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The Shoelace Protocol

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By Jill Arnold

Precipitous births that occur unexpectedly at home or on the side of the road regularly make the local news, usually with a touchy-feely headline about how an older sibling or the neighbor’s dog delivered the baby in the caul assisted by a kitten, who instinctively tore the sac with her wee, precious claws. One detail that appears in a good percentage of these stories is that someone was able to miraculously save the newborn from its own blood by following the 911 dispatcher’s instructions to tie off the cord with a shoelace.

In discussing this protocol yesterday on Facebook, a midwife and an OB both stated that the better protocol would be to leave the cord alone, and not just in the case of a surprise birth. Don’t tie it off and don’t cut it. Don’t rush. Keep the shoelace on your shoe.

Sarah, a reader of The Unnecesarean and a 911 dispatcher, took the time to share the national protocol, including the shoelace protocol, with the community. If you’ve ever wondered what dispatchers are trained to say in the case of birth, please thank Sarah for sharing.




We have several protocols that we are required to use when taking 9-1-1 calls. These scripts are a national standard. I will try to make this as simple as possible…


Standard birth protocol


-Listen carefully and do exactly as I say. Where is she now? (Get her as close to the phone as possible) Lay her on her back in the center of a bed or lay her on her back in the center of a bed or on the floor. I’m going to tell you how to deliver the baby.


-Make sure all clothing below her waist is removed. Raise her head with pillows, but don’t let her sit up or go to the bathroom.


-I want you to get some dry towels and a blanket to wrap the baby in. Get a string or shoelace to tie around the umbilical cord after delivery. Get a safety pin also, if you can.


-I want you to look at her vagina very carefully to see how close the baby is to being born. (Do not pull on the baby or cord.)


-Okay. With each contraction place the palm of your hand against her vagina to apply firm but gentle pressure to keep the baby’s head from delivering too fast and tearing her. Do you understand?


-As the baby delivers, support the baby’s head and shoulders and hold the hips and legs firmly. Remember, the baby will be slippery. Don’t drop it. Is the baby completely out?


-Is the baby crying or breathing?


(In case of: Cord wrapped around baby)

-It’s common for the umbilical cord to be wrapped around the baby’s neck or body. Listen carefully and I’ll tell you exactly what to do next. Slide your finger under the cord. Without stretching the cord tight, carefully pull it over the baby’s head. Is the baby breathing now?


-Gently wipe off the baby’s mouth and nose. Dry the baby off with a clean, dry towel. Cover the baby’s head but not its face. Without pulling the cord tight, put the baby in the mother’s arms or on her belly. Be sure to keep the baby and the mother warm.


-Listen carefully and I’ll tell you exactly what to do next. Without pulling on the cord, tie a string (shoelace) tightly around the umbilical cord, about 6 inches from the baby. Do not cut it. Do it now and tell me when it’s done.


-Do not pull on the cord. The afterbirth should deliver soon. Tell me if anything changes. Is the afterbirth out yet?


(In case of ruptured cord)

-I want you to clench the bleeding area of the cord in your hand and squeeze it tightly. Hold it for one minute. Don’t let go. (In this case, we instruct the caller to tie the cord 3 inches above and below the rupture)


-Wrap the afterbirth in a towel and keep it. The doctor will need to examine it to be sure it all came out. Are the mother and baby all right?


-It’s important that you watch the baby and the mother to be sure they’re both all right. Use a blanket to keep the mother warm. If anything changes, tell me immediately. Tell me when the paramedics arrive.


—-I know that you’re dying to know what’s up with the safety pin, so without further ado…


(In case of: Sac Not Broken - Baby born)

-Help is on the way. If the sac doesn’t immediately break open, then pinch the sac with your fingers and twist it hard, using your fingernails to tear it open. Then push your finger into the hole and tear away the sac. Is the sac broken now?

(If no:) -Open the safety pin and use the sharp end to tear a hole in the sac. Be very careful not to cut the baby. Is the sac broken now?



We have other protocols for various emergency situations, including baby or mom not breathing.


Here is the breech protocol: (We have two, one for breech delivery, one for breech positioning)


-Now look at her vagina very carefully and confirm which part of the baby you see. Remember, do not pull on the baby or cord.


(If the answer is foot/feet, leg(s), buttocks then we do breech delivery. If the answer is hand(s) without head, arm(s) without head, cord without head then we do the breech positioning protocol.)


Breech delivery:

-I want you to prepare a soft area on the ground, no more than a foot from the mother’s bottom. Use something clean and soft. This is to put the baby on when it comes out. Do you understand me so far?


-This could be a difficult delivery. Listen carefully and I’ll tell you exactly what to do next. Bring the mother’s bottom to the edge of the bed. Tell the mother to grab her knees and pull them to her chest. Do you understand?


-Do not touch the baby. The mother should be able to deliver this way. Let the baby hang down toward the ground. Don’t be afraid that the baby will fall; just make sure you have a soft area for the baby to land. Remember, do not pull on the baby or cord. Tell me what’s happening.


(Baby’s head stuck)- If the baby’s arms are out, but the head does not come with the next contraction, help the mother to stand. Have her bend her knees and squat. Now tell her to push really hard. Is the baby completely out?


Breech positioning:

Listen carefully. Do not push anything back into the vagina. Have her roll over and get up on her elbows and knees. Tell her to stop pushing with the pains and take deep breaths instead. Do it now and tell me when it’s done. Was she able to get on her elbows and knees?


We have more protocols, and more what-ifs, but it can get pretty complicated/confusing to follow. With each question, depending on what the caller says, there are different questions that we have to ask afterwards. So, there are so many possibilities, but I have highlighted a few major protocols for you to see.


Note from Sarah: If you have a medical emergency, please do call 9-1-1, and do not rely on what I have typed above. Also, please understand that this is a national protocol, and not necessarily my opinion of the way that things should be done. So, just to be perfectly clear, I assume no responsibility, this is meant for informational purposes only. Thank you.


Photo credit: tk-link/Flickr

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Reader Comments (13)

What happens if an operator deviates from the script? Or does that just not happen?

Not terrible except for supine positioning, not letting mom go to the bathroom, and that dang shoelace.

February 20, 2011 | Unregistered Commentermrsculpepper

I can actually understand not letting mom go to the bathroom. If the baby is coming so fast that the paramedics don't have time to get there, you don't want mom delivering on, or possibly into, the toilet.

My question is what the response is if the opperator is told that they are waiting for the cord to stop pulsing to tie it off. Is it accepted or argued?

February 20, 2011 | Unregistered CommenterDianna

'Lay her on her back...'

Gah!! Wish that said, "or in whatever position the mother is most comfortable."

February 21, 2011 | Unregistered CommenterAmity

Ironic that they insist mom lay on her back and haul her knees to her ears for everything, but if the breach babe becomes stuck they suddenly remember "Oh yes! Squatting just might be useful!" Arg.

February 21, 2011 | Unregistered CommenterAron

I had a precipitous labor resulting in an "emergency" birth in a car. The delivery was perfect and uncomplicated, thank goodness, but I was also disturbed by the suggestion to tie off the cord immediately. My son was not breathing at first (turns out he just needed to be suctioned) and EMS did not arrive for 3 minutes, so I refused to tie off the cord, because it was the only oxygen he was receiving. They cut it when they arrived, but I am still uncomfortable sometimes imagining him spending those several minutes with no oxygen.

February 21, 2011 | Unregistered CommenterTaryn

This may be one of my favorite Unnecesarean posts ever. I had never thought about 9-1-1 protocols in relationship to birth. I wonder who wrote up the first ones, and how often they get reviewed/updated and by whom? Certainly, the cord-tying needs to go except when it ruptures as pointed out above. But how awesome would it be for midwives to participate in updating emergency protocols? **sighs wistfully**

February 21, 2011 | Unregistered Commenteremjaybee

Does ACOG know about this? It takes 13 years to learn to bring a baby into the world!!!!

February 21, 2011 | Unregistered CommenterSaanenMother

SaanenMother, I forgot about that one. Fortunately, Dr. Dorn was on top of that claim.

February 21, 2011 | Registered CommenterJill

Hmmm...my husband is a paramedic and I'll ask him what his department's protocols are for imminent birth (he's attended several). He has mentioned that it's the one call that most EMTs and paramedics dread because they just don't know how to handle it. I know that since he's been present for our two homebirths that his personal approach to those calls is much different than it used to be, and I can only hope his experience is having a positive influence on his peers.

February 21, 2011 | Unregistered Commenterlarissa

I'm an EMT, and our policy (in our county) is to clamp/cut the cord only after it has stopped pulsating.

February 21, 2011 | Unregistered CommenterErica
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