Delayed cord clamping

Delayed cord clamping – or optimal cord clamping as it is starting to become known – is when a delay is made between a baby being born and its umbilical cord being clamped and cut. This delay is considered anything from around a minute or longer. This has been discussed much in the press in 2015 as many important institutions have recognised studies that show that delayed cord clamping has huge benefits and adjusted their guidelines accordingly.

Early cord clamping

It is fairly routine in western society to clamp and cut a babies cord immediately after birth (within seconds) but it is a relatively recent phenomena and, as we are discovering, it is not remotely evidence-based.

Historically, evidence can be found of early cord clamping (ECC)as early as the 1600s but really only took hold as a routine procedure from about the 1960s, touted as a way to reduce post-partum haemorrhage (PPH) in mothers.

It can also been seen to help reduce the incidence of jaundice due to a reduction of bilirubin in the baby’s blood – however, there has been no evidence of this link found and anyway, jaundice in itself is not a life-threatening condition in most cases especially when treated in a western country.

Here is a lovely blog post detailing how this baby was resuscitated with the cord intact and the placenta providing blood to the baby while the medical team helped baby.

Baby’s blood at birth

At birth around one third of the baby’s blood is in the placenta. In the few minutes immediately after birth, the placental blood is transfused into the baby, stimulating it’s heart and lungs and helping its organs start working independently. As the baby’s body takes over its life support from the placenta, the blood transfer between the baby and placenta equalises, the wharton’s jelly that surrounds the veins and artery inside the cord starts to solidify, and the cord starts to naturally close off.

Early clamping of the umbilical cord means that this extra 33% of the baby’s blood is not getting to the baby.

Here is a great video that shows you the volumes of blood involved and the equivalent amounts for an adult

Stop the mess!

In fact the only reason why the cord is clamped is because it is being cut too early when blood is still present. So if it isn’t clamped you get blood all over the floor as the placenta is still trying to pump the blood into the baby!

So why do we do it?

Beats me!

Benefits to the baby

Image source: Credit: https://en.wikipedia.org/wiki/File:Delayed_Cord_Clamping_Calmness,_3_Hours_Old.png#filelinks

There have been studies – some of which are linked to below or linked to articles that reference them – that show many benefits to the infant when delayed cord clamping happens.

• Improved iron levels up to 4-6 months (depending on study) [1] which resulted in 
• Significantly better personal-social and fine-motor functioning at 4 years old [1]
• lower risk of brain bleeds [2]
• Gives baby all the blood they need
• Helps stimulate organs at birth
• Helps achieve successful natural third stage (delivery of placenta)

What if my baby need resuscitating?

There is growing consensus that even if a baby requires resuscitation then it should be done next to the mother before the cord is clamped – after all, the cord is supplying the baby with oxygen so it seems pretty daft to cut off it’s life-line!

The UK Resuscitation council guidelines state that:

At present there is insufficient evidence to define an appropriate time to clamp the cord in babies apparently needing resuscitation. However, this may be because time is the wrong defining parameter and perhaps the cord should not be clamped until the baby has started breathing.[3]

What should the cord look like?

Delayed cord clamping of one or more minutes allow the blood to pump into the newborn and after 5+ minutes the cord will stop pulsating as the blood transfer eases off. It will start by looking very thick with dark veins inside, and end up looking thin and white.

(left) cord containing baby’s blood (right) cord after placental transfusion. IMage source: https://birthwithoutclamps.files.wordpress.com/2011/08/cord-engorged-clamped.png

There is also a wonderful birth photographer who has compiled photos of intact cords left to empty themselves of blood, check out her blog post.

Who else agrees?

In the 6 months between Dec 2014 and June 2015 3 major institutions have changed their guidelines in the face of this evidence.

UK Resuscitation Council Guidelines 2010

• Delayed clamping by at least one minute in healthy term infants, but ideally up to 3 minutes or until the cord has stopped pulsating.

NICE Guidelines Dec 2014

• Do not clamp the cord earlier than 1 minute from the birth of the baby unless there is concern about the integrity of the cord or the baby has a heartbeat below 60 beats/minute that is not getting faster.
• If the woman requests that the cord is clamped and cut later than 5 minutes, support her in her choice. [new 2014]

WHO guidelines Jan 2015

• Delaying cord clamping allows blood flow between the placenta and neonate to continue, which may improve iron status in the infant for up to six months after birth.

RCM Guidelines April 2105

• The paper states that immediate cord clamping reduces the flow of blood to the baby and can deprive the baby of iron. Iron deficiency in the first few months is associated with neurodevelopmental delay.
• Looking at existing evidence for term births, the paper looks at the Cochrane review, which concluded that the evidence justifies a more liberal approach to delaying clamping of the cord, as long as access to treatment for jaundice is available.
• Once delivered, the baby can be placed on the mother’s abdomen or chest with the cord intact and the timing of clamping should be recorded

References

https://www.scienceandsensibility.org/tag/umbilical-cord-clamping/

https://www.bellybelly.com.au/birth/cord-clamping-delaying-cord-clamping/

https://en.wikipedia.org/wiki/Wharton%27s_jelly

https://fn.bmj.com/content/100/4/F355.full?utm_content=buffer61311&utm_medium=social&utm_source=facebook.com&utm_campaign=buffer

https://www.resus.org.uk/EasySiteWeb/GatewayLink.aspx?alId=811

https://www.cordclamping.org/2015/06/10/resuscitation-without-clamping-the-umbilical-cord-27273339

https://awhonn.wordpress.com/2015/06/09/placental-transfusion-for-neonatal-resuscitation-after-a-complete-abruption/

https://awhonn.wordpress.com/2015/06/09/placental-transfusion-for-neonatal-resuscitation-after-a-complete-abruption/

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