Posts tagged delayed cord clamping

Your baby has just been born.  Would you let someone draw their blood and remove 30% of their blood volume?

I became a midwife before I birthed my own babies.  People often ask me how my practice changed after I became a mother and gave birth.  All midwives advocate for the needs of babies, but giving birth to my own baby afforded me a more direct and visceral connection to the baby’s birth experience than I had previously known (among other things!).   I am more deeply attuned to how both mother and baby experience labor, birth and the hours after birth — physiologically and emotionally;  From their passage through the pelvis (or abdomen) to their first moments touching, hearing and smelling each other, it is a sacred and biologically unique time.

Here you can clearly see the red, oxygen rich blood still in the cord that is about to be severed. This baby did not receive that cord blood that nature intended her to have.

Here you can clearly see the red, oxygen rich blood still in the cord that is about to be severed. This baby did not receive that cord blood that nature intended her to have.

Harmful cord clamping practices are one of the first interventions experienced by most babies born in the US.  (Sometimes they are also needlessly bulb-suctioned or removed from their mother).  Cutting the umbilical cord within seconds of the birth, also known as premature or early cord clamping, is a routine practice of hospital births attended by physicians.  It is another intervention that has become so second-nature to physicians, and has gone largely unchallenged in the delivery room.

Dr. Nicholas Fogelson is a minority advocate for  “delayed” or normal cord clamping within the medical community .  While he aptly draws a parallel between premature cord clamping and blood-letting in his latest video series, he is candid about just how far he has come in his practice:

For the majority of my career, I routinely clamped and cut the umbilical cord as soon as it was reasonable.   Occasionally a patient would want me to wait to clamp and cut for some arbitrary amount of time, and I would wait, but in my mind this was just humoring the patient and keeping good relations.  After all, I had seen all my attendings and upper level residents clamp and cut right away, so it must be the right thing, right?…….

During pregnancy, the baby’s blood circulates in a constant loop in and out of her body.  It flows through the body, back into the cord to the placenta, then back through the cord into baby’s body.  This pattern of circulation continues until shortly after the birth when the placenta separates from the inside of the uterus.  By the time the placenta separates, virtually all the oxygen-rich blood in the placenta and cord (up to 40% of the baby’s total blood volume) has made its way back into the baby.

Why do physicians cord the cut so soon after birth?  Most believe that babies if babies receive their full blood volume from the placenta they will have too many red blood cells (polycythemia) and become jaundice.   They aim to prevent this by clamping and cutting the cord immediately after birth which stops the flow of blood from the placenta into the baby.

Also, it happens to be extremely convenient for the Swiss clockwork *ideals* of a hospital. Cutting the cord right away allows staff to get on with two other routine postpartum practices: active management of third stage (which includes early cord clamping, pitocin and pulling on the cord to extract the placenta) and routine baby assessment.  While the doctor facilitates the birth of the placenta, nurses can move the unattached baby to the warmer to perform their standard newborn care and assessment.  On the warmer, babies are typically suctioned, dried, swaddled, perhaps given oxygen, etc.  Some mother-friendly hospitals have begun to perform newborn care on mom. (In homebirths, these things are almost always done on the mother’s abdomen, or just beside the mother, with the cord intact).

In hospital births, physicians typically clamp and cut the cord moments after birth, and often before giving the baby to the mother.

In hospital births, physicians typically clamp and cut the cord moments after birth, and often before giving the baby to the mother.

In premature cord clamping we have an intervention that has become almost universally embedded into hospital birth on account of convenience and a desire to avoid jaundice –  the only trade-off is a loss of up to 40% of baby’s blood!?  Despite popular medical opinion, research favors delayed cord clamping for both preterm and term babies and has not found a significant association with either polycythemia requiring treatment or jaundice requiring treatment.

Two meta-analysis addressed the subject in the last five years — the JAMA and Cochrane reviews.  While the Cochrane review did report a small increase in jaundice requiring phototherapy among late cord-clamped babies (5% as opposed to 3% in the early clamping group), these results were based on one particular study that has been criticized by experts and physicians for a number of good reasons.  It is an unpublished PhD paper written by one of the review authors, and since the study was not published or peer reviewed its design raises a number of questions: we don’t know whether the physicians referring to treatment were blinded, whether confounding factors were accounted for, or what threshold for treatment was used 12 years ago in Australia when the study was undertaken.  The JAMA review found no increase in jaundice requiring phototherapy.

I’ve seen a good number of jaundice babies in my years attending homebirths, so for argument’s sake let’s say babies who have delayed cord clamping do develop more jaundice.  Is really worth significantly reducing their blood volume in order to reduce their odds of becoming jaundice?   Jaundice is “physiologic,” meaning normal.  Many healthy babies will become jaundice regardless of when their cord was clamped.  The vast majority of newborns with jaundice are normal and healthy and do not require medical intervention.  Depriving infants their full blood volume is not a reasonable response to something as common as jaundice.

DSC_5102

The placenta has been born, the cord is flaccid and pale, and the parents are ready to clamp the umbilical cord. The baby has received her full blood volume.

Why should we leave the cords alone?
It would be highly dangerous and to remove one-third of the baby’s blood from their body before they were born, yet doing it immediately after birth has become the norm.  Reknown physician and author of Zoonomia, Erasmus Darwin, recognized the danger in premature cord clamping in the 1800s:

Another thing very injurious to the child, is the tying and cutting of the navel string too soon; which should always be left till the child has not only repeatedly breathed but till all pulsation in the cord ceases.  As otherwise the child is much weaker than it ought to be, a portion of the blood being left in the placenta, which ought to have been in the child. (Zoonomia)

A little more physiology can help us understand why that blood is vital: Immediately after birth, babies transition from breathing amniotic fluid to breathing air.  This change requires the heart to pump far more blood to the lungs than it had before.  All the blood from the placenta and cord is needed in this process. The blood from the placenta also sends more oxygen around the body.  This transition process can take longer and be more difficult if the cord is cut early, preventing the baby from receiving her or his full blood volume.  In these cases babies often require supplemental oxygen — oxygen that would have been supplied by the umbilical cord.  We know now too that keeping the cord intact during resuscitation actually helps babies who are having trouble transitioning and breathing.  (Check out this new innovative mobile warmer unit from the UK that allows babies to be resuscitated with their cords intact).

Preterm babies also benefit greatly from delayed or physiologic cord clamping.  The benefits of keeping their full blood volume extend beyond the newborn period into infancy as well.  Babies have greater hemoglobin (iron) levels in the months after birth and benefit from the stem cells, antibodies and other life-sustaining components of their blood.

This cord has finished pumping blood from the placenta to the baby. You can see only a residual amount of blood through the cord. It is pale, flacid, thin and elongated.

This cord has finished pumping blood from the placenta to the baby. You can see only a residual amount of blood through the cord. It is pale, flacid, thin and elongated.

 

This cord was still pumping blood from the placenta to the baby when it was clamped. You can see blood in the vessels; the blood pressure gives the cord its shape.

This cord was still pumping blood from the placenta to the baby when it was clamped. You can see blood in the vessels; the blood pressure gives the cord its shape.

 

 

 

 

 

 

 

 

 

 

How do you know when the cord is ready to be cut? If the cord is still fat, taught, and spiraling it’s not time to cut yet.  If blood spurts out when it was cut, it was cut prematurely.  In most cases it is just as easy to wait until the placenta is born to cut the cord.  At homebirths, midwives typically wait to clamp and cut the cord until it  has stopped pulsing or the placenta has been born.  Waiting for the placenta also ensures that mothers and babies remain undisturbed in those precious and finite moments after birth.

I encourage women whose care providers insist on premature cord clamping to familiarize themselves with the subject and ask their physicians if they are aware of the body of research supporting delayed cord clamping.  You are your baby’s best advocate!

 

 

Resources:

Leaving Well Alone: A Natural Approach to the Third Stage of labour  –  Sarah J Buckley, MD

Delayed Cord Clamping Should Be Standard Practice in Obstetrics  –  Nicholas Fogelson, MD

Cord clamping researcher Judith Mercer talks about her study of delayed cord clamping for preterm, very low birth weight babies

This exceptional short video features renown midwives and physicians discussing cord clamping practices and the effects on babies: We Can Be Much Kinder

In hospital births, early cord clamping is one of the first interventions the newborn experiences. Physicians routinely cut the cord moments after birth, often before giving the baby to her mother.

I recently attended a planned hospital birth of a client who transferred out of my care shortly before her birth. We transferred her care to our small, local, natural birth-friendly hospital. A gracious family practice physician took over her care. Two of my client’s main hopes for her birth were delayed cord clamping (of at least a minute or two), and to receive her baby immediately from the hands of the doctor.  The doctor and I discussed the mother’s wishes more than once while she labored, and she was amenable to both. I had such high hopes for this baby’s entrance; We were going to have a somewhat physiological experience here!

After a few pushes baby comes out, pink and happy, and I’m watching, waiting…… still waiting for baby to be in mom’s arms. The doctor holds the baby down by the mother’s thighs, taking ample time to do unusual and unnecessary things. First, she bulbed the vigorous baby four or five times, then leisurely picked up a piece of gauze and slowly wiped the baby’s face. The energy shifted in the room from pure joy and excitement to mistrust and anger. She had previously agreed to give the baby immediately to the mother and now she was stalling. We were all very confused. What was she doing?

Meanwhile the mother was pleading desperately to have her baby: “Please, pleeeease, give me my baby.” I will never forget the sound of this mother begging to hold her baby. It caused me visceral pain. Every second of it broke my heart. I pray I will never again be in a situation where I, or anyone else, would withhold a newly born baby from her pleading mother.

After mother and baby were settled and nursing I seized a brief moment to talk to the doctor in the hallway. I asked her why she did not honor the mother’s desire to immediately hold her baby, as she had previously agreed to. She stated that she did honor the mother’s request to immediately receive her baby (“immediately is often a relative in the hospital), but that she also was attempting to honor her request for delayed cord clamping — requests that, in her mind, were mutually exclusive. She argued that she could not give the baby to the mother while the cord was intact because the baby’s blood would back flow into the placenta. In her mind, the delayed clamping needed to happen first, then the mother could have her baby. The two things could not happen simultaneously. We all know that thousands of babies are placed on their mother’s bellies every day, and probably have been since humans started having babies, but somehow the rules have changed.

A typical midwife-attended homebirth, where the cord is not prematurely cut and the baby receives her full blood volume. The parents decide when they are ready to cut the cord, with baby still nestled on mom.

I was stumped. Of all the bizarre medical model theories and logic I’ve encountered, this one was new to me. Typically physicians oppose delayed cord clamping because they believe the baby will receive too much of his or her own blood volume through the cord. This doctor was afraid that baby would not receive enough of her own blood because it would back-flow into the placenta if the baby was on the mother’s abdomen.

After debriefing with some of my peers I discovered that fears about blood draining out of the baby is not uncommon. But since the medical community largely opposes ‘delayed cord clamping,’ the question about where the baby should be while waiting to cut the cord rarely comes up in OB-attended births.

To be fair, there is some logic in the belief the blood will backflow out of the baby. If a woman gives birth and someone holds the baby up two feet above the mother’s body for any length of time, yes, common sense tells us the force of gravity will encourage blood flow downward, away from the baby. However, there are two problems with application of this logic.  First, suspending the baby above the mother should never happen. There is no valid reason to suspend a baby feet above her mother moments after birth. You may have seen this in birth scenes from the 80′s, but this is not an appropriate or even reasonable practice. Second, we now know that a complex feedback process  determines when the cord vessels close and thereby minimizing blood flow out of the baby and maximizing blood flow into the baby. It has very little to do with the position of the baby in relationship to the placenta.

Nature came up with a perfect design here. We can’t outsmart this one. Keeping the baby at the level of the mother’s abdomen is practical, normal, and biologically best. Fortunately for babies born in the hospital , some contemporary evidence-based OBs are coming around to accepting what midwives and mothers have long known: leaving the cord intact allows the baby to receive her full blood volume along with all the stem cells, red blood cells, oxygen, immune-boosting antibodies, and whatever other undiscovered life-giving properties our blood supplies.