I was recently asked to talk
about delayed cord clamping (DCC) for a few friends who are due to deliver and
want to know how to talk to their obstetrician about the subject. I
understand that this isn’t a breastfeeding topic, but I thought it was good
information to share, so here goes.
First, I think we should start
with the professional opinion from the OB’s professional organization:
“Abstract: Delayed umbilical cord clamping appears to be beneficial for
term and preterm infants. In term
infants, delayed umbilical cord clamping increases hemoglobin levels at birth
and improves iron stores in the first several months of life, which may have a
favorable effect on developmental outcomes.
There is a small increase in jaundice that requires phototherapy in this
group of infants. Consequently, health
care providers adopting delayed umbilical cord clamping in term infants should
ensure that mechanisms are in place to monitor for and treat neonatal
jaundice. In preterm infants, delayed
umbilical cord clamping is associated with significant neonatal benefits,
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. Delayed umbilical cord clamping was not
associated with an increased risk of postpartum hemorrhage or increased blood
loss at deliver, nor was it associated with a difference in postpartum
hemoglobin levels or the need for blood transfusion. Given the benefits to most newborns and
concordant with other professional organizations, the American College of Obstetricians
and Gynecologists (ACOG) now recommends a delay in umbilical cord clamping in
vigorous term and preterm infants for at least 30-60 seconds after birth. The ability to provide delayed umbilical cord
clamping may vary among institutions and settings; decisions in those
circumstances are best made by the team caring for the mother-infant dyad. “ ACOG Committee Opinion # 684, January
2017.
So what does that say? First, I want to clear something up, it is actually,
“normal cord clamping”, cutting immediately is an intervention started just
before the Viet Nam War, but most OBs don’t know that. OK, on with the show. It says that DCC is good for almost all
babies. That it helps newborns
transition from the womb to the outside world, that newborns who don’t get DCC
are more likely to be anemic and suffer developmental problems (associated with
newborn anemia). It says that preterm
infants are especially put at risk if you cut the cord immediately, and that
there is no risk to mother or baby if you allow the cord to transfer blood to
the baby after birth. I should just stop
there, but I feel like I need to help explain it to people, so here goes some
physiology.
First, you should know that I
wrote my master’s thesis on delayed cord clamping and that I was lucky enough
to study under one of the world’s foremost experts on the topic, Dr. Judy
Mercer CNM, when I was in midwifery school.
I know the concepts VERY well. So
here is how it happens. In the uterus,
the baby does not send much blood to the lungs, in fact, only 8% of the baby’s
blood goes to the lungs before birth. This
is because the baby is not breathing air and doesn’t need his lungs yet. There is just enough blood to help them grow
and develop. 30% of term baby’s blood
and 50% of the preterm baby’s blood is in the placenta at all times. That amazing organ is actually an organ that
is outside the baby’s body and it is where he gets his oxygen and his food, and
where he sends his waste products for mom to get rid of. At birth however, he has to start using his
lungs and when he takes his first breath, the lungs require 40% of the cardiac
output. So when he is born, umbilical cord changes
from a two-way street to a one-way street and begins to pump blood to the baby
very quickly (8%+30%=38%, which is amazingly close to the 40% of his blood that
he will need when he begins to breathe air).
If the physician (I say physician
because EVERY midwife learned this in school for the last 30 years and the
doctors are incredibly far behind on this one), if the physician clamps and
cuts the cord immediately, they do some horrible things to the baby. First, they cut off that blood transfusion
and force the baby to take the blood from their arms and legs. Hello blue hands and feet! If you took 30% of my blood away, I would
also have blue hands and feet. That
means that baby no longer has the resources needed to do much and they sleep
for the first day or two because a sudden and profound loss of blood volume
will make you very tired. Have you ever
given blood? Imagine you gave 4 times in
10 minutes, how would you feel? How
would you look? You would look like a newborn, exhausted, with blue hands and
feet, pale face and red eyelids. These
babies also don’t breastfeed as well, partly because they don’t have the energy
to eat.
What is even worse than a pale
baby is that when a baby doesn’t have enough blood he doesn’t have the ability
to carry and use oxygen. That means that
well-meaning physicians who want to cut the cord and pass the baby to the
waiting team to help the baby breath, have accidently made it worse. When you leave 30% of his blood behind, all
the oxygen in the world will be of little help, because without blood he can’t
use the oxygen. This is why immediate
cord clamping is so very dangerous to preterm babies. First, they lose 50% of their blood, and they
are weak and vulnerable to begin with. They
really can’t afford to lose the blood, and shifting all that blood from the
arms and legs to the heart and brain leads to brain bleeds (intraventricular
hemorrhage), and loss of blood to the intestines causing them to dye (necrotizing
enterocolitis).
So why did physicians start doing
it in the first place? In the 50’s there
was a high rate of baby’s having too many red blood cells (polycythemia). The assumption was that the babies had too
much blood, but they didn’t, they had too many red blood cells (there is a
difference). So the physicians assumed
it was because blood was flowing into the baby after birth from the umbilical
cord. They were wrong and no one has
asked why they were wrong, but that was what I wrote my thesis on, so I’ll tell
you what it was. In the 1960 census they
reported 97% of women of childbearing age smoked >10 cigarettes a day. We know that mothers who smoke cause
polycythemia in their babies. So, what
actually happened, was that we had a VERY HIGH-RISK population, but no one knew
it. No one knew that smoking was bad for
you back then, and so the scientists never thought to look at smoking as a cause
of the problem. As so often happens,
they made an assumption (the wrong assumption), things got better, and they
used that as evidence that they were right.
There weren’t, but then again, that happens all the time.
Now there are times when
immediate cord clamping may be a wise idea.
If the baby, God forbid, is born without a heartbeat, then there will be
no transfer of blood to the baby after birth.
That baby needs immediate attention, and there is little value in
waiting to start working on him. That
doesn’t mean every baby born in trouble, only the babies born without a heartbeat. If a mother has high blood pressure, is
diabetic, is a smoker, or a narcotic drug abuser, those babies have all had to
compensate for those stresses, like the babies of the 50’s, they will probably
benefit from immediate cord clamping.
So there you have it. Immediate cord clamping is bad for your baby,
delayed cord clamping is the physiologic norm, and your physician should be
told to read their professional policies and put them into practice. Once in a while I get someone who tells me
that their physician won’t practice delayed cord clamping. I always say the same thing, FIRE THAT
PROVIDER!! Do you really want a
physician caring for your baby when you know that they are 30 years behind the
evidence? Their own professional
organization came out in 2012 and said it was most likely safe and effective,
then 5 years later they put out the statement I quoted above. If the provider is that far behind, what
other things are they doing wrong? I
have no patience for health care providers who are not up to date on their own
professional organization’s rules.
Okay, that got a little harsher
than I wanted it to get, and I’m sorry.
But I’m not going to change what I said.
I urge you to ask your physician about delayed cord clamping and ask
them what their professional organization recommends on the topic. If they won’t educate themselves, maybe they
will listen to you?
Reference:
ACOG (2017) Committee Opinion
#684. Delayed Umbilical Cord Clamping
after Birth. Obstetrics and Gynecology;
129: e5-10.
