Delayed Cord Clamping - What Are We Waiting For?

Before the 1950's it wasn’t uncommon for obstetricians to wait at least five minutes before clamping and cutting. It was just after the 60's that delayed cord clamping was thought to have no benefit and the timing of the cord was shortened. Today, the majority of obstetricians cut the cord in the first 15 seconds of the baby’s birth. Many providers have been taught that this is the way it should be done, and more importantly they were taught that it could be detrimental to the mother or baby if they waited longer - despite any evidence to back up those concerns. As new research has come out over the past several years, there has been much resistance. Part of this is due to the fact that cutting the cord immediately allows for a faster delivery of the placenta (and subsequently they get out of the delivery
room faster too), and partly because it’s hard to undo years of negative misconceptions (i.e. the baby will be more likely to become jaundiced, the baby might get polycythemia, and/or receive too much blood).

Things are changing, and more and more research is coming out, and it’s getting harder for providers to ignore the evidence and not provide delayed cord clamping in normal birth situations.  We are starting to see guidelines being set due to the overwhelming evidence that the benefits of delaying cord clamping outweigh any potential risks.  In fact, those who are still hesitant to start implementing this practice are being asked to show their burden of proof to the contrary.  So who are these organizations out there are changing their guidelines?  

The World Health Organization:  WHO has has endorsed delayed cord clamping of at least 1-3 minutes for the past several years. 

The Neonatal resuscitation program (which is developed and maintained by the American Academy of Pediatrics and is the gold standard in all US hospitals for providers who care for babies immediately after birth):  In June of 2016, the Neonatal Resuscitation Program revised and updated their guidelines. “Evidence suggests that cord clamping should be delayed for at least 30 to 60 seconds for most vigorous term and preterm newborns.”

Finally, ACOG had to back up the guideline and issue new practices:  In December of 2016, ACOG (The American College of Obstetricians and Gynecologists), released it’s recommendations that all doctors and midwives delay the cord clamping for a minimum of 30-60 seconds for all healthy newborns.

In the United States we think of this as a new practice, but some countries have been doing this much longer. For example, in the UK, the National Institute for Health and Care Excellence (NICE) changed its guidelines back in 2012. They stated that doctors and midwives should not routinely clamp the cord ‘earlier than one minute from the birth of the baby’, and instead should wait one to five minutes - and longer if the mother requests it. (Studies showed that 53% of surveyed providers in the UK routinely delay cord clamping/cutting already in 2009).
Here in the DFW metroplex, almost all midwives (including those who work in hospitals), and many OB’s support delayed cord clamping. We get change by asking, and helping providers understand “myth-conceptions”. We have not only seen change, but also improvements, such as delaying cord clamping/cutting in the OR during cesarean births in several hospitals (with certain providers) in our area!

So What Are We Waiting For?

What are the benefits?

• Increases blood volume
• Decreases the risk of brain bleeds by 50%
• Increases iron levels (when delayed for at least 2 minutes)
• Is linked to long-term neuro-developmental benefits (improving fine motor andsocial skills)
• Less chance of baby needing a blood transfusion for low blood pressure and/or anemia
• Decreases the chance of late-onset sepsis (a bacterial infection usually caused by environmental factors)
• Provides a higher respiratory rate, and lowers the risk of developing infant respiratory disease
Are there any risks?

What are the potential risks?

There may be a slight increase in billirubin levels increasing the chances of needing phototheraphy for neonatal jaudice. Studies range from “no significant difference” to ‘a slight increase’ in the risk of jaundice. A study (McDonald and Middleton's), found that 3% of babies who experienced early cord clamping, compared to 5% of babies who experienced delayed cord clamping required treatment for jaundice. Despite the increased risk, WHO, ACOG and many other organizations around the world state that ‘the benefits of delayed cord clamping outweigh the risks of jaundice’.

What medical circumstances might interfere with your decision to do delayed cord clamping?

The World Health Organization states that delayed cord clamping in under a minute should occur “when a newly born term or preterm babies require positive-pressure ventilation, the cord should be clamped and cut to allow effective ventilation to be performed.” - And/or - "newly born babies who do not breathe spontaneously after thorough drying should be stimulated by rubbing the back 2–3 times before clamping the cord and initiating positive-pressure ventilation.” Basically this means that anytime a term baby is born, it should be given the opportunity to cry while being dried and stimulated on the mother’s belly for at least a few seconds before clamping and cutting the cord and handing it over to the NICU team for more care.

A preterm baby may not get even a minute depending on how small they are,
and how they are reacting immediately after birth. If a preterm baby is doing well, it is extremely beneficial to delay clamping the cord.

Sometimes providers will not delay cord clamping/cutting when there is thick meconium present at birth. Many providers are more comfortable handing the baby over to the NICU team immediately after birth so that they can start suctioning the baby’s mouth and throat before vigorous crying occurs. However, the newest Neonatal Resuscitation guidelines (starting in 2015), state this protocol: “Non-vigorous newborns with meconium-stained fluid do not
require routine intubation and tracheal suctioning; however, meconium-stained amniotic fluid is a perinatal risk factor that requires presence of one resuscitation team member with full resuscitation skills, including endotracheal intubation.” Most babies come out crying before suctioning can be done, so many hospitals are now taking a ‘wait and see’ approach and suctioning well after birth if it is needed.

The United States would be wise to implement a table such as the LifeStart where bedside resuscitation can occur while keeping the umbilical cord attached. Birth centers and home birth midwives already have this practice in place, by having portable oxygen nearby. Instead of bringing baby to the oxygen equipment, they bring the equipment to the baby! Hospitals across the globe are using the LifeStart (or other similar tables) for bedside resuscitation, why can't we?

What non-medical reasons are there for cutting the cord early?

The main reason for implementing this practice is care providers preference. According to the study “Attitude of obstetricians towards delayed cord clamping: A questionnaire-based study” published in July of 2009 by Ononeze & Hutchon (1) - the main reason for not doing it? “Difficulty with implementation in clinical practice”. Hmmmm. I’m not sure why it’s harder to hand the baby to it’s mother and wait a few short minutes, but my bet is on the fact that waiting is boring and time consuming. (Oops, did I just get cynical?)

Some providers are still hesitant because of the myths that have been perpetuated through the years (stated in the first paragraph). I truly believe that they feel it is very unsafe to implement this practice (and I’ve heard some go as far as to tell clients that they have seen baby’s go to the NICU because of it)! Any provider who says that it is NOT safe or not beneficial to delay cord clamping needs to challenged to come up with a recent study as to why it is NOT safe or
beneficial. (They can’t). There are some that will refuse to implement this practice at all, while others will say they will only to change their minds during the birth. A few more are likely to meet you somewhere in the middle. Some will say they can “milk the cord” for a few seconds (no proven benefits), some will be okay with a 30-60 second delay. More often than not, from what I have seen, more than half of the providers that say they will wait, end up finding a reason to cut it sooner anyway. 

Cord blood banking may be another reason delayed cord clamping can’t/won’t be done. Most cord blood banking companies require a specific amount of blood in order to bank it - and this requires cutting and clamping the cord sooner. There *are* some cord blood banks that can bank a much smaller amount and claim that parents may be able to delay up to a full 2 minutes. It is never a guarantee that you will get both, so make sure you have a final decision to do one or the other if it comes down to it, so you don’t have to make that split-second decision!

Are there any medical reasons for cutting the cord early?

Yes, there are medical circumstances that may require more focus on the mother or baby. For example, placenta abruption, or even if the placenta is partially (and prematurely) separating from the uterus. When this happens, there is less oxygen transferring to baby, and baby may not benefit much or at all from the cord staying intact anyway. In some cases, the mother and baby may both need attention separately.

When is the ideal time to cut when both mom and baby are doing fine?

When the cord stops pulsating - or at least 3 minutes after birth.  It's pretty easy to tell when it's time to cut the cord.  First of all, you can feel for a pulse by squeezing the cord near your baby's belly 'button'.  You can also see the changes as well: 
At first, the cord is dark blue and coiled like an old fashioned telephone cord and you can feel the pumping easily with your fingers. As the blood supply drains from the placenta into your baby, the cord becomes white and flat while the pulse in the cord becomes weak until non-existent.  A great visual can be found here:  https://www.nurturingheartsbirthservices.com/blog/?p=1542

If your provider is still hesitant, don't be afraid to find out what their concerns are.  Have they read the updated guidelines, and if so, why are they not implementing them yet?  Can they meet you somewhere in the middle?  How strongly do you feel bout this?  Would you switch care providers if they are against delayed cord clamping in normal birth situations?   Tell me your thoughts below! 

References:
(1) “Attitude of obstetricians towards delayed cord clamping: A questionnaire-based study” published in July of 2009 by Ononeze & Hutchon -
www.tandfonline.com/doi/full/10.1080/01443610802712918?scroll=top&needAccess=true
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1564438/
http://www.medicalnewstoday.com/releases/70525.php
Downey C, Bewley S Third stage practices and the neonate. Fetal and Maternal Medicine Review 2009;20:229–46
http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Delayed-Umbilical-Cord-Clamping-After-Birth

More reading:
https://www.scienceandsensibility.org/p/bl/et/blogid=2&blogaid=526
http://www.bellybelly.com.au/birth/delayed-cord-clamping/
See my Pinterest board on delayed cord clamping for more reading and video resources!