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Vitamin K and newborns: what you need to know | Labour & birth articles & support | NCT

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If you’ve heard people talk about Vitamin K but are feeling a bit clueless, here’s the information you’ll need.

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Birthing the placenta - knowledge and options

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Birthing the placenta - knowledge and options

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What is the third stage of labour?

The third stage of labour is the time between when you have your baby and when the placenta (or afterbirth) comes out (Begley et al, 2011; NICE, 2017).

Once your baby's born, the release of the hormone oxytocin will make the uterus contract and become smaller. This'll make the placenta start to separate.

You will have some bleeding during the third stage of labour as you pass the placenta (Begley et al, 2011).

Active management versus physiological management

Generally, you have two options for how you do the third stage of labour: active management and physiological management. But there's also a third option - mixed management - combining active and physiological approaches (Begley et al, 2011; NICE, 2017).

Physiological management:

It's generally practised in midwife-led units and in home births.

It allows the placenta to be ready to come out mainly by pushing, gravity, contractions and sometimes by nipple stimulation.

It doesn't use oxytocin injections.

The umbilical cord is clamped and cut once it has stopped pulsing or when the placenta has come out.

It can take up to one hour (and shouldn't take more).

Skin-to-skin contact and breastfeeding can help it along, by making your body produce more oxytocin.

It involves sitting in an upright position to encourage the placenta to come out.

Your midwife will monitor your blood loss and keep you and your baby warm.

You'll push the placenta out once it has separated and moved down to your vagina.

It's mostly used if you're at low risk of heavy blood loss.

You can change to active management at any time if needed. (Begley et al, 2011; NICE, 2017)

When the placenta is out, your midwife will clamp and cut the cord. But if you want, you can ask them to wait until it has finished pulsating (RCM, 2013a). Delaying cord clamping for at least a minute has been shown to be beneficial for babies(Science Direct, 2021).

Active management:

Involves an injection of a drug called syntocinon or ergometrine in your thigh soon after your baby's born.

It speeds up the delivery of the placenta - it usually happens within 30 minutes of having your baby. Your midwife will apply some pressure to your belly and pull gently on the umbilical cord to ease the placenta out.

You'll have the umbilical cord cut between one and five minutes after you give birth.

It lowers the risk of heavy blood loss.

It might make you feel sick or vomit, and can increase your risk of high blood pressure.

(Begley et al, 2011; RCM 2013b; NICE, 2017)

Should I have active management or physiological management?

Generally, active management is recommended for all women, to avoid severe haemorrhage. Though this is more of an issue in low-income countries where women are more likely to be poorly nourished, anaemic or have infectious diseases (Begley et al 2015).

If you do go through a haemorrhage though, you'll need to be transferred to a hospital if you're not already there. You'll then be offered treatment that involves:

oxytocin or another drug called ergometrine, which helps the womb to contract and stop the bleeding

your placenta being removed if it hasn't been delivered already

fluids through a drip

oxygen through a facemask.

If the bleeding continues, you'll be given more oxytocin, ergometrine or other drugs. In some cases, an examination under anaesthesia and surgery and/or a blood transfusion might be needed (NICE, 2017).

Retained placenta and problems after birth

If all or some of your placenta has not come out within one hour of you having your baby, this is called a retained placenta.

If that happens to you, you'll need to be put on an intravenous drip. You might also be offered a vaginal examination to see whether you need an operation to remove the placenta. You'll also be offered pain relief (NICE, 2017).

If you do have the placenta removed under anaesthesia, you'll need to have it done within a few hours of the birth to avoid haemorrhage (Weeks, 2001). You'll then need to be transferred to an obstetric unit if you are not already there and might be advised to have an epidural or spinal anaesthetic when the placenta is actually removed (NICE, 2017).
This page was last reviewed in July 2018.
Further information

Our support line offers practical and emotional support with feeding your baby and general enquiries for parents, members and volunteers: 0300 330 0700.

We also offer antenatal courses which are a great way to find out more about birth, labour and life with a new baby.

Important information on the third stage of labour can be found in NICE guidelines.

Begley CM, Gyte GML, Murphy DJ, et al. (2011) Active versus expectant management of women in the third stage of labour. Cochrane Database Syst Rev.(11):CD007412. Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007412.pub3... [Accessed: 13th August 2018]

NICE. (2017) Intrapartum care for healthy women and babies. Available from: https://www.nice.org.uk/guidance/cg190/ifp/chapter/delivering-the-placenta [Accessed: 13th August 2018]

Rabe H, Gyte GML, Díaz‐Rossello JL, Duley L. (2019) Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database of Systematic Reviews. Available from: (9):CD003248. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003248.pub4... [Accessed: 4th October 2019]

RCM. (2013) How to conduct active management of the third stage of labour. Available from: https://www.rcm.org.uk/news-views-and-analysis/analysis/how-to-conduct-active-management-of-the-third-stage-of-labour [Accessed: 13th August 2018]

Weeks AD. (2001) The retained placenta. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2704447/] African Health Sciences. 1(1):36-41. [Accessed: 13th August 2018]

Science Direct (2021) A randomized controlled clinical trial on peripartum effects of delayed versus immediate umbilical cord clamping on term newborns [Accessed: 27 August 2021] https://www.sciencedirect.com/science/article/abs/pii/S0301211521002098...
Further reading
Begley CM, Gyte GML, Devane D, McGuire W, Weeks A. (2015) Delivering the placenta with active, expectant or mixed management in the third stage of labour. Cochrane Database Syst Rev. 2015.(3):CD007412. Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007412.pub3... [Accessed: 13th August 2018]

Jangsten E, Mattsson LA, Lyckestam I, Hellstrom AL, Berg M. (2011) A comparison of active management and expectant management of the third stage of labour: a Swedish randomised controlled trial. British J Obst Gynaecol. 118(3):362-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21134105 [Accessed: 13th August 2018]

RCM. (2013) How to promote a physiological third stage of labour. Available from: https://www.rcm.org.uk/news-views-and-analysis/analysis/how-to-promote-a-physiological-third-stage-of-labour [Accessed: 13th August 2018]

Midwife thinking An actively managed placental birth might be the best option for most women https://midwifethinking.com/2015/03/11/an-actively-managed-placental-bi...

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Third stage of labour: delivering placenta and cord clamping | Labour & birth articles & support | NCT

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The third stage of labour is the time between when you have your baby and when the placenta (or afterbirth) comes out.

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Intrapartum care for healthy women and babies | Guidance and guidelines | NICE

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Intrapartum care for healthy women and babies | Guidance and guidelines | NICE

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1.1 Place of birth

Choosing planned place of birth

Women at low risk of complications

1.1.1 Explain to both multiparous and nulliparous women who are at low risk of complications that giving birth is generally very safe for both the woman and her baby. [2014]

1.1.2 Explain to both multiparous and nulliparous women that they may choose any birth setting (home, freestanding midwifery unit, alongside midwifery unit or obstetric unit), and support them in their choice of setting wherever they choose to give birth:

1.1.3 Using tables 1 and 2, explain to low‑risk multiparous women that:

Table 1 Rates of spontaneous vaginal birth, transfer to an obstetric unit and obstetric interventions for each planned place of birth: low‑risk multiparous women (sources: Birthplace 2011; Blix et al. 2012)

Table 2 Outcomes for the baby for each planned place of birth: low‑risk multiparous women (source: Birthplace 2011)

1.1.4 Using tables 3 and 4, explain to low‑risk nulliparous women that:

Table 3 Rates of spontaneous vaginal birth, transfer to an obstetric unit and obstetric interventions for each planned place of birth: low‑risk nulliparous women (sources: Birthplace 2011; Blix et al. 2012)

Table 4 Outcomes for the baby for each planned place of birth: low‑risk nulliparous women (source: Birthplace 2011)

1.1.6 Commissioners and providers[] should ensure that all 4 birth settings are available to all women (in the local area or in a neighbouring area). [2014]

1.1.7 Give the woman the following information, including local statistics, about all local birth settings:

Access to midwives, including:

Access to medical staff (obstetric, anaesthetic and neonatal).

Access to pain relief, including birthing pools, Entonox, other drugs and regional analgesia.

The likelihood of being transferred to an obstetric unit (if this is not the woman's chosen place of birth), the reasons why this might happen and the time it may take. Refer to table 5 if no local data are available. [2014]

Table 5 Primary reasons for transfer to an obstetric unit (source: Birthplace 2011)

* Main reason for transfer to an obstetric unit for each woman (there may be more than 1 reason).

1.1.8 If further discussion is wanted by either the midwife or the woman about the choice of planned place of birth, arrange this with a consultant midwife or supervisor of midwives, and/or a consultant obstetrician if there are obstetric issues. [2014]

1.1.9 When discussing the woman's choice of place of birth with her, do not disclose personal views or judgements about her choices. [2014]

Medical conditions and other factors that may affect planned place of birth

1.1.10 Use tables 6, 7, 8 and 9 as part of an assessment for a woman choosing her planned place of birth:

Table 6 Medical conditions indicating increased risk suggesting planned birth at an obstetric unit

Haematological

Haemoglobinopathies - sickle‑cell disease, beta‑thalassaemia major

History of thromboembolic disorders

Immune thrombocytopenia purpura or other platelet disorder or platelet count below 100×10 ⁹/litre

Von Willebrand's disease

Bleeding disorder in the woman or unborn baby

Atypical antibodies which carry a risk of haemolytic disease of the newborn

Risk factors associated with group B streptococcus whereby antibiotics in labour would be recommended

Hepatitis B/C with abnormal liver function tests

Carrier of/infected with HIV

Toxoplasmosis - women receiving treatment

Current active infection of chicken pox/rubella/genital herpes in the woman or baby

Tuberculosis under treatment

Table 7 Other factors indicating increased risk suggesting planned birth at an obstetric unit

Previous complications

Unexplained stillbirth/neonatal death or previous death related to intrapartum difficulty

Previous baby with neonatal encephalopathy

Pre‑eclampsia requiring preterm birth

Placental abruption with adverse outcome

Eclampsia

Uterine rupture

Primary postpartum haemorrhage requiring additional treatment or blood transfusion

Retained placenta requiring manual removal in theatre

Caesarean section

Shoulder dystocia

Current pregnancy

Multiple birth

Placenta praevia

Pre‑eclampsia or pregnancy‑induced hypertension

Preterm labour or preterm prelabour rupture of membranes

Placental abruption

Anaemia - haemoglobin less than 85 g/litre at onset of labour

Confirmed intrauterine death

Induction of labour

Substance misuse

Alcohol dependency requiring assessment or treatment

Onset of gestational diabetes

Malpresentation - breech or transverse lie

BMI at booking of greater than 35 kg/m ²

Recurrent antepartum haemorrhage

Small for gestational age in this pregnancy (less than fifth centile or reduced growth velocity on ultrasound)

Abnormal fetal heart rate/doppler studies

Ultrasound diagnosis of oligo‑/polyhydramnios

Table 8 Medical conditions indicating individual assessment when planning place of birth

Haematological

Atypical antibodies not putting the baby at risk of haemolytic disease

Sickle‑cell trait

Thalassaemia trait

Anaemia - haemoglobin 85-105 g/litre at onset of labour

Table 9 Other factors indicating individual assessment when planning place of birth

Previous complications

Stillbirth/neonatal death with a known non‑recurrent cause

Pre‑eclampsia developing at term

Placental abruption with good outcome

History of previous baby more than 4.5 kg

Extensive vaginal, cervical, or third‑ or fourth‑degree perineal trauma

Previous term baby with jaundice requiring exchange transfusion

Current pregnancy

Antepartum bleeding of unknown origin (single episode after 24 weeks of gestation)

BMI at booking of 30-35 kg/m ²

Blood pressure of 140 mmHg systolic or 90 mmHg diastolic or more on 2 occasions

Clinical or ultrasound suspicion of macrosomia

Para 4 or more

Recreational drug use

Under current outpatient psychiatric care

Age over 35 at booking

Women's experience in all birth settings

1.1.12 Providers, senior staff and all healthcare professionals should ensure that in all birth settings there is a culture of respect for each woman as an individual undergoing a significant and emotionally intense life experience, so that the woman is in control, is listened to and is cared for with compassion, and that appropriate informed consent is sought. [2014]

1.1.13 Senior staff should demonstrate, through their own words and behaviour, appropriate ways of relating to and talking about women and their birth companion(s), and of talking about birth and the choices to be made when giving birth. [2014]

One‑to‑one care in all birth settings

1.1.14 Maternity services should:

Service organisation and clinical governance

1.1.15 Ensure that all women giving birth have timely access to an obstetric unit if they need transfer of care for medical reasons or because they request regional analgesia. [2014]

1.1.16 Commissioners and providers[] should ensure that there are:

robust protocols in place for transfer of care between settings (see also section 1.6)

clear local pathways for the continued care of women who are transferred from one setting to another, including:

1.1.17 Commissioners and providers[] should ensure that there are multidisciplinary clinical governance structures in place to enable the oversight of all birth settings. These structures should include, as a minimum, midwifery (including a supervisor of midwives), obstetric, anaesthetic and neonatal expertise, and adequately supported user representation. [2014]

1.4 Initial assessment

1.4.1 When performing an initial assessment of a woman in labour, listen to her story and take into account her preferences and her emotional and psychological needs. [2014]

1.4.2 Carry out an initial assessment to determine if midwifery‑led care in any setting is suitable for the woman, irrespective of any previous plan. The assessment should comprise the following:

Observations of the woman:

Review the antenatal notes (including all antenatal screening results) and discuss these with the woman.

Ask her about the length, strength and frequency of her contractions.

Ask her about any pain she is experiencing and discuss her options for pain relief.

Record her pulse, blood pressure and temperature, and carry out urinalysis.

Record if she has had any vaginal loss.

Observations of the unborn baby:

Ask the woman about the baby's movements in the last 24 hours.

Palpate the woman's abdomen to determine the fundal height, the baby's lie, presentation, position, engagement of the presenting part, and frequency and duration of contractions.

Auscultate the fetal heart rate for a minimum of 1 minute immediately after a contraction. Palpate the woman's pulse to differentiate between the heartbeats of the woman and the baby.

In addition (see also recommendation 1.4.5):

If there is uncertainty about whether the woman is in established labour, a vaginal examination may be helpful after a period of assessment, but is not always necessary.

If the woman appears to be in established labour, offer a vaginal examination. [2014]

1.4.3 Transfer the woman to obstetric‑led care, following the general principles for transfer of care described in section 1.6, if any of the following are observed on initial assessment:

1.4.4 If any of the factors in recommendation 1.4.3 are observed but birth is imminent, assess whether birth in the current location is preferable to transferring the woman to an obstetric unit and discuss this with the coordinating midwife. [2014]

1.4.5 When conducting a vaginal examination:

be sure that the examination is necessary and will add important information to the decision‑making process

recognise that a vaginal examination can be very distressing for a woman, especially if she is already in pain, highly anxious and in an unfamiliar environment

explain the reason for the examination and what will be involved

ensure the woman's informed consent, privacy, dignity and comfort

explain sensitively the findings of the examination and any impact on the birth plan to the woman and her birth companion(s). [2014]

Measuring fetal heart rate as part of initial assessment

1.4.6 Offer auscultation of the fetal heart rate at first contact with a woman in suspected or established labour, and at each further assessment:

1.4.7 Be aware that for women at low risk of complications there is insufficient evidence about whether cardiotocography as part of the initial assessment either improves outcomes or results in harm for women and their babies, compared with intermittent auscultation alone. [2017]

1.4.8 If a woman at low risk of complications requests cardiotocography as part of the initial assessment:

1.4.9 Offer continuous cardiotocography if any of the risk factors listed in recommendation 1.4.3 are identified on initial assessment, and explain to the woman why this is being offered. (See also section 1.10 on fetal monitoring.) [2017]

1.4.11 If fetal death is suspected despite the presence of an apparently recorded fetal heart rate, offer real-time ultrasound assessment to check fetal viability. [2017]

1.6 General principles for transfer of care

Transfer of care refers to the transfer between midwifery‑led care and obstetric‑led care. This may or may not involve transport from one location to another. Women who are receiving midwifery‑led care in an obstetric unit can have their care transferred to obstetric‑led care without being moved.

1.6.1 Base any decisions about transfer of care on clinical findings, and discuss the options with the woman and her birth companion(s). [2014]

1.6.2 If contemplating transfer of care:

talk with the woman and her birth companion(s) about the reasons for this and what they can expect, including the time needed for transfer

address any concerns she has and try to allay her anxiety

ensure that her wishes are respected and her informed consent is obtained. [2014]

1.6.3 When arranging transfer of care, the midwife attending the labour should contact the ambulance service (if appropriate) and the coordinating midwife in the obstetric unit. The coordinating midwife should then alert the relevant healthcare professionals (obstetric, anaesthetic and neonatal). [2014]

1.6.4 When arranging transfer from one location to another, ensure the following:

Before transfer, the woman is dressed, wrapped in a blanket or otherwise covered in a way that she feels is comfortable and appropriate.

The woman is made to feel as comfortable as possible before and during transfer.

Any ambulance staff or other personnel involved are aware that some positions may make the woman uncomfortable or afraid and could affect her labour, so she should be encouraged to choose how to move and what position to adopt if possible, in accordance with ambulance service protocols.

Communication and companionship are maintained. Explain the arrangements for transfer to the woman and her birth companion(s). A midwife who has been involved in her care up to that point should travel with her and carry out a handover of care that involves the woman.

Arrangements are in place to enable the woman's birth companion(s) to travel with her in the ambulance if that is what she wants. If this is not possible or not wanted, check that the birth companion(s) have or can arrange their own transport. [2014]

1.6.5 If a woman is transferred to an obstetric unit after the birth (see section 1.16), ensure that her baby goes with her. [2014]

1.9 Pain relief in labour: regional analgesia

Information about regional analgesia

1.9.2 Provide information about epidural analgesia, including the following:

Care and observations for women with regional analgesia

1.9.4 Always secure intravenous access before starting regional analgesia. [2007]

1.9.5 Preloading and maintenance fluid infusion need not be administered routinely before establishing low‑dose epidural analgesia and combined spinal-epidural analgesia. [2007]

1.9.6 Undertake the following additional observations for women with regional analgesia:

1.9.7 Encourage women with regional analgesia to move and adopt whatever upright positions they find comfortable throughout labour. [2007]

1.9.8 Once established, continue regional analgesia until after completion of the third stage of labour and any necessary perineal repair. [2007]

1.9.9 Upon confirmation of full cervical dilatation in a woman with regional analgesia, unless the woman has an urge to push or the baby's head is visible, pushing should be delayed for at least 1 hour and longer if the woman wishes, after which actively encourage her to push during contractions. [2007]

1.9.10 After diagnosis of full dilatation in a woman with regional analgesia, agree a plan with the woman in order to ensure that birth will have occurred within 4 hours regardless of parity. [2007]

1.9.11 Do not routinely use oxytocin in the second stage of labour for women with regional analgesia. [2007]

1.9.12 Perform continuous cardiotocography for at least 30 minutes during establishment of regional analgesia and after administration of each further bolus of 10 ml or more. [2007, amended 2014]

1.10 Monitoring during labour

Measuring fetal heart rate

1.10.1 Do not offer cardiotocography to women at low risk of complications in established labour. [2017]

1.10.2 Offer intermittent auscultation of the fetal heart rate to women at low risk of complications in established first stage of labour:

1.10.3 If there is a rising baseline fetal heart rate or decelerations are suspected on intermittent auscultation, actions should include:

1.10.4 Advise continuous cardiotocography if any of the following risk factors are present at initial assessment (see section 1.4) or arise during labour:

1.10.5 Do not offer continuous cardiotocography to women who have non-significant meconium if there are no other risk factors. [2017]

1.10.6 Do not regard amniotomy alone for suspected delay in the established first stage of labour as an indication to start continuous cardiotocography. [2007, amended 2014]

1.10.7 Address any concerns that the woman has about continuous cardiotocography, and give her and her birth companion(s) the following information:

1.10.8 If continuous cardiotocography has been started because of concerns arising from intermittent auscultation, but the trace is normal (see table 11) after 20 minutes, return to intermittent auscultation unless the woman asks to stay on continuous cardiotocography (see recommendation 1.4.8). [2017]

Telemetry

1.10.9 Offer telemetry to any woman who needs continuous cardiotocography during labour. [2014]

Interpretation of cardiotocograph traces

1.10.10 Use tables 10 and 11 to define and interpret cardiotocograph traces and to guide the management of labour for women who are having continuous cardiotocography. These tables include and summarise individual recommendations about fetal monitoring ( 1.10.11 to 1.10.35), fetal scalp stimulation ( 1.10.38 and 1.10.39), fetal blood sampling ( 1.10.40 to 1.10.55) and intrauterine resuscitation ( 1.10.36 and 1.10.37) in this guideline. [2017]

Table 10 Description of cardiotocograph trace features

Overall care

Make a documented systematic assessment of the condition of the woman and unborn baby (including cardiotocography [CTG] findings) every hour, or more frequently if there are concerns.

Do not make any decision about a woman's care in labour on the basis of CTG findings alone.

Take into account the woman's preferences, any antenatal and intrapartum risk factors, the current wellbeing of the woman and unborn baby and the progress of labour.

Ensure that the focus of care remains on the woman rather than the CTG trace.

Remain with the woman in order to continue providing one-to-one support.

Talk to the woman and her birth companion(s) about what is happening and take her preferences into account.

Principles for intrapartum CTG trace interpretation

When reviewing the CTG trace, assess and document contractions and all 4 features of fetal heart rate: baseline rate; baseline variability; presence or absence of decelerations (and concerning characteristics of variable decelerations* if present); presence of accelerations.

If there is a stable baseline fetal heart rate between 110 and 160 beats/minute and normal variability, continue usual care as the risk of fetal acidosis is low.

If it is difficult to categorise or interpret a CTG trace, obtain a review by a senior midwife or a senior obstetrician.

Accelerations

None or early

Variable decelerations with no concerning characteristics* for less than 90 minutes

Variable decelerations with no concerning characteristics* for 90 minutes or more

OR

Variable decelerations with any concerning characteristics* in up to 50% of contractions for 30 minutes or more

OR

Variable decelerations with any concerning characteristics* in over 50% of contractions for less than 30 minutes

OR

Late decelerations in over 50% of contractions for less than 30 minutes, with no maternal or fetal clinical risk factors such as vaginal bleeding or significant meconium

Less than 5 for more than 50 minutes

OR

More than 25 for more than 25 minutes

OR

Sinusoidal

Variable decelerations with any concerning characteristics* in over 50% of contractions for 30 minutes (or less if any maternal or fetal clinical risk factors [see above])

OR

Late decelerations for 30 minutes (or less if any maternal or fetal clinical risk factors)

OR

Acute bradycardia, or a single prolonged deceleration lasting 3 minutes or more

Table 11 Management based on interpretation of cardiotocograph traces

Correct any underlying causes, such as hypotension or uterine hyperstimulation

Perform a full set of maternal observations

Start 1 or more conservative measures*

Inform an obstetrician or a senior midwife

Document a plan for reviewing the whole clinical picture and the CTG findings

Talk to the woman and her birth companion(s) about what is happening and take her preferences into account

Obtain a review by an obstetrician and a senior midwife

Exclude acute events (for example, cord prolapse, suspected placental abruption or suspected uterine rupture)

Correct any underlying causes, such as hypotension or uterine hyperstimulation

Start 1 or more conservative measures*

Talk to the woman and her birth companion(s) about what is happening and take her preferences into account

If the cardiotocograph trace is still pathological after implementing conservative measures:

obtain a further review by an obstetrician and a senior midwife

offer digital fetal scalp stimulation (see recommendation 1.10.38) and document the outcome

If the cardiotocograph trace is still pathological after fetal scalp stimulation:

consider fetal blood sampling

consider expediting the birth

take the woman's preferences into account

Need for urgent intervention

Acute bradycardia, or a single prolonged deceleration for 3 minutes or more

Urgently seek obstetric help

If there has been an acute event (for example, cord prolapse, suspected placental abruption or suspected uterine rupture), expedite the birth

Correct any underlying causes, such as hypotension or uterine hyperstimulation

Start 1 or more conservative measures*

Make preparations for an urgent birth

Talk to the woman and her birth companion(s) about what is happening and take her preferences into account

Expedite the birth if the acute bradycardia persists for 9 minutes

If the fetal heart rate recovers at any time up to 9 minutes, reassess any decision to expedite the birth, in discussion with the woman

Abbreviation: CTG, cardiotocography.

* If there are any concerns about the baby's wellbeing, be aware of the possible underlying causes and start one or more of the following conservative measures based on an assessment of the most likely cause(s): encourage the woman to mobilise or adopt an alternative position (and to avoid being supine); offer intravenous fluids if the woman is hypotensive; reduce contraction frequency by reducing or stopping oxytocin if it is being used and/or offering a tocolytic drug (a suggested regimen is subcutaneous terbutaline 0.25 mg).

Overall care

1.10.11 When a woman is having continuous cardiotocography:

1.10.12 When reviewing the cardiotocograph trace, assess and document contractions and all 4 features of fetal heart rate:

baseline rate

baseline variability

presence or absence of decelerations, and concerning characteristics of variable decelerations if present (see recommendation 1.10.22)

presence of accelerations. [2017]

1.10.13 Do not make any decision about a woman's care in labour on the basis of cardiotocography findings alone, but also take into account:

1.10.14 Supplement ongoing care with a documented systematic assessment of the condition of the woman and unborn baby (including any cardiotocography findings) every hour. If there are concerns about cardiotocography findings, undertake this assessment more frequently. [2017]

Baseline fetal heart rate

1.10.15 Use the following categorisations for baseline fetal heart rate:

1.10.16 Take the following into account when assessing baseline fetal heart rate:

Baseline variability

1.10.17 Use the following categorisations for fetal heart rate baseline variability:

1.10.18 Take the following into account when assessing fetal heart rate baseline variability:

Decelerations

1.10.19 When describing decelerations in fetal heart rate, specify:

1.10.20 Describe decelerations as 'early', 'variable' or 'late'. Do not use the terms 'typical' and 'atypical' because they can cause confusion. [2017]

1.10.21 Use the following categorisations for decelerations in fetal heart rate:

reassuring:

non-reassuring:

variable decelerations with no concerning characteristics for 90 minutes or more

variable decelerations with any concerning characteristics in up to 50% of contractions for 30 minutes or more

variable decelerations with any concerning characteristics in over 50% of contractions for less than 30 minutes

late decelerations in over 50% of contractions for less than 30 minutes, with no maternal or fetal clinical risk factors such as vaginal bleeding or significant meconium

1.10.22 Regard the following as concerning characteristics of variable decelerations:

1.10.23 If variable decelerations with no concerning characteristics (see recommendation 1.10.22) are observed:

1.10.24 Take the following into account when assessing decelerations in fetal heart rate:

1.10.25 Take into account that the longer and later the individual decelerations, the higher the risk of fetal acidosis (particularly if the decelerations are accompanied by tachycardia or reduced baseline variability). [2017]

Accelerations

1.10.26 Take the following into account when assessing accelerations in fetal heart rate:

Categorisation of traces

1.10.27 Categorise cardiotocography traces as follows:

normal: all features are reassuring (see table 10)

suspicious: 1 non-reassuring feature and 2 reassuring features (but note that if accelerations are present, fetal acidosis is unlikely)

pathological:

Management

1.10.28 If there is a stable baseline fetal heart rate between 110 and 160 beats/minute and normal variability, continue usual care as the risk of fetal acidosis is low. [2017]

1.10.29 If there is an acute bradycardia, or a single prolonged deceleration for 3 minutes or more:

1.10.30 If the cardiotocograph trace is categorised as pathological (see recommendation 1.10.27):

1.10.31 If the cardiotocograph trace is still pathological after implementing conservative measures:

obtain a further review by an obstetrician and a senior midwife

offer digital fetal scalp stimulation (see recommendation 1.10.38) and document the outcome.

If the cardiotocograph trace is still pathological after fetal scalp stimulation, consider:

expediting the birth (see recommendations 1.13.34 to 1.13.37).

Take the woman's preferences into account. [2017]

1.10.32 If the cardiotocograph trace is categorised as suspicious (see recommendation 1.10.27):

1.10.33 If the cardiotocograph trace is categorised as normal (see recommendation 1.10.27):

Conservative measures

1.10.34 If there are any concerns about the baby's wellbeing, be aware of the possible underlying causes and start one or more of the following conservative measures based on an assessment of the most likely cause(s):

encourage the woman to mobilise or adopt an alternative position (and to avoid being supine)

offer intravenous fluids if the woman is hypotensive

reduce contraction frequency by:

1.10.35 Inform a senior midwife or an obstetrician whenever conservative measures are implemented. [2017]

Intrauterine resuscitation

1.10.36 Do not use maternal facial oxygen therapy for intrauterine fetal resuscitation, because it may harm the baby (but it can be used where it is administered for maternal indications such as hypoxia or as part of preoxygenation before a potential anaesthetic). [2014]

1.10.37 Do not offer amnioinfusion for intrauterine fetal resuscitation. [2014]

Fetal scalp stimulation

1.10.39 If digital fetal scalp stimulation (during vaginal examination) leads to an acceleration in fetal heart rate, regard this as a sign that the baby is healthy. Take this into account when reviewing the whole clinical picture. [2017]

Fetal blood sampling

1.10.40 Do not carry out fetal blood sampling if:

there is an acute event (for example, cord prolapse, suspected placental abruption or suspected uterine rupture) or

the whole clinical picture indicates that the birth should be expedited or

contraindications are present, including risk of maternal-to-fetal transmission of infection or risk of fetal bleeding disorders. [2017]

1.10.41 Be aware that for women with sepsis or significant meconium (see recommendation 1.5.2), fetal blood sample results may be falsely reassuring, and always discuss with a consultant obstetrician:

1.10.42 Before carrying out or repeating fetal blood sampling, start conservative measures and offer digital fetal scalp stimulation (see recommendations 1.10.34 and 1.10.38). Only continue with fetal blood sampling if the cardiotocograph trace remains pathological (see recommendation 1.10.27). [2017]

1.10.43 When considering fetal blood sampling, take into account the woman's preferences and the whole clinical picture. [2017]

1.10.44 When considering fetal blood sampling, explain the following to the woman and her birth companion(s):

1.10.45 Do not take a fetal blood sample during or immediately after a prolonged deceleration. [2017]

1.10.46 Take fetal blood samples with the woman in the left-lateral position. [2017]

1.10.47 Use either pH or lactate when interpreting fetal blood sample results. [2017]

1.10.48 Use the following classifications for fetal blood sample results:

1.10.49 Interpret fetal blood sample results taking into account:

1.10.50 If the fetal blood sample result is abnormal:

1.10.51 If the fetal blood sample result is borderline and there are no accelerations in response to fetal scalp stimulation, consider taking a second fetal blood sample no more than 30 minutes later if this is still indicated by the cardiotocograph trace. [2017]

1.10.52 If the fetal blood sample result is normal and there are no accelerations in response to fetal scalp stimulation, consider taking a second fetal blood sample no more than 1 hour later if this is still indicated by the cardiotocograph trace. [2017]

1.10.53 Discuss with a consultant obstetrician if a third fetal blood sample is thought to be needed. [2017]

When a fetal blood sample cannot be obtained

1.10.54 If fetal blood sampling is attempted and a sample cannot be obtained, but the associated fetal scalp stimulation results in a fetal heart rate acceleration, decide whether to continue the labour or expedite the birth in light of the clinical circumstances and in discussion with the woman and a senior obstetrician. [2017]

Record keeping

1.10.56 To ensure accurate record keeping for cardiotocography:

1.10.57 Individual units should develop a system for recording relevant intrapartum events (for example, vaginal examination, fetal blood sampling and siting of an epidural) in standard notes and/or on the cardiotocograph trace. [2014]

1.10.58 Keep cardiotocograph traces for 25 years and, if possible, store them electronically. [2007, amended 2014]

1.10.59 In cases where there is concern that the baby may experience developmental delay, photocopy cardiotocograph traces and store them indefinitely in case of possible adverse outcomes. [2007, amended 2014]

1.10.60 Ensure that tracer systems are available for all cardiotocograph traces if stored separately from the woman's records. [2007, amended 2014]

1.10.61 Develop tracer systems to ensure that cardiotocograph traces removed for any purpose (such as risk management or for teaching purposes) can always be located. [2007, amended 2014]

1.11 Prelabour rupture of membranes at term

1.11.1 Do not carry out a speculum examination if it is certain that the membranes have ruptured. [2007]

1.11.2 If it is uncertain whether prelabour rupture of the membranes has occurred, offer the woman a speculum examination to determine whether the membranes have ruptured. Avoid digital vaginal examination in the absence of contractions. [2007]

1.11.3 Advise women presenting with prelabour rupture of the membranes at term that:

the risk of serious neonatal infection is 1%, rather than 0.5% for women with intact membranes

60% of women with prelabour rupture of the membranes will go into labour within 24 hours

induction of labour[] is appropriate approximately 24 hours after rupture of the membranes. [2007]

1.11.4 Until the induction is started or if expectant management beyond 24 hours is chosen by the woman:

do not offer lower vaginal swabs and measurement of maternal C‑reactive protein

to detect any infection that may be developing, advise the woman to record her temperature every 4 hours during waking hours and to report immediately any change in the colour or smell of her vaginal loss

inform the woman that bathing or showering is not associated with an increase in infection, but that having sexual intercourse may be. [2007]

1.11.5 Assess fetal movement and heart rate at initial contact and then every 24 hours after rupture of the membranes while the woman is not in labour, and advise the woman to report immediately any decrease in fetal movements. [2007]

1.11.6 If labour has not started 24 hours after rupture of the membranes, advise the woman to give birth where there is access to neonatal services and to stay in hospital for at least 12 hours after the birth. [2007]

1.12 First stage of labour

See recommendation 1.3.1 for the definition of the first stage of labour.

1.12.1 Do not offer or advise clinical intervention if labour is progressing normally and the woman and baby are well. [2007]

1.12.2 In all stages of labour, women who have left the normal care pathway because of the development of complications can return to it if/when the complication is resolved. [2007]

Duration of the first stage

1.12.3 Inform women that, while the length of established first stage of labour varies between women:

Observations during the established first stage

1.12.4 Do not routinely use verbal assessment using a numerical pain score. [2007]

1.12.5 Use a pictorial record of labour (partogram) once labour is established. [2007]

1.12.6 Where the partogram includes an action line, use the World Health Organization recommendation of a 4‑hour action line[]. [2007]

1.12.7 Record the following observations during the first stage of labour:

1.12.8 Give ongoing consideration to the woman's emotional and psychological needs, including her desire for pain relief. [2007]

1.12.9 Encourage the woman to communicate her need for analgesia at any point during labour. [2007]

Possible routine interventions in the first stage

1.12.10 Do not routinely offer the package known as active management of labour (one‑to‑one continuous support; strict definition of established labour; early routine amniotomy; routine 2‑hourly vaginal examination; oxytocin if labour becomes slow). [2007]

1.12.11 In normally progressing labour, do not perform amniotomy routinely. [2007]

1.12.12 Do not use combined early amniotomy with use of oxytocin routinely. [2007]

Delay in the first stage

1.12.13 If delay in the established first stage is suspected, take the following into account:

1.12.14 If delay in the established first stage is suspected, assess all aspects of progress in labour when diagnosing delay, including:

cervical dilatation of less than 2 cm in 4 hours for first labours

cervical dilatation of less than 2 cm in 4 hours or a slowing in the progress of labour for second or subsequent labours

descent and rotation of the baby's head

changes in the strength, duration and frequency of uterine contractions. If delay is diagnosed, transfer the woman to obstetric‑led care. Follow the general principles for transfer of care described in section 1.6. [2014]

1.12.15 If delay in the established first stage of labour is suspected, amniotomy should be considered for all women with intact membranes, after explanation of the procedure and advice that it will shorten her labour by about an hour and may increase the strength and pain of her contractions. [2007]

1.12.16 Whether or not a woman has agreed to an amniotomy, advise all women with suspected delay in the established first stage of labour to have a vaginal examination 2 hours later, and diagnose delay if progress is less than 1 cm. [2007]

1.12.17 For women with intact membranes in whom delay in the established first stage of labour is confirmed, advise the woman to have an amniotomy, and to have a repeat vaginal examination 2 hours later whether her membranes are ruptured or intact. [2007]

1.12.18 For all women with confirmed delay in the established first stage of labour:

1.12.19 For a multiparous woman with confirmed delay in the established first stage of labour, an obstetrician should perform a full assessment, including abdominal palpation and vaginal examination, before a decision is made about using oxytocin. [2007]

1.12.20 Offer all women with delay in the established first stage of labour support and effective pain relief. [2007]

1.12.21 Inform the woman that oxytocin will increase the frequency and strength of her contractions and that its use will mean that her baby should be monitored continuously. Offer the woman an epidural before oxytocin is started. [2007]

1.12.23 Advise the woman to have a vaginal examination 4 hours after starting oxytocin in established labour:

1.13 Second stage of labour

Definition of the second stage

1.13.1 For the purposes of this guideline, use the following definitions of labour:

Observations during the second stage

Duration of the second stage and definition of delay

1.13.3 For a nulliparous woman:

1.13.4 For a multiparous woman:

1.13.5 For a nulliparous woman, suspect delay if progress (in terms of rotation and/or descent of the presenting part) is inadequate after 1 hour of active second stage. Offer vaginal examination and then offer amniotomy if the membranes are intact. [2007, amended 2014]

1.13.6 For a multiparous woman, suspect delay if progress (in terms of rotation and/or descent of the presenting part) is inadequate after 30 minutes of active second stage. Offer vaginal examination and then offer amniotomy if the membranes are intact. [2014]

1.13.7 If full dilatation of the cervix has been confirmed in a woman without regional analgesia, but she does not get an urge to push, carry out further assessment after 1 hour. [2007]

The woman's position and pushing in the second stage

1.13.9 Discourage the woman from lying supine or semi‑supine in the second stage of labour and encourage her to adopt any other position that she finds most comfortable. [2007]

1.13.10 Inform the woman that in the second stage she should be guided by her own urge to push. [2007]

1.13.11 If pushing is ineffective or if requested by the woman, offer strategies to assist birth, such as support, change of position, emptying of the bladder and encouragement. [2007]

Delay in the second stage

1.13.24 If there is delay in the second stage of labour, or if the woman is excessively distressed, support and sensitive encouragement and the woman's need for analgesia/anaesthesia are particularly important. [2007]

1.13.26 After initial obstetric assessment of a woman with delay in the second stage, maintain ongoing obstetric review every 15-30 minutes. [2007]

Expediting birth

1.13.34 If the birth needs to be expedited for maternal or fetal reasons, assess both the risk to the baby and the safety of the woman. Assessments should include:

1.13.35 Talk with the woman and her birth companion(s) about why the birth needs to be expedited and what the options are. [2014]

1.13.36 Inform the team about the degree of urgency. [2014]

1.13.37 Record the time at which the decision to expedite the birth is made. [2014]

1.14 Third stage of labour

1.14.1 Recognise that the time immediately after the birth is when the woman and her birth companion(s) are meeting and getting to know the baby. Ensure that any care or interventions are sensitive to this and minimise separation or disruption of the mother and baby. [2014]

Definition of the third stage

1.14.2 For the purposes of this guideline, use the following definitions:

The third stage of labour is the time from the birth of the baby to the expulsion of the placenta and membranes.

Active management of the third stage involves a package of care comprising the following components:

routine use of uterotonic drugs

deferred clamping and cutting of the cord

controlled cord traction after signs of separation of the placenta.

Observations in the third stage

1.14.4 Record the following observations for a woman in the third stage of labour:

1.14.5 If there is postpartum haemorrhage, a retained placenta or maternal collapse, or any other concerns about the woman's wellbeing:

Active and physiological management of the third stage

1.14.6 Explain to the woman antenatally about what to expect with each package of care for managing the third stage of labour and the benefits and risks associated with each. [2014]

1.14.7 Explain to the woman that active management:

1.14.8 Explain to the woman that physiological management:

1.14.10 Advise the woman to have active management of the third stage, because it is associated with a lower risk of a postpartum haemorrhage and/or blood transfusion. [2014]

1.14.11 If a woman at low risk of postpartum haemorrhage requests physiological management of the third stage, support her in her choice. [2014]

1.14.12 Document in the records the decision that is agreed with the woman about management of the third stage. [2014]

1.14.13 For active management, administer 10 IU of oxytocin by intramuscular injection with the birth of the anterior shoulder or immediately after the birth of the baby and before the cord is clamped and cut. Use oxytocin as it is associated with fewer side effects than oxytocin plus ergometrine. [2014]

1.14.14 After administering oxytocin, clamp and cut the cord.

1.14.15 After cutting the cord, use controlled cord traction. [2014]

1.14.16 Perform controlled cord traction as part of active management only after administration of oxytocin and signs of separation of the placenta. [2014]

1.14.17 Record the timing of cord clamping in both active and physiological management. [2014]

1.14.18 Advise a change from physiological management to active management if either of the following occur:

1.14.19 Offer a change from physiological management to active management if the woman wants to shorten the third stage. [2014]

1.14.20 Do not use either umbilical oxytocin infusion or prostaglandin routinely in the third stage of labour. [2014]

Postpartum haemorrhage

Risk factors

1.14.29 Advise women with risk factors for postpartum haemorrhage to give birth in an obstetric unit, where more emergency treatment options are available.

1.14.30 If a woman has risk factors for postpartum haemorrhage, highlight these in her notes, and make and discuss with her a care plan covering the third stage of labour. [2007]

Management

1.14.31 If a woman has a postpartum haemorrhage:

1.14.32 Administer a bolus of one of the following as first‑line treatment for postpartum haemorrhage:

1.14.33 Offer second‑line treatment for postpartum haemorrhage if needed. No particular uterotonic drug can be recommended over any other; options include:

1.14.34 Assess the need for adjuvant options for managing significant continuing postpartum haemorrhage, including:

1.14.35 Allocate a member of the healthcare team to stay with the woman and her birth companion(s), explain what is happening, answer any questions and offer support throughout the emergency situation. [2014]

1.14.36 If the haemorrhage continues:

1.14.37 Be aware that no particular surgical procedure can be recommended over any other for treating postpartum haemorrhage. [2014]

1.14.38 The maternity service and ambulance service should have strategies in place in order to respond quickly and appropriately if a woman has a postpartum haemorrhage in any setting. [2014]

1.15 Care of the newborn baby

Initial assessment of the newborn baby and mother-baby bonding

1.15.1 Record the Apgar score routinely at 1 and 5 minutes for all births. [2007]

1.15.2 Record the time from birth to the onset of regular respirations. [2014]

1.15.3 If the baby is born in poor condition (on the basis of abnormal breathing, heart rate or tone):

1.15.4 Do not take paired cord blood samples (for blood gas analysis) routinely. [2014]

1.15.5 Ensure that a second clamp to allow double‑clamping of the cord is available in all birth settings. [2014]

1.15.6 Encourage women to have skin‑to‑skin contact with their babies as soon as possible after the birth[]. [2007]

1.15.7 In order to keep the baby warm, dry and cover him or her with a warm, dry blanket or towel while maintaining skin‑to‑skin contact with the woman. [2007]

1.15.8 Avoid separation of a woman and her baby within the first hour of the birth for routine postnatal procedures, for example, weighing, measuring and bathing, unless these measures are requested by the woman, or are necessary for the immediate care of the baby[]. [2007]

1.15.9 Encourage initiation of breastfeeding as soon as possible after the birth, ideally within 1 hour[]. [2007]

1.15.10 Record head circumference, body temperature and birth weight soon after the first hour following birth. [2007]

1.15.11 Undertake an initial examination to detect any major physical abnormality and to identify any problems that require referral. [2007]

1.15.12 Ensure that any examination or treatment of the baby is undertaken with the consent of the parents and either in their presence or, if this is not possible, with their knowledge. [2007]

Neonatal resuscitation

1.15.13 In the first minutes after birth, evaluate the condition of the baby - specifically respiration, heart rate and tone - in order to determine whether resuscitation is needed according to nationally accredited guidelines on neonatal resuscitation. [2014]

1.15.14 All relevant healthcare professionals caring for women during birth should attend annually a course in neonatal resuscitation that is consistent with nationally accredited guidelines on neonatal resuscitation. [2014]

1.15.15 In all birth settings:

1.15.16 If a newborn baby needs basic resuscitation, start with air. [2014]

1.15.17 Minimise separation of the baby and mother, taking into account the clinical circumstances. [2014]

1.15.18 Throughout an emergency situation in which the baby needs resuscitation, allocate a member of the healthcare team to talk with, and offer support to, the woman and any birth companion(s). [2014]

Care of babies in the presence of meconium

1.15.19 In the presence of any degree of meconium:

1.15.21 If there has been significant meconium and the baby is healthy, closely observe the baby within a unit with immediate access to a neonatologist. Perform these observations at 1 and 2 hours of age and then 2‑hourly until 12 hours of age. [2014]

1.15.22 If there has been non‑significant meconium, observe the baby at 1 and 2 hours of age in all birth settings. [2014]

1.15.23 If any of the following are observed after any degree of meconium, ask a neonatologist to assess the baby (transfer both the woman and baby if they are at home or in a freestanding midwifery unit, following the general principles for transfer of care described in section 1.6):

1.15.24 Explain the findings to the woman, and inform her about what to look out for and who to talk to if she has any concerns. [2014]

Babies born to women with prelabour rupture of the membranes at term

1.15.25 Closely observe any baby born to a woman with prelabour rupture of the membranes (more than 24 hours before the onset of established labour) at term for the first 12 hours of life (at 1 hour, 2 hours, 6 hours and 12 hours) in all settings. Include assessment of:

1.15.26 If there are no signs of infection in the woman, do not give antibiotics to either the woman or the baby, even if the membranes have been ruptured for over 24 hours. [2007]

1.15.27 If there is evidence of infection in the woman, prescribe a full course of broad‑spectrum intravenous antibiotics. [2007]

1.15.28 Advise women with prelabour rupture of the membranes to inform their healthcare professionals immediately of any concerns they have about their baby's wellbeing in the first 5 days after birth, particularly in the first 12 hours when the risk of infection is greatest. [2007]

1.15.29 Do not perform blood, cerebrospinal fluid and/or surface culture tests in an asymptomatic baby. [2007]

1.15.30 Refer a baby with any symptom of possible sepsis, or born to a woman who has evidence of chorioamnionitis, to a neonatal care specialist immediately. [2007]

1.16 Care of the woman after birth

Initial assessment

1.16.1 Carry out the following observations of the woman after birth:

Perineal care

1.16.2 Define perineal or genital trauma caused by either tearing or episiotomy as follows:

first degree - injury to skin only

second degree - injury to the perineal muscles but not the anal sphincter

third degree - injury to the perineum involving the anal sphincter complex:

3a - less than 50% of external anal sphincter thickness torn

3b - more than 50% of external anal sphincter thickness torn

3c - internal anal sphincter torn.

fourth degree - injury to the perineum involving the anal sphincter complex (external and internal anal sphincter) and anal epithelium. [2007]

1.16.3 Before assessing for genital trauma:

1.16.4 Perform the initial examination gently and with sensitivity. It may be done in the immediate period after birth. [2007]

1.16.5 If genital trauma is identified after birth, offer further systematic assessment, including a rectal examination. [2007]

1.16.6 Include the following in a systematic assessment of genital trauma:

1.16.7 Ensure that the timing of this systematic assessment does not interfere with mother-baby bonding unless the woman has bleeding that requires urgent attention. [2007]

1.16.10 Document the systematic assessment and its results fully, possibly pictorially. [2007]

1.16.11 All relevant healthcare professionals should attend training in perineal/genital assessment and repair, and ensure that they maintain these skills. [2007]

1.16.12 Undertake repair of the perineum as soon as possible to minimise the risk of infection and blood loss. [2007]

1.16.13 When carrying out perineal repair:

1.16.14 If the woman reports inadequate pain relief at any point, address this immediately. [2007]

1.16.15 Advise the woman that in the case of first‑degree trauma, the wound should be sutured in order to improve healing, unless the skin edges are well opposed. [2007]

1.16.16 Advise the woman that in the case of second‑degree trauma, the muscle should be sutured in order to improve healing. [2007]

1.16.17 If the skin is opposed after suturing of the muscle in second‑degree trauma, there is no need to suture it. [2007]

1.16.18 If the skin does require suturing, use a continuous subcuticular technique. [2007]

1.16.19 Undertake perineal repair using a continuous non‑locked suturing technique for the vaginal wall and muscle layer. [2007]

1.16.20 Use an absorbable synthetic suture material to suture the perineum. [2007]

1.16.21 Offer rectal non‑steroidal anti‑inflammatory drugs routinely after perineal repair of first‑ and second‑degree trauma provided these drugs are not contraindicated. [2007]

1.16.22 Observe the following basic principles when performing perineal repairs:

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Intrapartum care for healthy women and babies

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Choosing planned place of birth Women at low risk of complications 1.1.1 Explain to both multiparous and nulliparous women who are at low risk of complications that giving birth is generally very safe for both the woman and her baby.

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Thinking outside the box Pondering placentophagy Part 1

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Thinking outside the box Pondering placentophagy Part 1

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Optimal cord clamping campaign

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Blood to Baby | Optimal Cord Clamping | BloodtoBaby

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Blood to Baby | Optimal Cord Clamping | BloodtoBaby

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Information about the campaign to raise awareness about Optimal Cord Clamping and Delayed Cord Clamping, Blood to Baby

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Penny Simkin on Delayed Cord Clamping