Showing posts with label cord clamping. Show all posts
Showing posts with label cord clamping. Show all posts

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!

Wednesday 6 January 2010

Obstetricians attitude to delayed cord clamping

Obstetricians attitude to cord clamping Midwives who work with women in a one to one relationship based way with childbearing women weren't at all surprised when researchers found massive benefits with leaving the cord alone after birth for the newborn. Midwives working with women they know are also very aware of the benefits to the mother of leaving the cord alone after birth. Mainstream maternity care has yet to recognise or discover that aspect.

Photo from Wikipedia


Now that current evidence indicates that leaving the umbilical cord to pulsate for at least 3 minutes after birth confers many benefits to newborns, recommendations have been made to change established hospital practice and leave the cord to pulsate. Benefits for the baby from the extra minutes of blood transferred from the placenta include: stem cells, optimal lung and cerebral perfusion, increased number of red blood cells, appropriate blood volume transfer and placentally transferred oxygen during those precious moments as the baby switches from intra to extra uterine life and circulation; reduced rate of sepsis, reduced rates of intraventricular haemorrhage and reduced rates of necrotising enterocolitis.

Two intrepid researchers, both consultant obstetricians, sought to discover whether obstetricians have changed practice in regards to cord clamping in light of the new insights about the value of cord blood to the infant following birth.

Doctors Ononeze and Hutchon‌ said in their article in the Journal of Obstetrics and Gynaecology (2009)

"Questionnaires were given to obstetricians from 43 different units in UK, other EU countries, USA, Canada, Australia etc. There was a 100% responserate. 53% adopted the recommendation only occasionally whereas 37% have never. Difficulty with implementation in clinical practice was the main reason for failure to adopt recommendation. Unawareness of the evidence of the benefits of delayed cord clamping was the reason in half of the non-compliant group".

Interesting that so many obstetricians a) didn't know about the benefits of leaving the cord to pulsate after birth and b) didn't believe the evidence and c) found it difficult to do in practice. The researchers disagreed leaving the cord to pulsate was difficult in practice, so we can only assume it is because the doctors were not prepared to wait those few minutes.

Given that evidence informed practice is touted at every opportunity in contemporary health care, it is very surprising that our medical colleagues are not up to date and can't find ways to put evidence to work for the better health of babies.

"There is no consensus amongst medical and midwifery staff as to when to clamp the cord following delivery of the newborn. The tradition in obstetric practice is to clamp the cord immediately after birth".

The lack of consensus in timing of cord clamping may well exist in the system that approaches birth as a moving conveyor belt experience in a factory, however those of us who work in relationship based practice are agreed that the best time to cut the clamp and cut the cord depends upon the mother's thinking about how to manage her placenta. For those women who want to leave the baby and placenta attached, then the cord is never clamped and cut. The cord falls off the baby's umbilicus in it's own time. For others, they choose to birth their placenta, then clamp and cut it. Once women understand the process of third stage, they choose to manage it themselves and do very well.

Fabulous to see these two obstetricians doing such great work. Their perspective and honesty is commendable.

Journal of Obstetrics and Gynaecology. 2009 Apr;29(3):223-4.