like to have a sampling of what the practice is from as many locales as possible. In particular, I’m interested in your answers to the following questions: 

At what point after a normal birth is the cord severed?  (immediately, after ____ minutes, or after _______ has occurred, etc.)

What is the method of severing the cord?

How is the umbilical stump cared for afterward?

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Essential Newborn Care. What is it really?

Keep the baby with the mama!

Keep the baby WITH THE MAMA!

Keep the baby WARM!
(if you are in a warm climate, then there’s not a lot to do in this area)

Make sure the baby is breathing!

I’ve been enjoying my research on this topic today. The term “Essential Newborn Care” just sounds so, well, BIG. And, indeed, it *is* big! … But I find it quite humorous that we can’t just use words like

“Keep the baby with the mommy.”

I do have some comments on and appreciation for this directive from the WHO Philippines office…

Essential Newborn Care (ENC) 

The ENC Protocol is a step-by-step guide for health workers and medical practitioners issued by the Department of Health for implementation under Administrative Order 2009-0025.

What are these step-by-step interventions?

Immediate drying

Using a clean, dry cloth, thoroughly dry the baby, wiping the face, eyes, head, front and back, arms and legs.

[COMMENT:  If baby is vigorous, drying and rubbing off all the vernix really isn’t such a great idea (see the instructions later in the directive regarding bathing the baby). OTOH, if everyone is taught to dry the baby, then you don’t have to worry about differentiating between a vigorous and nonvigorous baby … because you’ll just be stimulating all of them!]

Uninterrupted skin-to-skin contact

Aside from the warmth and immediate bonding between mother and child, it has been found that early skin-to-skin contact contributes to a host of medical benefits such as the overall success of breastfeeding/colostrum feeding, stimulation of the mucosa—associated lymphoid tissue system, and colonization with maternal skin flora that can protect the newborn from sepsis and other infectious disease and hypoglycemia.

[COMMENT: LOVE THIS “Intervention”]

Proper cord clamping and cutting

Waiting for up three minutes or until the pulsations stop is found to reduce to chances of anemia in full term and pre-term babies. Evidence also shows that delaying cord clamping has no significant impact on the mother.

[COMMENT: YES!!! While not my idea of delayed cord clamping, THREE MINUTES is a LIFETIME in the medical world!  It’s interesting that three minutes is the time called out here, seeing as the research supports a 4 minute cord infusion … but, 3 minutes is definitely better than immediate!]

Non-separation of the newborn from the mother for early breastfeeding initiation and rooming-in

The earlier the baby breastfeeds, the lesser the risk of death. Keeping the baby latched on to the mother will not only benefit the baby (see skin-to-skin contact) but will also prevent doing unnecessary procedures like putting the newborn on a cold surface for examination (thereby exposing the baby to hypothermia), administering glucose water or formula and foot printing (which increases risk of contamination from ink pads) and washing (the WHO standard is to delay washing up to 6 hours; the vernix protects the newborn from infection). 

[COMMENT:  Non-separating of the newborn from the mother is an intervention?  I do love this recommendation overall, though.]


Now … the harder part is to figure out just how do you get the basics of essential newborn care ingrained into the heart and hands of everyone who is at a birth?  I think the reality is that for births that take place out of the hospital / birth center, then the chances that these basics are happening are greater.  I am hoping to take a look at this with one of the groups of TBAs … much my hunch is that the report will be that they are indeed practicing these “interventions.”


WHO | Preventing those so-called stillbirths

by Jonathan M Spector a, Subhash Daga b

Increased recognition of the disproportionately large contribution of newborn health to global child survival has fuelled efforts to address neonatal mortality in resource-limited settings. Stillbirths have not been as well studied despite the fact that more than 3 million stillbirths occur annually, a disease burden that approaches that of postnatal deaths. The poorest countries have the highest incidences with two regions, sub-Saharan Africa and south Asia, together accounting for nearly 70% of worldwide stillbirths.1 Limited health services undeniably constitute the major determinant in perinatal mortality, but there is growing concern that high stillbirth rates in many regions are also being driven by less apparent, potentially preventable factors.

Birth asphyxia, defined as the failure to establish breathing at birth, accounts for an estimated 900 000 deaths each year and is one of the primary causes of early neonatal mortality.2 Guidelines for neonatal resuscitation, such as those endorsed by WHO and the American Academy of Pediatrics, represent a standard practice set that improves outcomes in asphyxiated newborns. These algorithms stress the importance of drying, stimulating and warming babies in distress, as well as clearing their airways. In the face of persistent apnoea or bradycardia, ventilation with the use of bag-and-mask or equivalent device is indicated, and is felt by many to constitute the critical step in managing asphyxiated infants.3 Newborns have a remarkable ability to withstand hypoxia and many improve rapidly with timely implementation of these techniques. Few infants go on to require chest compressions or pharmaceutical administration.

Despite being a relatively simple and inexpensive intervention, effective neonatal resuscitation is not universal. Translation of resuscitation principles into practice might be straightforward in health-care environments that benefit from highly-skilled and well-outfitted resuscitation teams, but is understandably difficult in settings where practitioners lack training in newborn care and where access to essential resuscitation equipment is limited. In parts of many low-income countries, for example, resuscitation algorithms may be nonexistent or inappropriate. Bulb syringes and bag-and-mask devices may be sub-standard or unavailable; even when present and functioning, staff may be unfamiliar with their use. Moreover, stethoscopes, which can play a crucial role in helping practitioners to recognize a live birth by detecting a heart rate, may also be either inaccessible or unused. Customary practice in some regions dictates use of a stethoscope only by doctors, who may not regularly attend deliveries.

Given that perinatal asphyxia occurs with regular frequency and that health-care workers in many areas of the world are ill-equipped to manage it, there is no mystery as to why large numbers of newborns are dying in the immediate postpartum period. What is unknown, however, is the accuracy and consistency with which these fatalities are being recorded. Obtaining reliable information that describes perinatal mortality in less developed countries can be challenging due to high rates of home births as well as variation in terminology and data collection systems.

Strictly speaking, stillbirths are fetal deaths. Nevertheless, live-born infants who are inadequately resuscitated and die may be misclassified as stillbirths for several reasons.4 Unskilled health workers may simply not be able to distinguish between the two conditions. The health-care team or family may prefer a stillbirth diagnosis to circumvent matters of culpability or to avoid acknowledging the tragic reality of limited medical proficiency in that region. Logistical or financial incentives relating to, for instance, vital registration or burial practices may also play a role. Finally, traditional belief systems may influence categorization since stillbirths and child deaths can carry differential spiritual significance in the eyes of local community members. Since documentation at peripheral health centres directly informs district, provincial, and central level reporting, systematic errors introduced locally adversely impact the legitimacy of national and regional statistics.

Our experience working alongside neonatal care providers in sub-Saharan Africa and India illustrates how resuscitation practices influence stillbirth statistics. In rural Sudan, we have seen a cyanotic, apnoeic newborn with a pulse be set aside following birth and left to herself to initiate the process of spontaneous breathing. After nearly two minutes of non-intervention by the delivery attendants, we were compelled to step outside of our role as observers and act quickly to provide stimulation and positive pressure ventilation. The infant responded to manual breaths and the outcome was good. Subsequent discussions with the local staff indicated that the infant would have been considered stillborn had she died.

On another occasion, midwives at a large public hospital in Liberia were observed to routinely favour medication administration alone in the management of apnoeic newborns. This approach was confirmed as common institutional practice by written assessment in which 78% of delivery practitioners failed to correctly identify positive pressure ventilation as a key element in resuscitation of asphyxiated babies (Spector, unpublished data, 2007). More than 2000 deliveries are conducted at this hospital annually, yet there was virtually no documentation of neonatal deaths. In contrast, the recorded stillbirth rate was extremely high (70 out of 1000 live births).

Can improvement in neonatal resuscitation skills result in decreased stillbirths? Evidence suggests that it can. In Dahanu, India, the stillbirth rate dropped from 18.6% to 9% over a three-year period with introduction of a traditional birth attendant training programme in which neonatal resuscitation was a central component.5 This finding is consistent with a recent study in Fatehpur, India, through which nurses and ward aides with minimal education were trained in a basic neonatal resuscitation programme. Recorded stillbirth rates decreased in the hospitals where the course was taught. Participating physicians’ comments were revealing: following the intervention, nurses demonstrated skilful use of bag-and-mask during resuscitation whereas “before, the babies had died”.6

Misclassification of stillbirths has significant implications for national health policies and global strategies for reducing perinatal mortality, particularly with regard to resource allocation. Recognizing so-called stillbirths as newborn deaths resulting from birth asphyxia strengthens the appeal for investment in research that identifies effective and feasible mechanisms for delivery of essential newborn care. Priority interventions in parts of the world most affected should include high coverage of skilled birth attendants and integration of competency-based neonatal resuscitation training into existing programmes for maternal and child health. If just 1 in 100 stillbirths is actually a poorly-resuscitated viable newborn, greater than 30 000 lives could potentially be saved each year by improving neonatal resuscitation practices in austere settings. ■

Competing interests

None declared.


  • Lawn J. Shi buya K, Stein C. No cry at birth: global estimates of intrapartum stillbirths and intrapartum-related neonatal deaths. Bull World Health Organ2005; 83: 409-17 pmid: 15976891.
  • Lawn JE, Manandhar A, Haws RA, Darmstadt GL. Reducing one million child deaths from birth asphyxia: a survey of health systems gaps and priorities.Health Res Policy Syst 2007; 5: 4- doi: 10.1186/1478-4505-5-4 pmid:17506872.
  • Rehan VK, Phibbs RH. Delivery room management. In: Avery’s neonataology: pathophysiology and management of the newborn. 6th ed. Philadelphia: Lippincott Williams & Wilkins Press; 2005.
  • Stanton C, Lawn JE, Rahman H, Wilczynska-Ketende K, Hill K. Stillbirth rates: delivering estimates in 190 countries. Lancet 2006; 367: 1487-94 doi:10.1016/S0140-6736(06)68586-3 pmid: 16679161.
  • Daga SR, Daga AS, Dighole RV, Patil RP, Dhinde HL. Rural neonatal care: Dahanu experience. Indian Pediatr 1992; 29: 189-93 pmid: 1592499.
  • Cowles W. Decreasing perinatal mortality in rural India: a basic neonatal resuscitation program. Acad Emerg Med 2007; 14: e109- doi:10.1197/j.aem.2007.02.004.


  • UMass Memorial Children’s Medical Center, Worcester, MA, United States of America.
  • BJ Medical College and Sassoon General Hospital, Pune, India.

chlorhexidine + clean birth kit =

Healthier moms and babies!

Introducing initial plans for a small-scale pilot study on the effects of including chlorhexidine IN clean birth kits.

Chlorhexidine is a chemical antiseptic that is effective on gram-positive and gram-negative bacteria. Latest research shows significant reduction in neonatal infection when umbilical cords are treated even just once with chlorhexidine.

Clean birth kits contain a bar of soap for hand washing, a chux or plastic sheet/bag for a clean birth surface, clean gloves for universal precautions, clean string for tying the umbilical cord, a new razor blade for cutting the cord, and pictorial instructions illustrating the sequence of use of the items.

Chlorhexidine + clean birth kits will evaluate whether or not chlorhexidine is used when included in the kits, if it is used correctly, and the impact on infection rates in a small population.

Look and see: A picture of what incorporating TBAs to decrease mortality looks like

The most recent meta-analysis of available data, published in the British Medical Journal in December 2011, supports the concept on which the Train Midwives Save Lives project is based: While providing a skilled birth attendant at every birth is the ultimate goal (as stated by WHO, UNFPA, etc.), the reality is that incorporating traditional birth attendants in order to reduce perinatal and maternal mortality is crucial and the evidence supports this approach.

The full article is available through this link: Effectiveness of strategies incorporating training and support of traditional birth attendants on perinatal and maternal mortality: meta-analysis BMJ 2011;343:d7102

I really appreciate the following succinct pictorial of what it looks like to incorporate TBAs. If I could have drawn the end-goal of Train Midwives Save Lives, this is what it would look like. Note that neonatal resuscitation, newborn care, and clean delivery kits are the key elements of training and education.

Conclusions and policy implications from the BMJ article

Use of traditional birth attendants without an appropriate package of training, support, linkage with healthcare institutions, and resource supply is unlikely to be effective. Potentially important components that support strategies incorporating traditional birth attendants and that have been proved to be beneficial10 include training and support, as well as linkage with healthcare professionals, continued skill development, access to resources such as clean birth kits and resuscitation equipment, and effective referral pathways (fig 5).

The most effective intervention to improve perinatal and maternal outcomes is the use of skilled birth attendants. Although this intervention is a central goal, the economic, geographical, political, and social realities have limited the ability of national and international efforts to ensure the presence of skilled attendants at all births. This limited coverage has resulted in critical gaps, with 52 million women giving birth without skilled attendance every year.3 Therefore, other cadres of health workers might need to be considered to extend the coverage of maternal and neonatal care. Traditional birth attendants can improve the coverage of maternal and neonatal care, and evidence from this meta-analysis suggests that they can be a component of the strategies to improve perinatal outcomes. Traditional birth attendants often represent a more feasible, culturally acceptable, and accessible option for women in developing countries.11

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Clean birth practices

                                   The WHO six “cleans”

                               1. Clean hands of the attendant
                               2. Clean surface
                               3. Clean blade
                               4. Clean cord tie
                               5. Clean towels to dry the baby and then wrap the baby
                               6. Clean cloth to wrap the mother

I woke up this morning with the fact that we have to go back to basics in order to save maternal and newborn lives heavy on my heart. The research exists: Clean birth practices including clean birth kits reduce the number of deaths. It is hard to come by good “high quality” research because once one of these topics is addressed (for example, what is the impact on maternal infection if a clean birth surface is provided), then it quickly becomes unethical to test what happens if the clean surface is NOT provided. As a result, studies are generally “low” quality. I’ve been pondering this over the last months … how to really track the impact of little changes.

Read an excellent article this morning:

Clean birth and postnatal care practices to reduce neonatal deaths from sepsis and tetanus: a systematic review and Delphi estimation of mortality effect

Bottom line:

“Clean practices at birth and in the postnatal period could prevent many needless deaths, especially in settings with high baseline neonatal mortality and where the majority of births still take place at home, although in many facilities in low income settings, hygienic practices may also be sub optimal. The benefits of a clean birth have been recognised for centuries and if this basic and feasible action was achieved for every mother and baby of the 135 million births each year, over 100,000 lives could be saved each year “[94].

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Placental Abruption

I was reviewing an article for an amazing organization today. The topic was placental abruption. I, fortunately, have only seen one fatal abruption in my time as a midwife and that was only fatal because of location (far from hospital out in the bush). I am so sad, though, because even that mom likely would have lived had someone, anyone, had the money to pay for a car to take her to the hospital. Placental abruption is serious stuff and it costs moms and babies their lives.

I’m happy that we understand abruption and the cascade of events that can take place in the mother’s body if a moderate to severe abruption occurs. The worst case being that clotting factors are “used up” and she continues to bleed from the site of abruption, but does not continue to clot.

The solution? Get the baby and placenta delivered! Then, the uterus can clamp down and the bleeding can get under control (assuming that clotting factors are still present). Some simple training tools can be used to teach anyone who is working with pregnant women to recognize if abruption is possibly present. The diagnosis is made via signs and symptoms. Women and babies don’t have to die from this complication that affects up to 1% of pregnanies. (NOTE: included in this 1% are mild/minor abruptions. Moderate to severe abruptions are rarer.)

Bleeding. Pain at the site of the placenta. Aching pain. Pushing urge in labor WAY before it should be present. A firm uterus in the absence of effective contractions. A feeling of unease. Shock. Poor or absent fetal heart tones that don’t respond to stimulation or changes in position.

These moms are some of the few that really need to be in hospital for birth if at all possible. If not possible, then baby must come as soon as possible and actions taken to get that uterus to clamp down as quickly as possible.


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