Monday, 31 January 2011

The Umbilical Cord: When do we clamp it?

Clamping the umbilical cord immediately at birth was something that I was taught to do as a routine part of 'delivery' management. The reason for clamping the cord so quickly, I was told, was to stop the baby getting unnecessary blood because the extra blood would be all the more for the baby to process and they would be at risk of becoming jaundiced, caused by the breakdown of all the fetal blood cells.  A nuchal cord (cord around the neck of the baby) was felt for and cut before the shoulders and rest of the baby was born.

Added to the problem of extra blood with an uncut cord, was the fact that the woman was routinely injected with a synthetic form of oxytocin to hasten third stage. The injection of the synthetic oxytocic in third stage made the uterus contract. Authorities believed that if the cord wasn't cut swiftly, the uterine contractions caused by the injection would cause an even greater surge of blood into the new baby, causing the baby to be overloaded with blood and at even more risk of jaundice. 

Once I started working with childbearing women in a one to one way in private practice, the need to clamp and cut the umbilical cord immediately at birth was challenged by the women I worked with. They wanted the cord to be left alone until it stopped pulsating. Some even wanted the placenta to be born before the cord was cut. A few wanted the placenta and cord to be left attached to the baby and allowed to drop off itself, a process called Lotus birth.

The literature was mixed in regards to the advisability of leaving the cord to pulsate or clamping immediately. The opposed camps had reasons such as jaundice, blood volume, postpartum haemorrhage rates to explain their particular views and reasons for their recommendations. The reasons for cutting the cord have been proven to be spurious.  There is however a lot of evidence for leaving the cord alone.  Women and midwives have been talking about and promoting leaving the cord alone as a best practice strategy for several decades now and the evidence for doing so is only getting stronger.  Have a look at the way the cord changes in the minutes after birth.  The evidence for leaving the cord intact is also clear in the case of nuchal cords. Leaving them alone, gently 'somersaulting' the baby to untangle the cord as the baby is born works perfectly and there is no risk of having the baby's oxygen supply prematurely interrupted.  As beautifully explained on the Midwife Thinking blog, the oxygen carrying capacity of an intact cord is the baby's first line of resuscitation after birth. Our medical colleagues have been slower to take up the idea of leaving the cord alone. However a 2011 report has confirmed that iron stores are improved when the cord is left to stop pulsating. A more recent review found that "newborns with later clamping [were heavier and] had higher hemoglobin levels 24 to 48 hours postpartum and were less likely to be iron-deficient three to six months after birth, compared with term babies who had early cord clamping".

A wonderful demonstration of why the umbilical cord should be left alone is provided by Penny Simkin in this video.

Hope for a more balanced approach to the topic of cord clamping or leaving it alone is on the horizon as an obstetric doctor in the US has written about what he calls 'delayed cord clamping' and has produced the following videos for The Grand Rounds on this topic.

Delayed cord clamping Grand Rounds 1

Delayed cord clamping Grand Rounds 2

Delayed cord clamping Grand Rounds 3

Delayed cord clamping Grand Rounds 4 

For more information on the umbilical cord and placenta, go to Rachel Reed's Midwife Thinking blog.  There is a post on the placenta in birth films on this blog here.

Another aspect that hasn't really been explored in great detail as yet, is the perfusion of the newborn's brain at birth. My thinking is that leaving the cord alone allows the newborn's brain to be optimally perfused and ensures that the neuronal connections that proliferate in response to birth to wire in the best possible way, especially when the baby is skin to skin with her/his mother and exposed to the multisensory stimulation that occurs in a physiologically mediated birthing experience. The question to be asked is "do babies suffer subtle brain damage through premature clamping of the cord and less than optimal sensory experiences at birth?" I suspect they do.

Some women want the cord clamped and pulled to get the placenta out as quickly as possible, others see the placenta as the spiritual twin of the baby and want to keep the baby and placenta together.  There are many reasons for leaving the transition to extrauterine life and resuscitation system alone, what's your view?

I can see the day dawning when we look back and say "remember when we used to think that cutting the umbilical cord prematurely was a good thing to do" with incredulous amazement.

Postscript: There is an article (8th October 2014) in the Journal of Midwifery and Women's Health on clamping the umbilical cord at birth. Called "Is it time to Rethink Cord Management when Resuscitation is needed" the article provides compelling evidence for leaving the cord intact and resuscitating a compromised infant by the mother's side.

Post Postscript: A landmark paper published 26th May 2015 has added evidence to my theory of brain & gut damage associated with early cord clamping:

The authors concluded:

Delayed cord clamping (CC) compared with early CC improved scores in the fine-motor and social domains at 4 years of age, especially in boys, indicating that optimising the time to CC may affect neurodevelopment in a low-risk population of children born in a high-income country.

PPS A non peer reviewed article discusses the issues of hypovolaemia in newborns caused by premature cord clamping says this:
Modern human childbirth is “managed” obstetrics, designed to avoid complications and to preserve physiology – a normal, healthy outcome. However, management often intrudes on physiology, producing unintended consequences.
and raises concerns around the potential for multiple organ damage, including brain damage with premature cord clamping.

Now for anyone not yet convinced of the value in leaving the cord to do its magic, this post from AWHONN on a Placental Transfusion for Neonatal Resuscitation after a complete Abruption may help you to change your mind!

Time for practice change everyone!


Chrissy said...

I fought long and hard for a physiological 3rd stage with my first son and was able to achieve this. Unfortunately only one of the midwives on duty supported delayed cord clamping and my first sons cord was clamped with 3 mins of him being born. My husband cut the cord around 5 mins after he was born as the cord was rather short (40cm) and it was difficult to wrangle, baby, cord and yet to be born placenta. The placenta was birthed at 9mins postpartum much to the surprise of my Dr and midwives. With my 2nd son born at home his cord and placenta were left attached for nearly 2 hours, it just seemed right. For any subsequent baby's I hope to lotus birth as I feel it is a much gentler transition and I don't like scissors or clamps near a new babe's delicate skin.

Carolyn Hastie said...

Lotus birth is very gentle Chrissie. One thing I see as beneficial is that people aren't so keen on holding the baby - they are more likely to leave the baby with the mother. Also, the mother doesn't tend to go shopping before the cord and placenta drops off; she stays at home, being waited on and cared for by her family and friends. Both aspects are very good for the mother and the baby, above, beyond and apart from any cellular physiological considerations. :-) I'm so glad you were able to have the birth you wanted all the way through with your second child.

Anonymous said...

The video on the page is one of four. The rest can be found here:

It is a good presentation to take the time to watch.
I cannot see why the medical establishment is taking so long to catch on.

Carolyn Hastie said...

Thanks Judy, Nicholas loaded the others up after I did the blog post. They are useful to watch. As for our medical colleagues? They don't have time to read to update apparently. We just have to help them out with that. :-)

Maxine H said...

this was a great presentation - thanks Carolyn for sharing it. As someone about to embark on research I found it very illuminating with regard to his literature review: it's all to easy (or convention dictates) to limit searches to last 10 years etc when in fact some real insights can be garnered from going back a few decades or even to old texts.
The other thing that really struck me was his emphasis on the neonate needing to "transition" with regard to breathing and oxygenation. It is not something that is truly appreciated and yet from conception to the puerperium women are in the process of transitioning from one state to another: this is especially worth observing in labour, where all too much emphasis is placed on delineating and marking the time of one "stage" from another; of course the baby is going to need that too.
I liked that he talks only about delayed cord clamping (with an implicit assumption that active management of the birth of the placenta would still take place) as I think this is better way of reintoducing physiological and individualised management: I am sure that many attendants will see for themselves the placenta coming within a few minutes in many circumstances and hopefully this will lead them to question THAT routine practice.
I hope to hear/read more from this doctor.

Carolyn Hastie said...

The need for the neonate to transition from the intrauterine environment to the outside world has not been fully appreciated in the medical world, or even the mainstream midwifery world. The place where one really sees that transition is following a birth through water when the baby pinks up progressively because it is not generally crying. I love watching that baby awakening. Nicholas has done a great job of these videos and promoting 'delaying' cord clamping. Did you see his site? The link is The Grand Rounds. He also has a facebook page. Thanks for your comment Maxine, good to hear from you.

Alaanja said...

It's always been my practice to delay cord clamping - when I first started my placements as a student midwife I had a background in homebirth, where the midwives wouldn't think of clamping the cord early. Given the evidence, I see no reason why it shouldn't be my routine practice to delay clamping unless the woman requests otherwise. Where I have an opportunity I always explain to the women what I suggest and why, giving them the choice.

It was an absolute struggle to delay cord clamping as a student midwife. My latest experience was at a hospital where syntocinon for third stage was routinely given IV (the midwives didn't seem to have even heard of physiological third stage), and in women with no cannulas this often took a few minutes to organise. It was the perfect opportunity to delay cord clamping until the syntocinon was administered. The midwives though were heartily against this, for no reason that they were able to state to me coherently. When I brought in studies and left them in the tea room or made quiet suggestions, I was met with scorn and accused of being a cocky student. The midwives also showed little or no interest in professional development, completely uninterested in reading studies. I recall a conversation where they discussed how to get their 20 hours of PD over with as quickly as possible, using online modules about handwashing that only took 10 minutes to complete but counted as 45 minutes of learning.
In this hospital, though, delayed cord clamping was the least of my concerns - there were many awful practices including episiotomies at the drop of a hat (35% of primip women), routine cutting of the cord before birth when it was loosely around the baby's neck and a 6% successful VBAC rate (VBAC policy involving no food, hospital admission from the onset of early labour or prelabor, restricted fluids etc - policy hadn't been reviewed since 2002).

Carolyn Hastie said...

Wow, Alaanja, what an experience you've had. Tragic that the midwives didn't care enough to stay up to date or even be willing to discuss what were learning with you. There is absolutely no excuse for behaviour like that in midwifery. I feel for the women they were allocated to in labour and elsewhere. Very distressing to hear that those sort of behaviours are still endemic in some workplaces. Good on you for challenging the system and speaking up. I'm glad that there are people like you in midwifery, you give me heart and hope. An open, willing to learn mind, coupled with curiosity is our best resource. You seem to have that well and truly in your possession. I hope you keep it.
kind regards, Carolyn

Kate said...

During the 1990's I was raised on a horse farm where we bred valuable racehorses. We had a special paddock set up close to our house where the mares gave birth - with strategically placed lights we could observe the birth at night without unduly disrupting the mare. One of the most important stages of the birth was the placental transfusion. Human interference during foaling had led to foals being unable to stand long enough to obtain colostrum. Many foals experienced convulsions, followed by death, due to hypovolemia and ischemic brain damage. It took awhile for the horse industry to realise that pulling the foal out and away from the mother - or causing the mare to jump up immediately after the birth to protect her newborn from the 'predators' standing over them - caused the umbilical cord to prematurely snap before a significant transfusion of blood occurred.

I 'protected' the placental transfusion on more than one occasion with a mare that was 'known' to jump up immediately after birth. As the shoulders emerged I would dash out of the house with food to entice her to stay lying down longer. She would happily munch on my offerings while the cord remained safely intact and pulsating. Being so close to a newborn foal and mother was magical, especially in this case where my presence was to protect and restore physiology - not to destroy it.

This protection of physiology was not to be my own experience of giving birth, however. I will forever be sorry that my first baby was phlebotomised by immediate cord clamping, and even sorrier still my second child suffered from pre-birth cutting of a tight nuchal cord - causing irreparable damage.

The practice of immediate cord clamping and dangerous nuchal cord management is the absolute pits! Given our understanding of placental transfusion in mammal birth and evidence of the harm of early clamping, delayed cord clamping should have become standard practice a long time ago!

Carolyn Hastie said...

Thanks Kate for sharing your experience and understanding about cord clamping. I'm so deeply sorry that your babies have been affected by such practices. We can only hope that by sharing, researching and talking to those in positions of authority about evidence and developments in understanding maternal and prenatal/infant wellbeing that established and limited perspectives and damaging practices will change for the benefit of mothers and their babies.

Jennifer at Organic Baby University said...

Thanks so much for your blog! We will be sharing it with our followers on facebook. I was able to get my doctor to delay the cord cutting for 20 minutes. In fact, it served other purposes! The nurse kept trying to take my daughter away for tests that I had specifically asked to be delayed...over and over...and couldn't because she was still attached!! Sad about the cord blood is creating a new push for early cord clamping under the guise of health

Carolyn Hastie said...

Great that you were able to have your wishes fulfilled Jennifer. Amazing what an informed position can do for us when faced with such situations. I agree about the cord banking push. Fueled by dollar signs in the companies eyes and using parents fear of the future health of their children as a driver for behaviour the companies want to program into the collective consciousness. A raw example of the manipulation of market forces, greed and fear disguised as a 'health' option. Nothing could be further from the truth. My understanding is that if a child develops a problem, the 'authorities' are most unlikely to use their cord blood in the future because the inherent problem may well be in the stem cells. The other real issue is that if those stem cells are so darn good, then clearly, the baby needs them, every one of them.

Shay said...

Thanks for your website. I was told by my midwife my baby's cord had to be clamped quickly because I am Rh negative, and my husband is not. Could you please comment on that situation?

Nicholas Fogelson, MD said...

Thanks for linking up my video. I has gotten a lot of long term interest.

The question Shay asks is an interesting one, and is an example of one situation where immediate cord clamping may be a better course. If an infant is Rh+ but mother is Rh-, delayed clamping _may_ give greater opportunity for fetal anti-D related hemolysis and jaundice. I don't believe there is specific data on this situation, but I think given the relatively minimal benefits of delayed clamping at term, this would be a situation where immediate cord clamping would make some theoretical sense.

N Fogelson MD

Carolyn Hastie said...

Thanks for your comment Nick and yes, your vides have generated a lot of interest. Shay, I'm not sure how, but your comment slipped under my radar and I missed it. Glad Nick commented!!

I'm curious about the mechanics of separation of the placenta Nick. As a midwife who supports women who want to leave the cord intact, I have seen many placentas with extra lobes that take extra time to detach. I have been in awe of the woman's body intelligence in separating the placenta intact. I personally wonder about the idea that there is a higher chance of fetal blood transfer to the maternal blood system if the third stage has been completely physiological. I suspect the risk of transfer is greater with active management.

I'm also surprised that you said there are relatively minimal benefits of avoiding early cord clamping - if the infant gains approximately one tenth of it's blood volume at birth when the cord is left intact surely that's significant? That 'extra' blood helps with perfusion of lungs and brain, plus supplies stem cells?