Cord Management

Part of Midwifery and Childbirth

Safe clamping and cutting of the umbilical cord to protect the newborn from bleeding and infection.

Why This Matters

The umbilical cord is the baby’s lifeline during pregnancy — carrying oxygenated blood and nutrients from the placenta. After birth, it must be managed carefully: the timing of clamping affects how much blood the baby receives, the cutting technique must be clean to prevent infection, and the resulting stump must be cared for properly to prevent neonatal tetanus — historically one of the leading causes of newborn death.

Neonatal tetanus, caused by Clostridium tetani bacteria introduced through the cord stump, killed millions of infants globally for millennia. The bacteria typically entered through contaminated cutting instruments or through traditional practices of applying substances (dung, ash, oil, mud) to the cord stump. Simple, consistent practice — clean instrument, cord left dry and open to air — prevents it entirely.

The decision about when to cut the cord is also medically significant. Early cord clamping (before pulsation stops) became standard in 20th century hospitals for logistical reasons. Delayed cord clamping — waiting 1-3 minutes or until pulsation stops — has been shown to increase the infant’s iron stores and reduce the risk of anemia in the first months of life.

Timing: When to Cut the Cord

Delayed Cord Clamping (Recommended)

Current evidence strongly supports waiting at least 1-3 minutes after birth before cutting the cord. The cord continues to pulse after birth, actively transferring blood from the placenta to the baby. This placental transfusion — typically 80-100 mL of blood — represents 25-40% of the newborn’s circulating blood volume.

Benefits of delayed cutting:

• Higher iron stores in the infant for the first 3-6 months
• Better blood volume and less risk of early anemia
• No increased risk to mother or baby

Practical application: After the baby is born, place the baby on the mother’s chest or between her legs. Observe the cord — it will be visibly pulsating (throbbing with each heartbeat). Wait until the pulsation stops or diminishes significantly, then clamp and cut.

In most births, pulsation stops within 1-5 minutes. There is no need to rush.

When Immediate Clamping May Be Needed

• The baby needs immediate resuscitation and distance from the mother is required
• The cord is very short and prevents proper positioning of the baby
• The cord has wrapped tightly around the neck (nuchal cord — see below)
• Placental abruption with maternal hemorrhage requiring urgent placenta delivery

Even in these situations, a 30-60 second delay is still beneficial unless the situation is truly immediately life-threatening.

Preparing for Cord Clamping

Before birth, prepare:

1. Two cord ties or clamps: String, narrow strips of clean cloth, or any sturdy tie material, boiled for 10 minutes. Each approximately 30 cm long.
2. Cutting instrument: A clean, sharp blade — knife, scissors, or single-edge razor. Boiled for 10 minutes or flame-sterilized and cooled.
3. Clean handling: Everything that touches the cord must come from the clean supply only — not from instruments that have been on the ground or touched other surfaces.

How to Clamp and Cut

Step 1: Apply the First Tie

When ready to cut (after pulsation has stopped or after the appropriate wait time):

Tie the first cord tie firmly at 2-3 cm from the baby’s umbilicus. A square knot (right over left, then left over right) is secure and will not slip. Tie it snugly — it must fully occlude the cord to prevent bleeding from the baby’s side.

Step 2: Apply the Second Tie

Apply the second tie 3-5 cm further from the baby (toward the placenta) — so there is approximately 2-3 cm of cord between the two ties. This provides a clear, identified section to cut between.

The reason for two ties: if one slips or fails, the other prevents hemorrhage.

Step 3: Cut Between the Ties

Using the clean, prepared blade: cut cleanly through the cord between the two ties with one decisive stroke. Hesitation leads to ragged cuts.

The cord does not contain nerve endings — the baby does not feel the cut. The mother does not feel it either.

Step 4: Check Both Ends

• Baby’s cord end: Check that the cut surface is not bleeding. The tie should be holding the vessels closed. If any bleeding from the baby’s stump: apply another tie closer to the umbilicus immediately.
• Placental cord end: A small amount of blood from the placenta-side cut is normal. The tie will stop it.

Nuchal Cord (Cord Around the Neck)

A loop of umbilical cord around the baby’s neck is found in approximately 20-25% of deliveries. In most cases, it causes no problem — the cord is loose enough to slip over the head.

Assessment at delivery of the head: After the head delivers, before the body, run a finger around the baby’s neck to feel for the cord.

Loose nuchal cord: Slip it forward over the head before the body delivers, or backward over the face as the body delivers. Either works.

Tight nuchal cord (cannot be slipped free): The cord is too tightly wrapped to slip over the head.

Options:

1. Somersault maneuver: Do not clamp and cut. Instead, allow the baby to be born by somersaulting forward — the body delivers while the head remains close to the perineum and the cord is not under traction. Once born, the cord can then be unwound. This is the preferred modern approach — it preserves cord blood flow.
2. Double clamp and cut: If somersault is not possible, clamp the cord in two places close together and cut between the clamps to release the cord before the body delivers. This sacrifices the delayed clamping benefit but frees the cord.

Stump Care After Birth

The Clean and Dry Method

After cutting, the cord stump — 2-3 cm of dried tissue attached to the umbilicus — must be:

• Left open to air — not wrapped, not covered, not bandaged
• Kept dry — fold diapers below the stump to prevent urine contact; sponge-bathe rather than immersing the infant in water until the stump falls off
• Left alone — do not apply any substance to the stump

The stump dries and shrivels over 7-14 days, then falls off naturally.

Signs of Cord Infection

Inspect the stump at every diaper change:

• Normal: Drying, shriveling, changing color from yellow-green to brown to black. Slight odor as it dries is normal.
• Warning: Redness or swelling spreading from the base of the stump onto the surrounding skin. Pus or discharge. Unusual warmth. Infant has fever or is unwell.

Cord infection (omphalitis): Bacteria spreading from the stump into the abdominal wall and potentially the bloodstream. Neonatal emergency. Apply clean dressing with diluted antiseptic (diluted honey, clean thyme tea compress). Monitor closely. This can progress to life-threatening sepsis within hours in a newborn.

Never Apply Anything to the Stump

Soil, ash, dung, cooking oil, animal fat, traditional herbs applied internally to the stump — all have been associated with neonatal tetanus and omphalitis. The protective practice is inaction: clean the cord once with clean water if visibly soiled, then leave it completely alone to dry in open air. Simplicity is safety here.