Delayed Cord Clamping – Midwives Win the Argument
I think of some of the things we have recommended in Pediatrics out of convenience, tradition, lack of adequate thoughtfulness, or, worse, out of downright ignorance and I cringe. In January of this year the American College of Obstetricians and Gynecologists (ACOG) released a committee opinion that was meant to guide practice in the specific area of timing of cord clamping after a baby is born. It seems that the midwives had it right all along; delaying clamping of that cord may have benefits that reach from the immediate setting of mitigating birth trauma all the way to the possible enhancement of the aging brain.
It is interesting when you look at the current science of stem cell research and cord blood banking, the premise is that the cord blood contains enough high value components that it can be taken out, stored, and used in the future for the “rainy day” of cancer or other tragedies like Alzheimer’s. We are just now stopping to think of the implications of letting that baby have those components right off the bat! Those implications are turning out to be huge. We in medicine are the servants or even slaves of evidence. There is enough evidence now of the benefits of delayed cord clamping that ACOG has taken the step of making the definitive recommendations to delay clamping for at least 30-60 seconds. So, what are those recommendations based on?
“In term infants, delayed umbilical cord clamping increases hemoglobin levels at birth and improves iron stores in the first year of life which may have a favorable effect on developmental outcomes.” Wow! We know that iron in that first 1-2 years of life has a dramatic role in brain and nerve development. That’s why we test hemoglobin on all one-year olds. We have observed that a significant number of babies by 6-9 months are iron deficient. So how many of these would have had enough iron stores from cord blood to carry them through until their first birthday? Probably a significant number! How many developmental outcomes would have improved with that added iron store during that first year? A randomized study published in 2015 in JAMA Pediatrics concluded that “Delayed cord clamping compared with early clamping improved scores in the fine-motor and social domains at 4 years of age, especially in boys…” https://jamanetwork.com/journals/jamapediatrics/fullarticle/2296145. More studies are needed. The ACOG recommendation is one of the first definitive statements on term babies. Nice!
“Delayed umbilical cord clamping is associated with significant neonatal benefits in preterm infants, including improved transitional circulation, better establishment of red blood cell volume, decreased need for blood transfusion, and lower incidence of necrotizing enterocolitis and intraventricular hemorrhage.” How many times have I labored over a brand newborn in the delivery room who looked as pale as a ghost after being born by C/S or even vaginally with a low blood pressure and a rapid pulse after having that cord clamped as soon as that little body was out? How many of those would have transitioned more easily if we had just waited one minute? Or 3 minutes? Or even 5 minutes before clamping that cord? How many intracranial hemorrhages could we have prevented with this simple strategy? How many cases of NEC (that awful bowel disorder that causes a preemie’s bowels to slough and rot – necrotizing enterocolitis) could have been prevented with this simple intervention? How many babies have I had to get an IV going to support a low blood volume during those first hours to give crystalloid (saline) or even packed red cells? My mind swirls!!! Lastly, as some midwives have argued, is the vitamin K shot less necessary with the infusion of these rich cord fluids into the baby? I don’t know that there is enough evidence to base practice on, but if it is true that brain hemorrhage is dramatically reduced with delayed clamping in preemies, then one of the major arguments for vit K shot administration becomes less compelling. Interesting!
“Given the benefits to most newborns and concordant with other professional organizations, the American College of Obstetricians and Gynecologists now recommends a delay in umbilical cord clamping in vigorous term and preterm infants for at least 30-60 seconds.” I wonder how many other practices we need to evaluate and re-do?
Sleeping babies on their backs instead of tummies? … done.
Starting solids at six months rather than four months? … partially done.
Waiting until 12 months to introduce cow milk instead of six months? … done.
Pushing breast feeding as the best nourishment for a newborn during that first year of life instead of formula? … partially done.
Eliminating fruit juice from a child’s diet in the first year of life? … just starting.
Reducing the number of unnecessary C/S’s in the US? … not done.
Reducing the number of unnecessary antibiotics in kids and adults?... just starting.
Reducing the amount of carbohydrate intake as a society? … NOT DONE!! We still have that infernal food pyramid that the uninformed are trying to follow.
Reducing the Calcium/Magnesium ratio in our diets and supplements? … NOT DONE!!
We are still largely ignorant of the inflammatory nature of calcium, its deposition into artery walls, into kidneys, and other soft tissues when given in large amounts without the magnesium and vitamin K2 to drive it into bone.
There are always concerns raised when change is in the air. A) There is a concern that when a baby is left on the cord and placed on the mother’s belly, the blood will drain away from the baby into the placenta. Studies have not shown that to happen. B) If a baby’s cord is not clamped right away, that baby will be volume overloaded. That, again, has not been shown to be the case. Interestingly, that 80-100 ml (approximately 3 oz) of blood rushes in to fill the lung blood supply that has been limited during intrauterine existence. C) That baby will get jaundiced more readily. There is a slight increase in bilirubin but not enough to discourage delayed clamping. D) Delayed clamping will delay resuscitative efforts of the newborn. ACOG advises “during delayed umbilical cord clamping, early care of the newborn should be initiated, including drying and stimulating for first breath or cry, and maintaining normal temperature with skin-to-skin contact and covering the infant with dry linen. Secretions should be cleared only if they are copious or appear to be obstructing the airway. If meconium is present and the baby is vigorous at birth, plans for delayed umbilical cord clamping can continue…. If the placental circulation is not intact, such as in the case of abnormal placentation, placental abruption, or umbilical cord avulsion, immediate cord clamping is appropriate. Similarly, maternal hemodynamic instability or the need for immediate resuscitation of the newborn on the warmer would be an indication for immediate umbilical cord clamping.” E) Twins or triplets: there is little information about the safety or efficacy of delayed cord clamping in this group. I think that can be addressed on a case-by-case basis. F) So, no cord blood banking? When the cord banks have looked for something valuable to store away for the long haul, there is very little left that the baby did not take right up front. So, correct! Delayed clamping is not likely to be compatible with cord blood banking. In my book, that’s OK.
So, I would advise getting a Birth Plan in place that includes delayed cord clamping. There is such exceptional short and long-term benefit for such little effort that it is really a “no-brainer”.