o3 Deep Research output

Historical Origins and Rationale of Early Umbilical Cord Clamping

Early clamping of the umbilical cord – defined as severing or tying the cord in the first moments after birth – was not always the standard practice in Western obstetrics. Across history, recommendations on when to clamp the cord have shifted dramatically. Below, we chronologically explore how timing practices changed from antiquity to the modern era, identify key figures and innovations that drove these changes, and examine the major justifications that have been offered for routine early cord clamping (and the evidence for or against those rationales). Primary historical sources (original treatises, studies, etc.) are cited separately from later analyses or commentary.

Antiquity and Medieval Practices

In ancient and medieval times, midwives did tie and cut the cord, but there was no specific emphasis on immediate clamping. The main concern was simply to prevent bleeding. Soranus of Ephesus (2nd century AD), a Greco-Roman physician, advised that the newborn’s cord be tied in two places and cut in between – this avoided hemorrhage from both the infant and the mother’s side neonatology.net. This shows early understanding that the cord vessels needed ligation, but Soranus did not mention any precise timing relative to the placenta’s delivery. Similarly, medieval obstetric texts like the 12th-century Trotula compendium gave detailed instructions for cutting the cord (even suggesting a prayer or charm to recite and tying it with a special string), yet made no comment about how soon to do itpmc.ncbi.nlm.nih.gov. In essence, waiting for the placenta to be delivered before attending to the cord was the norm both by default and out of practical necessity in traditional births.

Historical and anthropological evidence suggests that in most pre-modern and non-Western settings, the cord was typically left alone until after the afterbirth. For example, 20th-century observers of indigenous African births noted that it was considered “completely wrong to touch the cord until the whole placenta is expelled”journals.co.za. The mother would remain in a birthing position, and the placenta would be delivered by natural effort or gravity, only then would the cord be tied off and cutjournals.co.za. This hands-off, physiological third stage (allowing the neonate to stay attached to the placenta until expulsion) was likely common in earlier eras as well. In summary, antiquity and medieval sources show cord tying was standard to prevent bleeding, but there was no directive to clamp immediately – early clamping as we think of it had not yet emerged as a distinct intervention.

17th Century: Earliest Advocacy of Immediate Cord Cutting

The practice of clamping and cutting the cord before placental delivery first gained traction in the mid-17th century. A pivotal figure was the French obstetrician François Mauriceau, whose 1668 obstetrics treatise marks one of the earliest clear endorsements of early cord intervention. Mauriceau recommended that after the baby was born, the cord should be immediately knotted and cut, and the birth attendant should promptly “relieve” the mother of the placentajournals.co.za. He feared that if one waited too long, the uterus might contract and “close” before the placenta was out, leading to a trapped (retained) placentajournals.co.za. To prevent this, he advised wrapping the cord around the hand and gently pulling as soon as the child was delivered, while using the other hand to stabilize the uterus – effectively an early form of controlled cord tractionjournals.co.za. Mauriceau did caution against excessive force (acknowledging that yanking could snap the cord and cause a dangerous retained placenta or even uterine inversion)journals.co.za. Nonetheless, his teaching represents a shift to an active management of the third stage: intervening immediately to extract the placenta, with the cord being clamped/ligated early as part of that maneuver.

Mauriceau’s influence (and that of other contemporary male “man-midwives”) made early cord cutting **increasingly routine by the late 1600s】journals.co.za. Notably, this was a departure from the practices of traditional midwives. Historians have observed that the 17th century saw the rise of male obstetric practitioners in Europe, whose approaches sometimes differed from the conservative, wait-and-see methods of midwives. In this case, the male physicians’ inclination to actively manage delivery of the placenta led to cord clamping “before the placenta dropped,” a practice not clearly documented before the 1600sreddit.com. Some commentators have even speculated that beyond medical reasoning (like Mauriceau’s fear of hemorrhage), male practitioners may have been motivated by impatience or discomfort with waiting for the afterbirth to deliver spontaneouslyreddit.com. In any event, by 1700 the idea of immediate cord tying and rapid placental delivery had entered obstetric doctrine, laying the groundwork for early clamping to become common.

18th Century: Debate and Dissenting Voices

During the 1700s, early cord clamping became more widespread in Western obstetric practice – but it was not without controversy. Even as many practitioners adopted the new habit of cutting the cord right after birth, others began to question it. Several prominent figures in the late 18th century argued that hastily clamping the cord was actually harmful to the newborn, and they advocated for a more delayed approach.

One early critic was Dr. Charles White of Manchester, who in 1773 strongly condemned the routine immediate cutting of the cord. He wrote that “the common method of tying and cutting the navel string in the instant the child is born… has nothing to plead in its favour but custom”pmc.ncbi.nlm.nih.gov. White classed early cord cutting as an “error in practice” sustained purely by tradition, implying there was no scientific or medical justification for it besides habit. Instead, he favored waiting and allowing nature to take its course.

Around the same time, Erasmus Darwin (physician and grandfather of Charles Darwin) joined the fray with an even more emphatic recommendation to delay. In 1801, Erasmus Darwin admonished in his book Zoonomia that cutting the cord too soon was “very injurious to the child” and urged that the cord not be tied or cut “till the child has not only repeatedly breathed but till all pulsation in the cord ceases.” Only then, he argued, would the baby receive the full benefit of the placental blood; otherwise the child would be “much weaker than it ought to be”pmc.ncbi.nlm.nih.gov. This remarkably prescient advice shows that some 18th-century practitioners recognized the importance of placental transfusion (i.e. the newborn continuing to get blood from the placenta for a short time after birth). Darwin’s view was essentially that of “delayed” cord clamping, over 200 years ahead of its time.

It’s important to note that White and Darwin were speaking out precisely because early clamping had become common practice by the late 18th century. Their writings indicate that many midwives and doctors of the era were, in fact, cutting the cord immediately upon birth as a routine – so much so that these men felt the need to publicly challenge the practice. Darwin even attempted to provide evidence: he cited the observation that infants allowed to continue pulsation were stronger, and this was later supported by crude experiments. In 1875, Dr. Pierre Budin measured the residual blood volume in delivered placentas when cords were clamped early, and found about 92 cubic centimeters of blood remained in the placenta – blood that would otherwise have circulated to the infantpmc.ncbi.nlm.nih.gov. This was a significant quantity, roughly on the order of 80–100 mL, and Budin concluded that the early-clamped neonate was effectively denied that amount of blood. His findings gave concrete, quantitative support to what Erasmus Darwin had intuited decades before.

Despite such warnings, the mainstream obstetric community was slow to embrace delayed clamping. Early cord tying/cutting continued to “plead custom” as its main justification through the 18th and into the 19th century, even as a minority of voices argued for a more physiological approachpmc.ncbi.nlm.nih.govpmc.ncbi.nlm.nih.gov. The stage was set for ongoing debate in the century that followed.

19th Century: Technological Advances and Entrenchment of Early Clamping

By the 1800s, cord clamping was commonly undertaken in Europe and America, but there remained considerable debate over how quickly it should be done. Obstetric textbooks of the 19th century show variability: some recommended tying the cord only after pulsations stopped, while others endorsed immediate severance. This era also saw technological developments – such as the invention of dedicated cord clamps – and new hypotheses that influenced cord management.

On the technology front, obstetricians historically used a simple ligature (a thread or tape) to tie off the cord. In 1899, Dr. E. Magennis introduced a metal “midwifery surgical clamp” as an alternative to the cloth ligaturepmc.ncbi.nlm.nih.gov. Magennis argued that an instrumental clamp would reduce the risk of infection, since it could be sterile, unlike possibly unclean ligature materialspmc.ncbi.nlm.nih.gov. His clamp design was adopted widely, and from that point on, the cord clamp became a universal tool in delivery rooms. (Magennis himself still advised that the clamp be applied only “when it has ceased to pulsate,” reflecting that at least in 1899 some practitioners were nominally waiting for pulsation to end before clampingpmc.ncbi.nlm.nih.gov. However, in actual practice the exact timing often went unremarked.)

Different obstetric schools promoted different timing. For example, some 19th-century practitioners took the approach of tying/clamping only the baby’s side of the cord and not immediately tying the placental side, thus allowing some blood to drain from the placenta after birth. The American obstetrician William Potts Dewees (circa 1820s) was cited by a later author as suggesting that “the evacuation from the open extremity of the cord will yield 2 or 3 ounces of blood, which favours contraction of the uterus and expulsion of the placenta.”journals.co.za In other words, letting the placental end bleed a bit was thought to help the uterus clamp down and the placenta detach. Accordingly, some doctors in the early 1800s would place a ligature on the fetal side to protect the baby from hemorrhage, but leave the maternal side open or only clamp it after a delay. This practice was essentially the opposite of trying to transfuse blood to the baby – instead, it was intentionally draining blood from the uterine side, a form of induced placental blood-letting intended to prevent hemorrhage and hasten placental delivery. There was, however, no consensus; others feared that not tying the cord on both sides could pose infection risks or make a mess. By late century, many practitioners began routinely clamping the cord in two places (both near the infant and near the placenta) as standard, partly to avoid any blood spilling on the bed when the cord was cutpmc.ncbi.nlm.nih.gov. This was one rationale given for double clamping: to “spare the bed linen” by preventing placental blood from gushing out of the cut endpmc.ncbi.nlm.nih.gov. Another rationale was that if the placental end was clamped, once the placenta detached the cord would visibly lengthen (since one clamp would move outward), providing a signal that it was time to pull out the placentapmc.ncbi.nlm.nih.gov. These 19th-century justifications were largely about hygiene and convenience, not infant health.

By 1861, practices still varied greatly according to an early edition of Williams’ Obstetrics. Some doctors would attempt to deliver the placenta immediately by cord traction or manual removal, while others waited. James Matthews Duncan and others wrote extensively on the third stage in the mid-1800s, reflecting ongoing debate. Toward the end of the century, however, active management was increasingly taught as the proper method for trained obstetricians. The general trend was toward more intervention: give ergot (a uterotonic) to the mother, clamp and cut the cord promptly, and deliver the placenta under gentle traction.

It’s important to note that although early cord clamping had become entrenched as routine by the late 19th century, some leading obstetricians remained aware of the infant’s need for placental blood. The French physician Pierre Budin (mentioned earlier) presented his experiment in 1875 quantifying neonatal blood loss with early clampingpmc.ncbi.nlm.nih.gov. And in the 1880s, Dr. J. H. Aveling and others advocated “autotransfusion” of the baby by delaying cord cutting when possible, especially if an infant was weak or asphyxiated at birth. Obstetric texts around 1900 sometimes noted that a baby would pink up better if the cord was not cut too soon. For instance, J. Whitridge Williams (author of the influential Williams Obstetrics) initially favored late cord tying, citing Budin’s 92 mL blood volume finding and reasoning that the infant draws in that blood with its first breathsjournals.co.za. In Williams’ 1st edition (1903) and several early editions, the recommendation was to wait ~1–2 minutes for the baby to begin breathing, unless there was a need to rush. This shows that the value of delayed clamping was recognized by some experts even as routine hospital practice was trending toward immediate clamping.

By the close of the 19th century, cord clamping/cutting was universally practiced in some form (no one advocated leaving the cord uncut indefinitely in medical settings), but the exact timing still lacked standardization. The invention of the hemostatic clamp and the rise of antiseptic technique had made the mechanics of cord cutting easier and cleaner – a far cry from the days of tying cords with a string from a lute (as Trotula suggested). Yet, as obstetrics entered the 20th century, the stage was set for early clamping to solidify into a doctrine, driven by new medical theories and institutional protocols.

Early–Mid 20th Century: Medicalization and the Dominance of Early Clamping

In the 20th century, obstetric practice moved definitively into hospitals and under physician management. This period saw early cord clamping become the dominant, standard practice in Western obstetrics, to the point that delayed cord clamping was largely viewed as an antiquated or “slow” approach until late in the century. Several developments and beliefs during the early-mid 1900s contributed to this dominance:

• Blood Transfusion and “Blood Banking” (1930s): In 1938, physicians discovered that placental/umbilical cord blood could serve as a useful source for human blood transfusionpmc.ncbi.nlm.nih.gov. A. H. Goodall published in JAMA about this “new source of blood for transfusion”pmc.ncbi.nlm.nih.gov. Given the interest in securing blood supplies (especially around World War II), obstetric protocols in some hospitals began clamping and cutting the cord early so that the placental blood could be collected in a sterile container. This meant intentionally foregoing the infant’s placental transfusion in order to use the blood for others. The practice wasn’t universal, but it introduced a systematic reason to clamp early: to harvest cord blood. (This is an early antecedent of today’s cord blood banking – see below.)

• **Emergence of Rh Factor Theory (1940s): Research into erythroblastosis fetalis (hemolytic disease of the newborn caused by Rh blood group incompatibility) peaked in the 1940s. It was hypothesized that clamping the cord immediately could prevent exchange of blood between mother and baby at birth, thereby reducing the infant’s exposure to maternal antibodiespmc.ncbi.nlm.nih.gov. At the time, doctors observed that some Rh-negative mothers had severe isoimmunization after birth and their babies were affected. Although we now know maternal–fetal hemorrhage mostly happens before or during delivery (not after), it was believed then that keeping the placenta circulation brief might help. Early cord clamping became recommended in cases of Rh incompatibility as a preventive measurepmc.ncbi.nlm.nih.gov. This rationale persisted into the 1950s, until the development of Rh immune globulin prophylaxis in the 1960s rendered it unnecessarypmc.ncbi.nlm.nih.gov. (With RhIg available, it no longer mattered how long the cord bled, since mothers could be treated to avoid antibody formation. But by then early clamping was already routine habit in most deliveries.)

• Obstetric Anesthesia and Newborn Resuscitation: The mid-20th century saw heavy use of obstetric anesthesia and analgesia, from ether/chloroform in earlier decades to narcotics and “Twilight Sleep.” These drugs often depressed newborns at birth, meaning babies didn’t breathe spontaneously right away. Pediatricians began attending deliveries to perform immediate care on limp infants. In this context, cutting the cord immediately was seen as necessary so the baby could be taken to a warming table for resuscitation. In fact, the editor of Williams Obstetrics (10th ed., 1950) noted that although it was ideal to delay clamping, in practice neonatal apnea, need for airway suctioning, or simply the expediency of moving the infant and repairing the mother’s perineum often dictated early clampingpmc.ncbi.nlm.nih.gov. Thus, “convenience” became a cited reason: obstetricians wanted the baby off the field to suture an episiotomy, and pediatric staff wanted the baby on their own table to assess breathingpmc.ncbi.nlm.nih.gov. This led to immediate cord clamping being built into the workflow of hospital deliveries.

• Virginia Apgar and Newborn Assessment: In 1953, Dr. Virginia Apgar introduced the Apgar score, a 1-minute (and 5-minute) evaluation of newborn vitality. Notably, Apgar’s seminal study explicitly excluded cases of “natural childbirth” where the cord was not immediately clampedpmc.ncbi.nlm.nih.gov. In her methodology, all babies were assessed after being separated from the placenta. She even remarked that keeping the cord intact longer was part of a “slow delivery” style not practiced in the cases studiedpmc.ncbi.nlm.nih.gov. The very image of mid-20th-century obstetrics became one of the baby being briskly clamped, cut free, and held by the obstetrician or pediatrician at one minute for evaluation (see image).

Apgar’s work didn’t intend to promote early clamping per se, but it reinforced the paradigm: everyone was now focused on the baby’s condition at 60 seconds, which practically required that the infant be physically separate and often away from the mother. Additionally, in operating rooms (for cesarean sections), maintaining a sterile field was paramount – surgeons found it more convenient to clamp and cut the cord right away to hand the baby off, because a newborn attached to the placenta would be an encumbrance during the suturing of the uterus and abdomenpmc.ncbi.nlm.nih.gov. Thus the rise in surgical deliveries (C-sections became more common after WWII) also institutionalized immediate clamping as standard procedurepmc.ncbi.nlm.nih.gov.

• Active Management of Third Stage: By mid-century, the concept of “active management” of the third stage of labor had coalesced. Pioneered in places like Dublin in the 1960s and later globally, active management comprised a package: routine injection of a uterotonic (like oxytocin) upon birth of the baby, early clamping and cutting of the cord, and controlled cord traction to deliver the placentapmc.ncbi.nlm.nih.gov. This approach was proven to reduce postpartum hemorrhage significantly, primarily due to the uterotonic drug contracting the uterus. Early cord clamping was simply bundled in – partly out of habit and partly out of the (mistaken) belief that it might speed up placental delivery or help prevent hemorrhage as well. For decades, active management (including immediate cord clamping) was taught as the standard of care worldwide, and any deviation (like “physiological” third stage with delayed clamping) was often viewed with skepticism in hospital practicepmc.ncbi.nlm.nih.govpmc.ncbi.nlm.nih.gov. It wasn’t until much later that researchers parsed out that early clamping was not actually a necessary component (see below).

By about 1950, therefore, routine early cord clamping had become dominant in Western obstetrics, entrenched through medicalization and hospital protocols. Surveys of practitioners illustrate this shift. For instance, in 1950, an American survey found the majority of obstetricians believed the timing of cord clamping was unimportant – they saw no harm in clamping immediately, reflecting the common practicepmc.ncbi.nlm.nih.gov. Over the next few decades, early clamping remained the default in most delivery rooms, even as research slowly started to question it. The practice endured largely due to institutional inertia and traditional teaching, despite periodic studies (from the 1960s onward) suggesting neonatal benefits to delaying. As one retrospective review noted, “from 1773 onwards, maternity practitioners have articulated the benefits of [delayed] cord clamping, yet this is not matched by practice”pmc.ncbi.nlm.nih.gov – a telling comment on how deeply the early-clamping habit took hold.

Late 20th Century to 21st: Re-evaluating Early vs. Delayed Clamping

Beginning in the late 20th century and into the 21st, there has been a significant re-examination of cord clamping timing. Researchers conducted randomized trials and systematic reviews that demonstrated clear benefits of delayed cord clamping for infants – including higher newborn iron stores, better neonatal adaptation, and reduced complications in preterm babies – with no increase in maternal hemorrhage riskpmc.ncbi.nlm.nih.govpmc.ncbi.nlm.nih.gov. These findings directly contradicted several historical justifications for early clamping. As evidence accumulated, professional guidelines started to change. By the 2010s, organizations such as the WHO, NICE (UK), and ACOG (USA) shifted to recommend delayed clamping (around 1–3 minutes or until cord pulsation ceases) for healthy deliveries. For example, ACOG in 2012 (and reaffirmed in 2020) officially endorsed waiting at least 30–60 seconds before clamping in vigorous term and preterm infantsacog.orgacog.org. They also emphasized that delayed clamping does not increase postpartum hemorrhage or other maternal risksacog.orgacog.org. This marked a reversal of over a century of standard practice.

However, the transition in practice has been gradual. Surveys even in the 2000s showed many obstetricians and midwives still clamped early out of habit or out of unfounded fears of neonatal jaundice or polycythemiapmc.ncbi.nlm.nih.govpmc.ncbi.nlm.nih.gov. The “strong influence of tradition”pmc.ncbi.nlm.nih.gov has been hard to overcome. Additionally, a new factor emerged in the late 20th century: private cord blood banking. Collecting blood for stem cell banking requires clamping the cord as early as possible (to maximize volume), and this commercial practice in some settings encouraged providers and parents to opt for immediate clamping for reasons unrelated to the birth itselfpmc.ncbi.nlm.nih.gov. Concerned about this, professional bodies have cautioned that cord blood collection should not compromise optimal timing of clampingpmc.ncbi.nlm.nih.gov. Many hospitals now have policies balancing these decisions.

Today, the pendulum is clearly swinging back toward delayed cord clamping as the evidence-based norm, particularly for uncomplicated births. The historical arc, therefore, has come full circle on the question of timing: what was common in the distant past (waiting for the cord to stop pulsating or the placenta to deliver) and argued for by a few Enlightenment-era physicians, is now being validated by modern science. Nonetheless, understanding why early cord clamping became so routine for so long requires appreciating the historical beliefs and circumstances that drove it. Below is a summary of the major rationales that have been offered over time for clamping the cord early – along with the evidence that later emerged to support or refute each rationale.

Major Historical Rationale for Early Cord Clamping (Hypotheses & Evidence)

• Preventing Newborn Blood Loss: The initial reason for tying or clamping the cord at all was to prevent hemorrhage from the newborn. In the moments after birth, if the umbilical cord is cut without being secured, the infant can indeed lose blood through the umbilical vessels until they naturally constrict. Thus from antiquity onward, tying the cord was recognized as essential to save the baby’s bloodpmc.ncbi.nlm.nih.gov. This is a sound practice and remains standard – however, it only necessitates tying off the baby’s end of the cord, not necessarily cutting the cord immediately or clamping the placental end. The physiological closure of the cord vessels (via Wharton’s jelly) occurs within minutes naturally. So while cord ligation is undoubtedly lifesaving, this justification alone does not dictate when to cut the cord from the placenta. It ensures the cord is secured to prevent neonatal bleeding, which can be done whether one clamps early or late. Evidence: Universal adoption of cord tying since ancient times confirms its necessity. It’s uncontroversial and not contested by modern delayed-clamping advocates – they still tie the cord, just after a delay.

• Avoiding Maternal Hemorrhage / Retained Placenta (Expedite Placental Delivery): A major historical motive for early clamping was the belief that it would help deliver the placenta faster and prevent postpartum hemorrhage. Mauriceau’s 17th-century recommendation was rooted in this: he feared the uterus would contract and trap the placenta if not removed immediatelyjournals.co.za. Early clamping allowed the practitioner to perform active management – pulling on the cord right after birth to extract the placenta, theoretically reducing the chance of a retained placenta and excessive bleeding. Some later practitioners (e.g., those following Dewees’ idea) even thought that letting the cord bleed a bit (by not tying the placental end) would aid uterine contraction and placental expulsionjournals.co.za. In summary, early cord clamping/cutting was an integral part of a strategy to quickly empty the uterus. However, evidence has shown this rationale to be largely unfounded. Modern studies and Cochrane reviews found that the timing of cord clamping has no significant effect on postpartum hemorrhage risk or the speed of placenta deliverypmc.ncbi.nlm.nih.gov. It is the uterotonic medications and proper uterine massage/traction that matter for hemorrhage, not whether the cord was clamped in 30 seconds vs 3 minutes. In fact, rushing can occasionally backfire – for instance, premature strong traction can cause the cord to snap or even invert the uterus, as Mauriceau himself cautioned againstjournals.co.za. Thus, the historical fear of the uterus “closing” too soon is not supported by clinical data; a uterus with good tone will expel the placenta whether the cord is clamped or not, and if it doesn’t, manual intervention is needed whether or not the cord was cut early. In practice, many modern obstetric protocols now omit early cord clamping from active management, since it confers no benefit to the motherpmc.ncbi.nlm.nih.gov.

• Keeping the Bed Clean & Observing Placenta Separation: Some pragmatic (if less lofty) reasons for early clamping were cited in the 19th and early 20th centuries. One was simply to prevent mess: by clamping or tying the placental end of the cord immediately after cutting, practitioners could avoid spilling blood on the delivery bed or floor. As one commentator quipped, it was about “sparing the linen”pmc.ncbi.nlm.nih.gov. Another reason was that with a clamp on the cord, it was easy to tell when the placenta had detached – the cord would lengthen and the clamp would move as the placenta slid down, signaling to the attendant that they could safely pull out the placentapmc.ncbi.nlm.nih.gov. These justifications were practical/visual aids rather than medically necessary steps. Evidence: These factors don’t impact health outcomes; they were about convenience. While certainly a clamped cord may drip less on the sheets, this must be weighed against the baby’s welfare. Modern delivery setups (with chux pads, etc.) manage blood spills, and the slight convenience of a clean bed is not considered a valid reason to deprive the baby of blood. As for noticing placenta separation, experienced birth attendants can observe other signs (gush of blood, uterus rising, cord lengthening even without a clamp on it). Thus, these rationales are considered trivial today, and early clamping “to spare the bed linen” has been rightly criticized as potentially sparing the linens at the expense of the childmdpi.com.

• Utilizing Cord Blood for Transfusion or Banking: At specific points in history, the baby’s placental blood has been viewed as valuable for uses other than the baby. In the late 1930s and 1940s, doctors began collecting cord blood for transfusions – especially during wartime and post-war blood shortages. To do this, the cord had to be clamped immediately and blood drained into a sterile bottlepmc.ncbi.nlm.nih.gov. This practice saved lives (using neonatal cord blood for transfusion in adults or other infants) but directly took 80–100 mL of blood away from the newborn. Similarly, in recent decades, private cord blood banking for stem cells has become popular, and to maximize the harvest, early clamping is performed. The rationale in both cases is essentially “use the cord blood elsewhere.” Evidence: We now know that about 30% of a newborn’s blood volume can reside in the placenta at birth, and much of it will transfuse to the baby in the first 1–3 minutes if not clampedpmc.ncbi.nlm.nih.govacog.org. Early clamping interrupts this, leaving a significant portion in the placenta (Budin measured ~92 mL on averagepmc.ncbi.nlm.nih.gov). While that blood can indeed be collected for other purposes, the downside is the infant receives less blood, potentially leading to lower iron stores. Modern ethical guidance generally holds that unless there’s a directed need (such as clamping early because the baby needs immediate resuscitation or the cord is around the neck tightly), the baby’s immediate health should take priority over elective collection of cord bloodpmc.ncbi.nlm.nih.gov. Many hospitals have policies to delay clamping for at least a minute even if parents plan to bank cord blood, acknowledging the newborn benefit. Thus, using cord blood as a resource was a historical driver of early clamping, but one that competes with the baby’s interest.

• Preventing “Over-Transfusion” (Polycythemia and Jaundice): As neonatal medicine advanced mid-century, some pediatricians became concerned that delayed clamping might cause harm by giving the baby too much blood. They observed that babies with excess red cells (plethoric or polycythemic infants) could develop jaundice or respiratory issues. It was theorized that not clamping the cord promptly could “over-transfuse” the baby, leading to a surplus of red blood cells and thus higher bilirubin levels or sluggish circulation. Indeed, some studies in the 1960s–1970s reported that babies who had delayed clamping had slightly higher hematocrits and a higher incidence of jaundice needing treatmentpmc.ncbi.nlm.nih.gov. This became a common rationale to justify early clamping in the late 20th century. However, the evidence over time has shown this risk to be minor and manageable. A notable randomized trial by Saigal et al. did find increased bilirubin and polycythemia in late-clamped infants, but follow-up analyses and meta-analyses found no significant long-term harm – any rise in hemoglobin/hematocrit tends to self-regulate, and although bilirubin levels are on average slightly higher with delayed clamping, the increase in jaundice requiring phototherapy is smallpmc.ncbi.nlm.nih.govacog.org. A 2013 Cochrane review confirmed that while delayed clamping does raise the risk of jaundice a bit, it significantly improves the infant’s iron stores for months and reduces anemiapmc.ncbi.nlm.nih.govpmc.ncbi.nlm.nih.gov. In term babies, the trade-off is considered well worth it; the extra iron and blood volume benefit neurological development, whereas jaundice can be safely managed with phototherapy if it occurspmc.ncbi.nlm.nih.govacog.org. In preterm infants, the benefits of delayed clamping (better circulation, fewer transfusions, less necrotizing enterocolitis and intraventricular hemorrhage) are even more pronounced, with no increase in complicationspmc.ncbi.nlm.nih.govacog.org. Thus, the historical worry about polycythemia/hyperbilirubinemia, while not entirely baseless, is not considered a valid reason to clamp early in modern practice – the net evidence favors delayed clamping despite a slight uptick in jaundice incidence.

• Facilitating Newborn Resuscitation and Care: Perhaps one of the most understandable reasons for early cord clamping has been the need to attend to the newborn after birth. If a baby is born in distress (not breathing or crying), the care provider may want to immediately cut the cord to perform interventions (stimulation, suctioning, intubation, etc.) at a warmer or resuscitation station. This was especially true in the mid-20th century when mothers often had general anesthesia or heavy sedation – newborns came out depressed and needed quick action, which usually meant separation from the mother. Virginia Apgar’s protocol, for instance, assumed the baby was separate and could be evaluated at 1 minute off the maternal perineumpmc.ncbi.nlm.nih.gov. Additionally, in sterile operating rooms, there was a notion that keeping the cord intact would contaminate the field (since the infant would be born onto a sterile field and then if left attached and handed up to the mother, it might bring unsterile elements into the surgical site)pmc.ncbi.nlm.nih.gov. So the cord was cut to maintain sterility and so the obstetrician could focus on the procedure. Evidence: Until recently, there were limited options to reconcile immediate neonatal care with an intact cord. However, new approaches (sometimes called “bedside resuscitation” or the use of a “turtle” or mobile resuscitation trolley that can be brought to the mother) allow babies to receive ventilation or suction while the cord is still connected. Studies have shown that most routine neonatal care (drying, stimulation, even CPR if needed) can be done with the baby on the mother’s abdomen or a nearby surface without cutting the cord. In fact, keeping the cord intact can help perfuse the baby during the first breaths – acting like an natural ECMO circuit. That said, if a baby is severely compromised and needs complex intervention that absolutely requires physical separation, clinicians may still clamp early. The key point is that this is a case-specific clinical decision, not a blanket policy. Historically, however, the training and available equipment (or lack thereof) forced early clamping as a default to enable any newborn care. Modern evidence suggests that in most cases, initial resuscitation measures can be done without immediate clamping, and doing so might even improve outcomes (by preventing the loss of blood volume to the placenta while the baby is struggling to establish circulation)pmc.ncbi.nlm.nih.gov. This rationale for early clamping is therefore weakening as practices adapt, but it remains one scenario where early clamping might be chosen for expediency. It’s worth noting that babies born from narcotized mothers in the 1940s–60s often were cut and rushed, but this was more due to maternal medication effects than an inherent need to cut the cord – a problem largely mitigated today by different anesthesia techniques.

• Convenience and Institutional Routine: Finally, an unspoken but powerful reason for the persistence of early clamping was simply habit and convenience. As noted in multiple surveys, many providers continued to clamp early well into the 2000s because “that’s how we’ve always done it,” or because they believed “it doesn’t make a difference”pmc.ncbi.nlm.nih.gov. In busy maternity wards, early clamping fits the assembly-line rhythm – the baby is passed to pediatric staff, the OB immediately turns attention to the placenta and any repairs, and the room can be readied for the next delivery. This workflow was deeply ingrained. Evidence: The influence of custom is not easily quantifiable, but it has been acknowledged in the literature. For instance, Downey and Bewley (2012) conclude that **“lack of knowledge [and] the strong influence of tradition” kept early clamping popular long after evidence was questioning itpmc.ncbi.nlm.nih.gov. In other words, even when scientific data began favoring delayed clamping in the late 20th century, practice was slow to change because it was simply easier for staff to continue the familiar routine. Only concerted education and changes in guidelines have gradually shifted this inertia.

In summary, numerous hypotheses were historically put forward to justify clamping the cord immediately, ranging from protecting the infant or mother from various harms to purely pragmatic concerns. Over time, most of these justifications have been proven irrelevant or outright false. Preventing infant hemorrhage requires cord ligation but not immediate separation; preventing maternal hemorrhage does not depend on early clamping; concerns about neonatal polycythemia are outweighed by benefits of extra blood; and issues of convenience can be overcome with proper technique and modern equipment. The one overarching reason early clamping took hold and stayed dominant so long was cultural and institutional momentum – once obstetrics moved into an era of intervention and standardization, early clamping became part of the standard package, “nothing to plead in its favour but custom,” as Charles White observed in 1773pmc.ncbi.nlm.nih.gov.

Today, historical reflection on this topic serves as a powerful reminder that practices can become ingrained without sound evidence. The resurgence of delayed cord clamping in our era is essentially a course-correction aligning modern practice with both ancient wisdom and current science. As one reviewer noted, the purported benefits of early clamping have repeatedly been proven either negligible or false, whereas its downsides (for the baby) are realpmc.ncbi.nlm.nih.gov. After centuries of debate, it appears the best interest of the newborn – and the mother – is served by a more physiological approach, unless specific circumstances dictate otherwise. The history of umbilical cord clamping thus encapsulates a broader story in medicine: the interplay of tradition, technology, individual innovators, and evidence in shaping the standards of care.

---

Primary Sources (Historical):

• Soranus of Ephesus (2nd century AD) – Gynaecology (as quoted by modern translators): Recommends tying the cord in two places and cutting in between to prevent bleeding from both mother and infantneonatology.net.

• Trotula (circa 12th century) – Trotula Compendium of Women’s Medicine: Provides instructions for cutting the newborn’s cord (tying and chanting a charm) but no mention of timing, implying no urgency to cut before placenta deliverypmc.ncbi.nlm.nih.gov.

• François Mauriceau (1668) – Traité des Maladies des Femmes Grosses (Treatise on Diseases of Pregnant Women): First clear advocacy of immediate cord management. Advised that the cord must be knotted and cut right after birth, and the placenta extracted promptly for fear the uterus might close and trap itjournals.co.za. Described wrapping the cord around the hand and gently pulling, while cautioning against too-forceful traction to avoid cord breakage or uterine inversionjournals.co.zajournals.co.za.

• Charles White (1773) – Treatise on the Management of Pregnant and Lying-In Women: Criticized the “common method of tying and cutting the navel string the instant the child is born” as having “nothing to plead in its favour but custom,” effectively calling early cord cutting an unjustified routinepmc.ncbi.nlm.nih.gov.

• Erasmus Darwin (1801) – Zoonomia, Volume III: Warned that it is “very injurious” to the infant to cut the cord too soon. Urged that the cord not be tied until the child has breathed repeatedly and cord pulsation has ceased, otherwise the child will be weaker than necessarypmc.ncbi.nlm.nih.gov.

• William Potts Dewees (circa 1820s) – Compendious System of Midwifery: Advised tying the cord on the infant side but leaving the placental end open briefly, claiming that 2–3 ounces of blood draining from the cut cord would help the uterus contract and the placenta to expel (as later quoted by 19th-century authors)journals.co.za.

• Pierre Budin (1875) – Report on placental blood volume: Conducted experiments by clamping cords at birth. Found approximately 92 mL of blood remained in the placenta with immediate clamping, blood that would otherwise transfuse to the newbornpmc.ncbi.nlm.nih.gov. This was one of the first quantitative demonstrations of the effect of early clamping on neonatal blood volume.

• E. Magennis (1899) – Lancet article “A Midwifery Surgical Clamp”: Introduced a steel umbilical cord clamp for routine use, proposing it as more hygienic than a tied string. Instructed that the clamp be applied after pulsation stopspmc.ncbi.nlm.nih.gov. This reflects both a technological innovation and an implicit timing recommendation (wait until pulsations cease).

• A. H. Goodall (1938) – Journal of the American Medical Association: “A New Source of Blood for Transfusion.” Announced that placental/cord blood could be collected and used for blood transfusionspmc.ncbi.nlm.nih.gov. This led to interest in early clamping to harvest cord blood.

• Nicholas J. Eastman (ed.), Williams Obstetrics, 10th ed. (1950) – In commentary, acknowledged benefits of delayed clamping but still included early cord cutting as part of management. Noted that clamping might be done sooner in practice due to concerns about newborn apnea (from maternal anesthesia), need to attend to perineal repair, and general conveniencepmc.ncbi.nlm.nih.gov.

• Virginia Apgar (1953, 1958) – Original papers on the Apgar Score (Curr. Res. Anesth. & Analg. 32:260–267, 1953; JAMA 168:1985–1988, 1958): Studied newborns at 1 minute postpartum, all of whom had already been cord-clamped. Apgar explicitly excluded deliveries where the cord was not immediately clamped, labeling those “natural childbirth” cases as outside her studypmc.ncbi.nlm.nih.gov. In the 1958 report, she remarked that leaving the cord intact was considered part of a “slow” delivery and noted it was avoided in the hospital contextpmc.ncbi.nlm.nih.gov. These papers illustrate the assumption of immediate clamping in mid-century neonatal assessment.

• N. J. Smith (1956) – California Medicine 84:313–317: “Management of Erythroblastosis Fetalis.” Advised that in Rh incompatibility cases, early cord clamping should be done to reduce the infant’s exposure to antibody-rich maternal bloodpmc.ncbi.nlm.nih.gov. This was an application of the (later disproven) theory that prompt cord cutting could mitigate Rh disease severity.

(The above primary sources are cited via either direct quotations from the original works or via later works that preserved their statements. They provide firsthand insight into the practices and reasoning in their respective periods.)

Secondary Sources (Historical Analysis and Commentary):

• Candice L. Downey & Susan Bewley (2012) – “Historical perspectives on umbilical cord clamping and neonatal transition,” J. Roy. Soc. Medicine 105(8):325–329. A comprehensive historical review of cord clamping practicespmc.ncbi.nlm.nih.govpmc.ncbi.nlm.nih.gov. Summarizes early literature (citing Botha 1968 on sources from 1668 onward)pmc.ncbi.nlm.nih.gov, quotes 18th-century critics like White and Darwinpmc.ncbi.nlm.nih.gov, covers 19th-century developments (e.g., Magennis’ clamp)pmc.ncbi.nlm.nih.gov, and details 20th-century shifts such as the influence of cord blood transfusion discoverypmc.ncbi.nlm.nih.gov, Rh disease hypothesispmc.ncbi.nlm.nih.gov, Apgar’s rolepmc.ncbi.nlm.nih.gov, and modern evidence from trials and reviews (e.g., Cochrane)pmc.ncbi.nlm.nih.govpmc.ncbi.nlm.nih.gov. Concludes that the reasons given for early clamping have changed over time but often failed scrutiny, and that tradition largely perpetuated the practicepmc.ncbi.nlm.nih.gov.

• M. C. Botha (1968) – “The management of the umbilical cord in labour,” S. African J. Obstet. Gynaecol. 6(2):30–33. An early analysis questioning routine cord clamping. Botha reviews historical practices, noting that before the 17th century, cutting the cord before placental delivery was not mentioned and that in 1668 Mauriceau made it the “rule”journals.co.za. Botha also recounts observing indigenous births where the cord was left untouched until the placenta delivered, which inspired him to study delayed vs. immediate clamping outcomesjournals.co.za. His article provided evidence from a small case series and encouraged re-thinking the necessity of immediate clamping.

• Stanley De Witt (1959) – “An Historical Study on Theories of the Placenta to 1900,” J. Hist. Med. Allied Sci. 14:360–374. Discusses evolving understanding of placental function over centuries (e.g., debates on maternal-fetal blood mixing). Helps contextualize why early obstetricians might or might not have valued placental blood transfer to the infant. (For instance, those who realized maternal and fetal blood were separate might be more inclined to let the baby have its blood, whereas earlier erroneous theories might have downplayed its importance.)

• Green, Monica H. (2002) – The Trotula: A Medieval Compendium of Women’s Medicine (translation). Provides an English translation of the Trotula texts, including instructions on newborn care such as cutting the cord. Useful for understanding medieval practices (showing that while cord cutting was routine, there was no urgency implied in these instructions)pmc.ncbi.nlm.nih.gov.

• Sarah Inch (1985) – “Management of the third stage of labour – a cascade of intervention?” Midwifery 1:114–122. A commentary by a midwife-historian on how interventions in third stage (including early clamping) became commonplace and how one intervention led to another. Puts the cord clamping issue in the context of an intervention “cascade.”

• Laura E. Bennet (2013) – “The art of cord clamping: sparing the linen or sparing the child?”, Journal of Physiology 591(8):2021–2022. A short historical commentary highlighting the 19th-century rationale of “sparing the linen” vs the modern push to prioritize the baby (the “child”). Emphasizes how earlier practice valued cleanliness and speed, whereas current physiology favors the infant’s blood volumemdpi.com.

• Hutchon, D. (2010) – “Why do obstetricians and midwives still rush to clamp the cord?”, BMJ 341:c5447. A contemporary editorial questioning persistent early clamping. Cites historical figures like White and Darwin and argues for embracing the physiological approach. Points out the lag between evidence and practice.

• ACOG Committee Opinion #814 (December 2020) – “Delayed Umbilical Cord Clamping After Birth.” Reflects the updated stance of the American College of Obstetricians & Gynecologists, including a brief historical note that prior to the mid-1950s, “early” was defined as <1 minute and that about 80–100 mL of blood transfers in the first 3 minutes after birthacog.org. Confirms current recommendations for at least 30–60 second delay for most infantsacog.org and notes that delayed clamping does not increase maternal hemorrhageacog.org but does slightly increase jaundice treatable with phototherapyacog.org. Serves as evidence of the modern consensus reversing earlier routine practice.

• WHO Guidelines (2012, 2014) and NICE (UK) Guidance (2007, 2014) – (Not individually cited above, but generally in agreement.) These guidelines globally shifted to recommend delayed cord clamping in active management of third stage, unless the newborn needs immediate resuscitation, and explicitly state that immediate clamping is not required for PPH prevention.

• Practicing Midwife journal articles (various, 2008–2010) – Several pieces (e.g., by Amanda Burleigh, etc.) in midwifery literature have revisited historical practices and encouraged a return to “optimal cord clamping,” citing many of the above historical sources and raising awareness in the practitioner community about the evidence for delay.

These secondary sources provide analysis, context, and synthesis of the historical data, helping connect the timeline of events and shifting rationales with current understanding. They distinguish the primary historical facts (what was done or said at the time) from hindsight interpretation and modern clinical data. All together, they tell the story of how early umbilical cord clamping became standard in Western medicine and why that standard is now being critically reevaluated and largely abandoned in favor of a practice that earlier generations like Erasmus Darwin could only advocate based on intuition and observation. The evolution was not linear or solely evidence-driven – it was influenced by individuals, inventions (like the cord clamp device), institutional protocols (like active management and Apgar scoring), and even socio-cultural factors (like the rise of male obstetricians and the demands of wartime medicine). Understanding this history deepens our appreciation for the balance between tradition and evidence in obstetric care.