MIDWIFERY SERVICES SOUTH TEXAS

Claudine Crews CPM LM

 

Clamping of the Umbilical Cord - Immediate or Delayed

   - Is this really an issue?

by Claudine Crews CPM, LM

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I've always believed waiting to clamp the newborn's umbilical cord is important because the baby continues to receive oxygen via the placenta as long as the cord is pulsing, a good thing if the baby doesn't breathe immediately. However, I also knew that immediate clamping of the cord was routine in almost all physician-attended birth. Most obstetricians believe immediate clamping is important and beneficial. Some even believe delayed cord clamping is dangerous. I disagreed with those beliefs and knew that there was no real evidence to support their views, but was it really an issue? An issue to make an issue of?

Research presented in an article by Dr. George M. Morley, MB, ChB Fellow American College of Obstetricians and Gynecologists, entitled "Neonatal Resuscitation: Life That Failed",  illustrates how important it is to not cut the umbilical cord until it stops pulsing. While there are several important reasons, the subject of this article is how crucial it is to leave the cord intact in protecting the brains of babies who suffer birth trauma or asphyxiation at birth - the exact opposite of what occurs in routine hospital births. 

As Dr. Morley states in his article1,

"Today, in US hospitals, if a child is born alive, the chances of it dying within a few days are virtually zero; even some babies without a heartbeat are resuscitated. Perhaps one third of all neonates receive some form of resuscitation treatment, and the success in terms of mortality is excellent. About 6 % to 10 % of all neonates are “morbid” and need NICU care – many of these are preemies; again, NICU mortality is extremely rare; however, in terms of neurological and mental disability, especially in NICU babies, long-term morbidity is anything but rare.  The life-saving procedures of neonatal resuscitation and NICU care are much less successful in preserving brains. If resuscitation does not result in a five minute Apgar of 7 or more, neurological impairment is likely.

The term “resuscitation” implies restoration of deficient life support systems, especially respiration; in the depressed newborn, that deficiency is in the placenta and cord, as the lungs have not yet begun to function. The rationale on which current resuscitation is based is that early detection of fetal asphyxia combined with rapid delivery and rapid establishment of pulmonary respiration (reversal of asphyxia) will prevent brain injury. If brain damage (neuron necrosis) has occurred in utero, resuscitation will not heal it; however, overt brain damage seldom is evident at birth, and it often appears after resuscitation. Hypoxic ischemic encephalopathy usually is diagnosed hours after birth when the child convulses; germinal matrix hemorrhage in preemies may develop a day or two after birth; mental and behavioral problems may not surface for years." 

The fetus grows and develops in an environment that is relatively low in oxygenated blood. This is not a flaw, it is how we are designed. As long as the fetus is not deprived of his total blood supply all of his organs, including his brain, are being adequately perfused with oxygen1. It has been adequate for 9 months and it remains adequate at birth.

 A full-term newborn has an average of 120 ml of blood per kilogram of body weight, or an average of a total fetal-placental blood volume of about 480 ml (16.9 oz.) At any given time about 70 % of his blood is in his body and 30 % is in the placental/cord unit2. (In premature babies the percentage of blood in the placental/cord unit is higher.) When a baby is subjected to immediate cord clamping he is loosing 30% - or more - of blood which should have been transfused into his body via the cord! A loss of 50 ml of blood to a baby weighing 7.5 lbs is equal to an adult weighing 150 lbs loosing 1000 ml of blood2.

Is this important? Most physicians have stated for years that the baby needs to be deprived of this blood, that it is dangerous to them. Does this make sense? How could the human race survived and thrived as it has if our normal physiology was so inherently flawed. Immediate cord clamping is a relatively new procedure. There is evidence as far back as 1773 that physicians understood the physiology of cord closure and transition from fetal-placental circulation/respiration to newborn-lungs circulation/respiration, and the importance of leaving the cord intact until pulsation ceased3:  

So why is immediate cord clamping almost universal? The practice evolved over several decades for a variety of stated, hypothetical reasons. It was first recommended in the 1930s as a method of reducing the amount of anesthesia that reached the infant. Then in the 1960s someone hypothesized that clamping the umbilical cord immediately would prevent newborn jaundice. It did not, as seen by the large number of babies whose cords are cut immediately at birth and are subsequently treated for jaundice. Another reason often quoted is that early cord clamping might prevent polycythemia, a pathological disorder in the number of cells in the blood. However, subsequent research has not proved this theory true. In fact, most cases of polycythemia occur with immediate cord clamping.

One reason not often mentioned for immediate cord clamping is a lack of time or patience on the part of the physician. Waiting on the cord to stop pulsing completely can take several minutes.

While the above rationales are the most frequently quoted, it was the development of improved methods of newborn resuscitation that eliminated delayed cord clamping in the hospital setting. This development caused a sharp division of care between mother and newborn. The physician responsible for the mother no longer cared for the baby once it was born. The newborn became the pediatric staff's responsibility. How could the pediatric staff "treat" the newborn if he was connected to his mother by the umbilical cord?

Sadly, since resuscitative measures are more likely to be needed in a premature baby or one experiencing problems, immediate clamping of the cord is deemed even more urgent since it is the pediatric staff's responsibility to provide these resuscitative measures - which is implemented across the room in an infant warmer.

One final blow was dealt to delayed cord clamping: Fear of litigation. In 1995 the American Academy of Obstetricians and Gynecologists (ACOG) released an Educational Bulletin (#216) recommending immediate cord clamping in order to obtain cord blood for blood gas studies in case of a future law suit. Why? Deviations in blood gas values at birth can reflect asphyxia, or lack of. Lack of asphyxia at birth is viewed as proof in a court of law that a baby was healthy at birth. Following an unpublished letter sent to ACOG by Dr. Morley, ACOG withdrew this Educational Bulletin in the February 2002 issue of Obstetrics and Gynecology, the ACOG journal. This action released them of liability resulting from the release of their previous bulletin2. Nevertheless, the damage has been done. 

Is it important that newborns are being deprived of 30 % to 50 % of their blood volume?  Risks associated with early cord clamping are 1, 2

·        Hypotension (low blood pressure)

·        Hypovolemia (low blood volume)

·        Anemia (low hemoglobin/iron)      

·        Hypoglycemia (low blood sugar)

·        Metabolic acidosis

·        Respiratory Distress Syndrome

·        Hypothermia (low body temperature when deprived of warm blood flow through the cord)

·        Higher incidence of cardiac murmurs in the first 14 days of life

·        Suboptimal flow of blood to the gastrointestinal tract increases risk of necrotizing enteritis in preterm babies

·        In the asphyxiated new born: Brain damage, including possibly cerebral palsy and autism

Benefits of delayed cord clamping include2

·        50 % larger red cell volume, enlarged blood volume, and higher hematocrit. The iron in these cells is stored by the body, which protect your baby from anemia. The notion that babies who are breastfed are anemic becomes irrelevant.

·        Increased amounts of white blood cells and antibodies which help the baby to fight off infections

·        Increased platelets, important in normal blood clotting     

·        Increased plasma proteins and other nutrient benefits that come with adequate perfusion

·        Better circulation in the first few hours after birth due to increased systemic vascular resistance

·        Less trouble with maintaining a normal temperature

·        The baby receives his or her own stem cells. These may contribute to health and well-being in ways we do not fully understand yet.

Is delayed clamping of the umbilical cord so important an issue that parents should discuss it with their doctor or midwife? Absolutely! The reasons given for immediate cord clamping don't hold water. We can't ignore the logic behind leaving the umbilical cord intact until it stops pulsing on its own.  Parents and birth professionals need to insist that all babies be allowed their full blood supply at birth.

References

1.  Morley GM, MB, ChB FACOG: Neonatal Resuscitation: Life That Failed

           http://www.obgyn.net/pb/pb.asp?page=/pb/articles/neonatal-resuscitation

      Published Feb 2003 OBGYN.net

2.  Frye, Anne: Holistic Midwifery Volume II Care during Labor and Birth Labrys Press 2004

3.  History of Cord Clamping http://web.archive.org/web/20041011050220/www.cordclamping.com/History.htm

 

For more information on cord clamping visit:

http://www.cordclamp.com

http://www.autism-end-it-now.org

 

 

By Claudine Crews CPM, LM

Certified Professional Midwife

Midwifery Services of South Texas

http://midwiferyservices.org