Delayed Cord Clamping

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.