Can the placenta be left attached to the baby until it atrophies during a normal vaginal delivery?

From the Guidelines

Leaving the placenta attached to the baby until it withers is not a recommended practice due to the risk of infection and other complications. When considering the optimal timing for cord clamping, the focus should be on balancing the benefits of placental transfusion with the need to prevent potential complications. According to a study published in the BMJ in 2006 1, delayed cord clamping for at least three minutes can provide optimal placental transfusion, reducing infant anaemia and improving child survival in resource-poor settings. However, this practice does not involve leaving the placenta attached indefinitely. Instead, it recommends clamping the cord after a specified delay, which allows for the beneficial transfer of blood to the newborn while minimizing risks. Key points to consider include:

• Delayed cord clamping should be considered for every infant born in a resource-poor setting, regardless of gestational age 1.
• The practice should be combined with the administration of oxytocin immediately after delivery to reduce maternal blood loss in the third stage of labour 1.
• When the state of the infant does not allow a clamping delay of three minutes, aiming for a delay of at least 60 seconds is recommended, with the infant placed between the mother’s legs 1. The primary concern with leaving the placenta attached until it withers is the increased risk of infection, as the placenta is dead tissue that begins decomposing immediately after delivery. This practice, known as lotus birth, is not supported by medical evidence and poses unnecessary risks to the newborn. In contrast, delayed cord clamping, as recommended by the study 1, offers a safe and effective way to provide newborns with the benefits of placental transfusion while minimizing complications.

From the Research

Placenta Attachment During Normal Delivery

• The placenta is typically separated and expelled from the uterus during the third stage of labor, which is defined as the time period between delivery of the fetus through delivery of the placenta 2.
• There is no evidence to suggest that keeping the placenta attached to the baby until it withers is a recommended or common practice during normal delivery.
• In fact, the third stage of labor is a critical period where uterine contractions lead to separation and expulsion of the placenta, and any delay or retention of the placenta can increase the risk of postpartum hemorrhage 2.

Management of Retained Placenta

• Retained placenta is a significant cause of maternal death from postpartum hemorrhage, and traditionally, it is managed by manual removal under anesthesia 3.
• However, uterotonics such as misoprostol and sulprostone may offer an alternative for delivering the retained placenta, as they induce uterine contractions 3.
• Intra-umbilical vein oxytocin injection has also been shown to be clinically effective for the management of retained placenta, reducing the need for manual removal and uterine atony 4.

Delayed Umbilical Cord Clamping

• Delayed umbilical cord clamping appears to be beneficial for term and preterm infants, increasing hemoglobin levels at birth and improving iron stores in the first several months of life 5.
• However, there is no direct evidence to suggest that delayed umbilical cord clamping is related to keeping the placenta attached to the baby until it withers.
• The American College of Obstetricians and Gynecologists recommends a delay in umbilical cord clamping in vigorous term and preterm infants for at least 30-60 seconds after birth 5.

Physiology and Pharmacology of Oxytocin

• Oxytocin is a reproductive hormone implicated in the process of parturition and widely used during labor to induce uterine contractions 6.
• Oxytocin is released in pulses with increasing frequency and amplitude in the first and second stages of labor, and its release and function during labor are stimulated by social support 6.
• Synthetic oxytocin is often administered after delivery to induce uterine contractility and prevent postpartum hemorrhage, but there is no evidence to suggest that it is related to keeping the placenta attached to the baby until it withers 6.