Delayed Cord Clamping

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Typically, the umbilical cord is cut immediately after birth in the hospital setting. Many organizations are beginning to recommend a change in practice to include delayed cord clamping. However, doctors are frequently hesitant to wait to clamp the cord. What does the evidence say?

This article will review findings from: Raju T. Timing of umbilical cord clamping after birth for optimal placental transfusion. Current Opinion in Pediatrics, 2013; 25: 180-187.

RESEARCH

Background

Before women began delivering in hospitals in the 1900’s, most midwives waited to cut the umbilical cord until several minutes after delivery, or waited until after the cord stopped pulsing. However, once “active management” of the third stage was instituted in the 1960’s, this practice changed. Active management involves giving medications and applying cord traction to deliver the placenta in an attempt to reduce postpartum hemorrhage and retained placenta. Immediate cord camping became part of this bundle of care for no physiologic reason; it was most likely introduced due to provider convenience, as well as ease of infant resuscitation should it be necessary.

Physiologic affects of delayed cord clamping include: “increased cerebral perfusion because of improved cardiac output; improved postnatal transition (e.g. APGAR scores, blood pressure, feeding success); increased urine output; and increased mean tissue oxygenation of the brain at 4 and 24 h of age” thought to be due to, “higher blood volume, improved cardiac function, and more stable systemic and cerebrovascular circulation.”

Systematic Review Findings

  1. Benefits: Term Infants
    • higher hemoglobin, hematocrit, and iron stores resulting in a lower incidence of iron deficiency anemia at 4 months old
  2. Benefits: Preterm Infants
    • higher hemoglobin, hematocrit, and iron stores resulting in a lower incidence of iron deficiency anemia at 4 months old
    • higher systemic blood pressure
    • increased blood volume and decreased need for blood transfusions
    • reduced likelihood of intravascular hemorrhage
    • higher transfer of stem cells
  3. Harms: Term and Preterm
    • increased bilirubin values resulting in an increased diagnosis of jaundice in the first week after birth, leading to a slightly higher use of phototherapy (3% in the immediate clamping group vs 5% in delayed clamping group)
  4. No difference regardless of delayed or immediate cord clamping:
    • maternal postpartum hemorrhage
    • retained placenta
    • need for maternal blood transfusion, operative delivery, episiotomy
    • infant APGAR scores or need for resuscitation
    • frequency of infant respiratory distress
    • incidence of polycythemia

Umbilical Cord Milking

Umbilical cord milking is sometimes used as an alternative to delayed cord clamping in situations where expedited cord cutting is advisable. Most frequently, this is done when a infant needs resuscitation but the benefits of delayed clamping are desired. For the procedure, the provider grasps the umbilical cord and “milks” an approximately 20cm segment toward the baby 2-4 times. It is not well studied, with only 4 trials reported and 3 of them done on preterm infants; however, results seem to be promising and do show benefit similar to delayed cord clamping. Details such as how much, how often, at what speed, optimal cord length, and optimal gestational age are yet unanswered.

Recommendations from Professional Organizations

The World Health Organization (WHO) was, “the first to recommend delayed cord clamping as a standard for all infants at birth.” Presently, most organizations recommend at least some form of delayed cord clamping. The WHO is the most generous, recommending, “In preterm births, delay cord clamping for 30-120s after birth; and in term births, up to 3 minutes after birth; also observe uterine contractions.” The American College of Obstetricians and Gynecologists (ACOG), is much stingier and non-committal, saying, “Evidence exists to support delayed umbilical cord clamping in preterm infants, when feasible (by 30-60s). Evidence is insufficient to confirm or refute the potential benefits from delayed cord clamping in term infants, especially in settings with rich resources.”

Concerns for Delayed Cord Clamping and Their Potential Solutions (summarized from chart in paper)

  1. Delay in initiating resuscitation in depressed asphyxiated TERM infant (abruption or uterine rupture):
    • Maternal emergency is a valid reason for immediate clamping; consider cord milking
    • In cases where there are no maternal issues, infants with fetal distress may benefit from improved placental transfusion, as they are more likely to be anemic, hypovolemic, or in shock
  2. Delay in initiating resuscitation in PRETERM infants with apnea:
    • Reduced umbilical venous return and inefficient pulmonary ventilation are the worst combination. Consider resuscitation with intact cord, or cord milking.
    • Placental transfusion is the first step in the resuscitation of preterm infants at risk for respiratory distress syndrome
  3. Assigning the time of birth, and reconciling with step-by-step resuscitation efforts:
    • Time of cord clamping should not affect assignment of time of birth
  4. Might affect umbilical cord blood banking
    • ACOG recommends that timing of clamping should not be altered for purposes of collecting cord blood for banking

Additional Issues

Additional research needs to be done to answer questions regarding where to hold the infant in relation to the placenta, optimal time to clamp for multiple gestations, length of delay for infants at risk of polycythemia (growth restriction, large for gestational age, infants of diabetic mothers), and length of delay in high risk mothers (HIV or hepatitis positive, placental abruption, placenta previa).

DISCUSSION

Many organizations recommend delayed cord clamping as the standard of care. ACOG remains neutral, however, and this is the group that most doctors in the US look to for recommendations. Because of this, instituting delayed cord clamping in the hospital setting in the US has been a particularly slow transition, met with a fair amount resistance. There is a great deal of misinformation surrounding delayed cord clamping. This ranges from only focusing on the potential harm (a slightly increased risk of jaundice – a difference of only 2% between groups, might I add), to the belief that the baby will “lose all it’s blood” (definitely not the case!). The research shows that there is minimal harm with great potential benefit, ESPECIALLY with preterm infants.

There was never any physiologic reason to begin the practice of immediate cord clamping in the first place. Delayed cord clamping is part of the normal, physiologic birth process and should be treated as such. If you are desiring a natural birth, your provider’s reaction to a request for delayed cord clamping can be a great barometer of where they are on a “natural/physiologic birth” scale. Ideally, it’s already part of their routine care. If they are unfamiliar with it, don’t automatically hold that against them, as their organization doesn’t currently recommend the practice. They should, however, be willing to have a discussion and do some research. Any response of “absolutely not”, or any sort of hostility, should be met with extreme caution on your end as the patient. If they are not willing to even entertain a normal, physiologic process such as delayed cord clamping, they will most likely adhere to other non-physiologic practices during labor, such as bed rest, no oral fluids or foods, pushing in stirrups, etc.

If delayed cord clamping is something you would like as part of your birth, I’d recommend putting it in your birth plan. I would also recommend having someone else in the room (a partner, doula, etc) remind the provider during delivery. If it is not part of their normal routine, they may forget and clamp immediately out of habit, even if they intended to provide delayed cord clamping.

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