Home > Obstetrics, Rants and Raves > Delayed Cord Clamping Should Be Standard Practice in Obstetrics

Delayed Cord Clamping Should Be Standard Practice in Obstetrics

There are times in our medical careers where we see a shift in thought that leads to a completely different way of doing things.   This happened with episiotomy in the last few decades.  Most recently trained physicians cannot imagine doing routine episiotomy with every delivery, yet it was not so long ago that this was common practice.

Episiotomy was supported in Medline indexed publications as early as the 1920s(1), and many publications followed in support of this procedure.  But by as early as the 1940s, publications began to appear that argued that episiotomy was not such a good thing(2).  Over the years the mix of publications changed, now the vast majority of recent publications on episiotomy focus on the problems with the procedure, and lament why older physicians are still doing them (3) (4).  And over all this time, practice began to change.

It took a long time for this change to occur, and a lot of data had to accumulate and be absorbed by young inquisitive minds before we got to where we are today, with the majority of recently trained OBs and midwives now reserving episiotomy only for rare indicated situations.

Though this change in episiotomy seems behind us, there are many changes that are ahead of us.   One of these changes, I believe, is in the way obstetricians handle the timing of cord clamping.

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?

Later in my career I was exposed to enough other-thinking minds to consider that maybe this practice was not right.   And after some research I found that there was some pretty compelling evidence that indeed, early clamping is harmful for the baby.  So much evidence in fact, that I am a bit surprised that as a community, OBs in the US have not developed a culture of delayed routine cord clamping for neonatal benefit.

I think that this is a part of our culture that should change.  This evidence is compelling enough that I feel like a real effort should be made in this regard.   So to do my part in this, I am blogging about it.

As this is Academic OB/GYN, of course I am going to lay out this evidence I speak of.  But before I do that, I want to present some logical ideas under which this evidence ought to be considered.

Prior to the advent of medical delivery, and for all time in animals, it has been the natural way of things for a baby to stay on the umbilical cord for a significant period of time after delivery.  Depending on culture and situation, the delay in cord separation could be a few minutes or even a few hours.  In some cultures the placenta is left on for days, which of course I find excessive and gross (5).  But whatever the culture and time on cord, the absence of immediate cord clamping allows fetal blood that was previously in the placenta to transfuse back into the baby.  Studies have demonstrated that a delay of as little as thirty seconds between delivery and cord clamping can result in 20-40 ml*kg-1 of blood entering the fetus from the placenta (6).

Considering this data, I have to think about evolution and function.  I am a strong believer in evolution, but even under creationist thinking I have to believe that if the system meant for babies to have been phlebotomized of 50-100 cc of blood at birth, we would have been born with higher hemoglobins.  Clearly the natural way of things is for this not to happen.

So does this mean that early cord clamping is necessarily harmful?  Absolutely not.   But what it means is that the burden of proof is on us to prove that early cord clamping, which amounts to planned fetal phlebotomy, is a beneficial thing.  Otherwise, all things being equal we ought to give the tykes a few minutes to soak up what blood they can from the placenta before we cut’em off.

So the question is whether or not there is strong data either way.

It is easy to imagine a randomized study of immediate vs. delayed cord clamping, with quantitative analysis of fetal lab values and clinical outcomes.  So easy in fact, that it has been done many times – and in just about every study, there is a clear benefit to delaying cord clamping, even if it is just for 30 seconds after delivery.  These benefits include important outcomes such as decreased rates of intraventricular hemorrhage and necrotizing enterocolitis in preterm neonates.  Furthermore, aside from some intermittent reports of clinically insignificant polycythemia and hyperbilirubinemia in term infants, there appears to be no harm that can be linked to delayed cord clamping. It feels like being a doctor 10-15 years ago looking to see if there is any data about episiotomy, and finding that there’s a lot, and it says we’ve been doing it wrong for awhile now.

So here’s the data:

Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial(7)

Randomized 72 VLBW infants (< 1500 grams) to immediate or delayed cord clamping (5-10 vs. 30-45 seconds).  Delayed cord clamp infants had significantly less IVH (5/36 in delayed group vs. 13/36 in immediate group, p = 0.03) and less late onset sepsis (1/36 vs. 8/36, p = 0.03).

The Influence of the Timing of Cord Clamping on Postnatal Cerebral Oxygenation in Preterm Neonates: A Randomized, Controlled Trial (8)

Randomized 39 preterm infants to immediate clamping vs. 60-90 second delay, and examined fetal brain blood flow and tissue oxygenation.  Results showed similar blood flow between groups, but increased tissue oxygenation in the delayed group and 4 and 24 hours after birth.

Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomized controlled trial(9)

Randomized 476 infants to immediate or 2 minute delayed clamping and followed them for 6 months.  Delayed clamped babies had higher MCVs (81 vs. 79.5), higher ferritins (50.7 vs. 34.4), and higher total body iron.  Effects were greater in infants born to iron deficient mothers.  Delayed clamping increased total iron stores by 27-47mg.  A follow up study showed that lead exposed infants with delayed clamping also had lower serum lead levels than immediate clamped infants, likely due to iron mediates changes in lead absorption.

A randomized clinical trial comparing immediate versus delayed clamping of the umbilical cord in preterm infants: short-term clinical and laboratory endpoints(10)

Infants delivering at 30 to 36 weeks gestation randomized to immediate vs. 1 minute delay.  Delayed group had higher RBC volumes (p = 0.04) and hematocrits (p < 0.005), though there was no difference in RBC transfusions.  There was a small increase in babies requiring phototherapy in the delayed group (p = 0.03) but no difference in bilirubin levels between groups.

Immediate versus delayed umbilical cord clamping in premature neonates born < 35 weeks: a prospective, randomized, controlled study (11)

Randomized 60 infants to clamping at 5-10 seconds vs. 30-45 seconds.  Delayed clamping infants had higher BPs and hematocrits.  Infants < 1500 grams with delayed clamping needed less mechanical ventilation and surfactant.  Trend towards more polycythemia in delayed group, but not statistically significant.

And that’s just some of it.  I’ll be happy to send you an Endnote file with a pile more of you’d like it.  If the burden of proof is on us to prove that immediate clamping is good, that burden is clearly not met.  And furthermore, there is strong evidence that delaying clamping as little as 30 seconds has measurable benefits for the infant, especially in premature babies and babies born to iron deficient mothers.

So basically, we should be doing this.  I’m going to try to effect some change in my department, but there are a lot of things that need to happen for us to change as a general culture.  It can’t just be the OBs.  L and D nurses and pediatricians need to buy in as well.

Some people will argue that premature babies need to be brought to the warmer right away for resucitation.  I don’t know the answer to this, but it’s worth study.  One might think that it is important to intubate a very premature baby right away, but I have to wonder if that intact cord will be better at delivering oxygen to the baby for 30-60 seconds than the premature lungs.  Particularly in cases of fetal respiratory acidosis, there is strong logical argument that a baby might be better resuscitated by unwrapping the cord and letting it flow a bit than trying to oxygenate it through its lungs.  Until that placenta is detached, you have a natural ECMO system.  Why not use it?  Certainly there are exceptions to this logical argument, abruption being the biggest one, and perhaps even severe pre-eclampsia and other poor feto-maternal circulation states.

I wonder at times why delayed cord clamping has not become the standard already; why by and large we have not heeded the literature.  It is sad to say that I believe it is because the champions of this practice have not been doctors, but midwives, and sometimes we are influenced by prejudice.  Clearly, midwives and doctors tend to have some different ideas about how labor should be managed, but in the end data is data.  We championed evidence based medicine, but tend to ignore evidence when it comes from the wrong source, which is unfair.  It is fair to critique the research and the methods used to write it, but it shouldn’t matter who the author is.  In this case, Mercer and other midwives have done the world a favor by scientifically addressing this issue, and their data deserves serious consideration.

To quote Levy et al (12) “Although a tailored approach is required in the case of cord clamping, the balance of available data suggests that delayed cord clamping should be the method of choice.”  We ought to heed this advice better.   Like episiotomy, this change in practice may take awhile, but we should get it started.   I’m going to work on it myself.  How about you?

1.            Martin DL. The Protection of the Perineum by Episiotomy in Delivery at Term. Cal State J Med 1921 Jun;19(6):229-31.

2.            Barrett CW. Errors and evils of episiotomy. Am J Surg 1948 Sep;76(3):284.

3.            Rodriguez A, Arenas EA, Osorio AL, Mendez O, Zuleta JJ. Selective vs routine midline episiotomy for the prevention of third- or fourth-degree lacerations in nulliparous women. Am J Obstet Gynecol 2008 Mar;198(3):285 e1-4.

4.            Gossett DR, Su RD. Episiotomy practice in a community hospital setting. J Reprod Med 2008 Oct;53(10):803-8.

5.            Westfall R. An ethnographic account of lotus birth. Midwifery Today Int Midwife 2003 Summer(66):34-6.

6.            Weeks A. Umbilical cord clamping after birth. Bmj 2007 Aug 18;335(7615):312-3.

7.            Mercer JS, Vohr BR, McGrath MM, Padbury JF, Wallach M, Oh W. Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial. Pediatrics 2006 Apr;117(4):1235-42.

8.            Baenziger O, Stolkin F, Keel M, von Siebenthal K, Fauchere JC, Das Kundu S, et al. The influence of the timing of cord clamping on postnatal cerebral oxygenation in preterm neonates: a randomized, controlled trial. Pediatrics 2007 Mar;119(3):455-9.

9.            Chaparro CM, Neufeld LM, Tena Alavez G, Eguia-Liz Cedillo R, Dewey KG. Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomised controlled trial. Lancet 2006 Jun 17;367(9527):1997-2004.

10.            Strauss RG, Mock DM, Johnson KJ, Cress GA, Burmeister LF, Zimmerman MB, et al. A randomized clinical trial comparing immediate versus delayed clamping of the umbilical cord in preterm infants: short-term clinical and laboratory endpoints. Transfusion 2008 Apr;48(4):658-65.

11.            Kugelman A, Borenstein-Levin L, Riskin A, Chistyakov I, Ohel G, Gonen R, et al. Immediate versus delayed umbilical cord clamping in premature neonates born < 35 weeks: a prospective, randomized, controlled study. Am J Perinatol 2007 May;24(5):307-15.

12.            Levy T, Blickstein I. Timing of cord clamping revisited. J Perinat Med 2006;34(4):293-7.

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  1. December 3, 2009 at 6:15 am

    I couldn’t be happier to see this post. I agree that the evidence is about as clear as you can ask for, but we’re far from having delayed clamping be the standard of care. I hang around enough blogs and online communities to know that many women face push-back or outright refusal by OBs when they ask for delayed clamping, so it’s great to have a rational, evidence-based OB source to send these women to.

    I appreciate the hat-tip to midwifery researchers. I’ll be the first to admit that not all midwives know, understand, or follow evidence. But there are some truly brilliant academic midwives out there whose work should be changing practice but is not because of preconceived notions of what constitutes the “right” evidence. Thanks for doing your part to reverse that bias.

    Prepare for the onslaught of natural birth advocates! I’m posting this on Facebook and Twitter. :)

  2. December 3, 2009 at 6:25 am

    Amy is absolutely on the money. This is one of many areas in medicine in general and obstetrics in particular where the standard practice has been remarkably inflexible and unchanged despite significant research to the contrary.

    I appreciate the way that you have presented the evidence as well as the physiologic rationale.

    Keep up the good work and spreading the evidence.

  3. December 3, 2009 at 6:55 am

    Saw you post this on Twitter. Fantastic! I will agree with Amy having been-there-done-that….I wish all OB’s “humored” their patients as willingly as you have. I am glad you wrote this as a doctor – a peer-voice that mothers can print out and take to their prenatal doctors.

    This will be a beneficial stepping-stone of communication for patients and doctors I believe. An easy way to create that all-important dialogue to reach a common ground understanding before labor begins. :-)

    Bravo! Angela <

  4. December 3, 2009 at 7:32 am

    I’d also like to suggest that delayed (or should we say “physiologic” and the current practice is “premature?”) cord clamping may also have benefits to the mother. Mouloud Agajani Delavar at the Faculty of Midwifery at Babol University of Medical Sciences, Iran published an article titled “A Study on Comparison between the Effect of Early and Late Cord Clamping on Third Stage of Labor” (I wish I had a date–I have a print out of this that does not have a date on it nor where I got it from–I think it was presented at a FIGO conference though) that found that in women with delayed clamping there was a statistically significant shortening of the 3rd stage and a statistically significant reduction in post-partum blood loss when delayed clamping was practiced.

    My personal experience has been that I have hemmorhaged 500-1000 cc in my first 3 births, which all had immediate cord clamping. My next two births I insisted on waiting for the placenta (which, admittedly, took 30 and 75 minutes), and I had less than 50 cc blood loss in the immediate post partum period, and my lochia was significantly lighter. I’ve also had one client who hemmorhaged with her first birth (which did include prostaglandin and Pitocin induction), but also had less than 50 cc blood loss with her second–again, immediate vs. delaying until the placenta came.

  5. December 3, 2009 at 7:37 am

    Thank you for writing this post and including the research sources that supports the evidence that delayed clamping has proven benefits. Such a simple, low cost, no risk action can have such benefits to the newborn!

    There have been several submissions to the http://www.myobsaidwhat.com site about the comments made by birth professionals to support immediate clamping!

    http://myobsaidwhat.com/2009/09/10/the-babys-blood-will-run-back-into-mom/

    Glad to see you working to change it from the inside out in your facility!

    My OB said What

  6. December 3, 2009 at 7:45 am

    Dear Dr. Fogelson:

    What a great resource you are providing in creating an avenue of discussion for evidence based practice that has somehow not yet become “mainstream” in general practice. I enjoyed this article very much and will be sharing it with students, clients, and others!

    I have also, always said, (as a strong believer in evolution) that if the cord was meant to detach right away after birth, it would, all on it’s own! And since it does not, that leads me to believe that there are some benefits to allowing the baby to continue to receive oxygenation and blood volume from the placenta.

    I encourage my students and clients to learn more about this and share what they have learned with their providers, so that their wishes can be supported in full at the time of birth.

    I am so enjoying your blogposts and am glad I have found you! keep it up please!

    Sharon Muza BS, CD, CDT (DONA) LCCE
    newmoonbirth.com

  7. December 3, 2009 at 7:45 am

    Thanks for all the comments. I am thinking of developing this further into a peer-reviewed article. There are a number of reviews already, but clearly we need more!

    NewMoonBirth>. I have also, always said, (as a strong believer in evolution) that if the cord was meant to detach right away after birth, it would, all on it’s own! And since it does not, that leads me to believe that there are some benefits to allowing the baby to continue to receive oxygenation and blood volume from the placenta.

    I appreciate this comment, but have this to say. We should not assume that what is natural is necessarily the best way. There are plenty of examples where we have not yet evolved into beings capable of dealing with natural problems. Certain conditions still require intervention to staunch the flow of nature. You could easily say “If we were meant to survive a placenta previa, we would have higher hemoglobins in pregnancy!” Certain conditions are so deadly that there is no chance to evolve resistance over time.

    That being said, I believe as evidence based physicians and practitioners, we should have a good evidence base to support us when we want to divert nature off its path, or in the absence of evidence, at least good physiologic reasoning.

    Nicholas Fogelson

    • Raffaella
      September 20, 2010 at 2:19 am

      Thank you for this great article. I plan to print it and share it with my OB this week when reviewing my birth preferences with him. What amount of time do you recommend delaying the clamping that would provide the maximum benefits? What amount of time do you think an OB would allow this to be delayed in a hospital setting?

  8. Danielle Arnold
    December 3, 2009 at 8:54 am

    Thank you very much for this fantastic blog. I have been researching delayed cord clamping for many years and have had to argue with 2 seperate OB’s about it. (though it needs to be said that I have never had this argument with either of my midwives….food for thought?). I am going to post a link you this blog on my own blog- informed parenting- and my Facebook profile, as I know that many people will feel vindicated by your blog.

  9. December 3, 2009 at 12:24 pm

    “If we were meant to survive a placenta previa, we would have higher hemoglobins in pregnancy!” Certain conditions are so deadly that there is no chance to evolve resistance over time.

    Of course! there are some things that need intervention or mom and/or baby would die! and I am glad that we have the ability to identify those problems and take appropriate action. Deviation from the norm (ie, previa) will always occur, but I consider that to be different then the premature clamping. Thank you for participating in such a great discussion

  10. December 3, 2009 at 12:33 pm

    I agree, and validate the delayed cord clamping argument with experience that has taught me, there is no rush to cut the baby’s life line immediately. You never know what will happen. I recently delivered a term baby girl who arrived by a beautiful water birth, and never took her first breath unassisted. As I lifted her to her mother’s arms, she grabbed my gloved finger and held tightly to it, eyes wide open. Despite my earnest efforts, seconds ticked by and even with rigorous stimulation, she would not cry, breathe or gasp. Instructing my RN to begin PPV with oxygen, the cord continued to support her as I then raced to clamp and cut the cord that had finally stopped pulsing. Artificial ventilation continued for 18 minutes while an endotracheal tube was placed. Her color remained pink throughout those slow motion-like minutes of uncertainty from her birth to when she was transported to the NICU (NEVER without oxygen because I left her attached as we prepared to bag and mask her.) Upon ex-tubation in the NICU, she crashed again, and it was there, we discovered she had a congenital growth (teratoma sac on a stalk) obscuring her nasopharyngeal airway that moved away, when PPV was applied. Imagine the outcome of the baby, had the cord been cut during those precious seconds when we struggled to assess and treat her apnea. After surgical removal of the teratoma she went home and is doing great with no adverse or long term effects that could have occurred from a lack of oxygen during her resuscitation, had her cord been cut immediately upon delivery.

    Lynette M. Elizalde-Robinson,BS,LM,CPM,CCEd
    NRP & ACLS Certified
    President, Louisiana Midwives Association

    • December 3, 2009 at 4:06 pm

      What’s interesting about your story is that if that baby had be prenatally diagnosed with that lesion, the likely plan would have been an EXIT procedure. With EXIT (Ex Utero Intrapartum Treatment) the baby is delivered by cesarean only far enough to operate on the lesion that needs repairing, with the baby continuing to be on maternal circulation until the procedure is complete. Prior to this procedure, defects that completely occluded the fetal airway were often fatal. With this procedure, these defects can be repaired before the baby ever needs to take its first breath. This procedure is not commonplace, but is available in a number of tertiary centers in the country.

  11. marianne
    December 3, 2009 at 1:51 pm

    There is a way to achieve this during a surgical birth or a preterm birth. A table similar to an over the bed table is placed close to mom, over her belly. Baby can be placed on it and recusitation measures done without cutting the cord. It can also be done during a Cesarean birth. I’ve seen it happen. Unless the cord is very short there is not a problem…

  12. December 3, 2009 at 2:13 pm

    Thank you for acknowledging our research. Very nice post. My colleague, Deb Erickson-Owens, and I are just beginning to put together a proposal for a large RCT on placental transfusion in term infants. No study on term infants has been completed in the US and it is high time that it be done. Will keep you posted on our progress. Again, it is always so nice to have one’s work acknowledged! Keep up the good work.

    • December 3, 2009 at 4:00 pm

      I practice in a center where a great deal of our medicaid population are iron deficient. Delayed clamping is likely to help those infants, and perhaps all term infants as well.

  13. December 3, 2009 at 5:15 pm

    Thank you, Nicholas, for the information on the EXIT procedure. This was a very healthy pregnancy, with no indication or suspect for the growth. First and second trimester US were unremarkable, as lab work and H&P showed no discernible alerts to prime investigation of this congenital malformation. Even the NICU Neonatologists admitted they had never seen anything like this before, and since my client never presented with problems during her prenatal care, and her labor was uneventful with no fetal distress during the entire time, I had no reason to believe she was incapable of a SNVD without complications. As a Licensed Midwife, my scope of practice is low-risk, in collaborative association with my OB/GYN. As this seems to be an extremely rare situation, can you point me in the direction of research info, and materials that will best inform me of early diagnosis and prevention procedures that I may pass on to my collaborating physician.

    • December 3, 2009 at 5:52 pm

      This case points out one of the differences between the care provided in tertiary centers versus midwife care. All in all, both parties can provide excellent care, but each has their strengths and weaknesses. I am wondering if your second trimester ultrasound was read by a Maternal Fetal Medicine physician. If this patient had been cared for in my center, she would have had an anatomy ultrasound read by an MFM, and very likely this lesion would have been antenatally diagnosed, and precautions might have been taken.

      Ultimately, one has to decide ones threshold for missing rare defects. One extreme (which I follow) is to have a high risk obstetrician scan every pregnancy in the mid second trimester. A middle ground is to have a routine ultrasound done by a tech which is read by a radiologist or general OB/GYN. The minimalist path is to not get an ultrasound at all unless there is some real reason (generally not done by OBs. Some FPs and lay midwifes have this philosophy.)

      In this day in age, we have the capability to diagnose >98% of congenital defects antenatally. I practice in a setting where all my patients can get MFM ultrasounds, so I do that. When MFMs do routine scans, they typically still do what would be considered a Level II ultrasound, which includes screening for just about any defect that can be detected on ultrasound. This is different from the Level I ultrasound that most generalist OB/GYNs and radiologists can provide, which screens only for certain heart defects, CNS defects, spina bifida, and certain urinary tract and GI abnormalities. Something like what you mentioned would probably be missed with a level I scan. When an MFM gets a referral for a routine scan, they are using the same equipment, and more importantly the same brain, as they would use to do a level I, so basically you are getting the level II for the price of a level I (which is all insurance is going to pay for unless there is good reason for a level II). MFMs are able to find these kinds of rare lesion more often than other practitioners because they spend years of training looking at abnormal fetuses, and usually have seen at least a few of any known lesion. Generalist OB/GYNs and radiologists usually get most of their experience looking at normal fetuses, since they work with a much lower risk population, and thus they are not as good at finding subtle defects.

      So my answer to your question is that you probably can’t expect to find these lesions antenatally unless you are going to refer every patient get their anatomy scan with an MFM. Even then there is a chance it could been missed.

      Of course if your screening scan was done by an MFM, then there really was nothing else that could have been done.

  14. December 4, 2009 at 2:56 am

    It was a 20 week anatomical, which I routinely schedule at an imaging center and is read by a radiologist if there are no prior indications for it to be done by the MFM specialist. It was missed. The OB and I also work in collaborative association with an MFM, but, he sees clients referred by us for abnormal quad screens, gestational diabetes,and diagnosing w/follow-up, etc. Besides my practice at the Birth Center, both the OB and MFM specialist have the highest Medicaid population practices in the area (I also work two days a week in the OB office seeing patients). I believe you have suggested that I rethink my sono protocols and utilize the services of our MFM for every 20 week anatomical as opposed to the imaging center. If a client risks out of my care, she then moves back up to the OB/GYN generalist, who determines if she is high risk and should be followed by the MFM. I will address this discussion at our next meeting. Thank you for the advice and the valuable information you have shared. I will continue to follow all information posted here, you’ve been most helpful.

    • December 4, 2009 at 4:55 am

      I’m not necessarily saying that you should start getting all MFM scans. I’m saying that this is what would be necessary to find these rare kinds of lesions. This is not to say that MFMs never miss lesions, but they do miss fewer, in my opinion.

      All MFM anatomy scanning is something that is common and standard in tertiary centers, and in some communities. In some communities, however, it is not practical. Sometimes there is limited MFM access and they are busy enough doing targeted scans and consultations that they do not have time for doing routine scanning.

      It is important to clarify that what you are doing is the standard of care. ACOG recommends a level I ultrasound for anatomy screening, and you are providing that. One just has to accept that finding very rare and subtle birth defects is not part of a level I (screening) ultrasound. Having MFMs perform your level ones gets you a better detection rate, at the same cost. If its available, its great. If not, that’s fine.

      This is also just my opinion. And to dispell any thoughts out there of turfism, I’m not an MFM. I’m a generalist OB/GYN, and am quite sure that I cannot find subtle lesions as well as an MFM who looks at them all day.

      • December 4, 2009 at 8:10 am

        This is what we do as well. While I prefer a homebirth for my personal birthings I do like to have the peace-of-mind from an Ultrasound. We always have a full diagnostic/anatomical ultrasound with all our pregnancies before settling on a home birth. :-) It was interesting to hear the difference in levels of specialization in this discussion. I called and our local hospital refers out to an MFM so it’s not readily available for mothers at the hospital either. The downside of rural living. *wry grin*

  15. December 4, 2009 at 7:37 am

    You are correct there is a benefit but primarily for preterm infants and for approx 45-60 sec delay. Not until stops pulsating. Also for term there is a risk see below. Balance is everything not to long or to short.. about 60 sec is best at term.

    (Dr Baiza posted entire posting of 2007 Cochrane Review, this was edited out for brevity and replaced with conclusion and a link to the PubMed Page for the cited article)

    McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD004074.

    Conclusion

    “… In this review delaying clamping of the cord for at least two to three minutes seems not to increase the risk of postpartum haemorrhage. In addition, late cord clamping can be advantageous for the infant by improving iron status which may be of clinical value particularly in infants where access to good nutrition is poor, although delaying clamping increases the risk of jaundice requiring phototherapy.”

  16. sarah
    December 4, 2009 at 2:44 pm

    I have what might be a strange question. I am a (canadian) family doc who delivers term, med-low risk babies at a community hospital. I would be happy to delay cord clamping (although my reading also agrees that it’s more beneficial for preterm babies and/or in communities with low iron levels, neither of which are our babies).

    But…what exactly do you *do* with the baby while you are hanging out for that 1-2 minutes? with a spontaneously crying baby, I usually clamp & then put up onto mom’s belly, drying & doing basic resus there. With delayed cord clamping, do you just kind of hang out with baby at level of perineum? this seems like an awkward time to start making conversation…”it’s a girl! yay! just…hanging out! okay…still a girl! gee, a minute is really a long time eh!”. Do you get the same beneficial effect if baby is non-clamped but elevated to mom’s belly?

    With a silent baby, I usually clamp & then move baby to a bedside warmer where mom can watch but we are a bit more controlled for resus. I understand the theory that delaying stimulation/drying/freeflow O2 is ok for a flatter baby, because they are getting mom’s circulation, but that seems even more awkward use of time as you all stare at this silent, floppy baby, waiting for the 60 seconds to pass. what on earth do you talk about for THAT minute?

    This all may sound silly, but it is a real consideration for me…would appreciate any insight from those of you further along than me.

    • December 4, 2009 at 3:50 pm

      Speaking only from personal experience – at all three of my births the baby was placed on my stomach or chest depending on length of the cord and the warmed blanket/towel placed over both of us to prevent chilling. Since I don’t bath the baby immediately that wasn’t an issue. My second born actually nursed right away. And by right away I mean within two minutes – greedy little girl. She had a very long cord compared to the other two obviously. Lol!

      Really the parents will be so busy exclaiming over their new arrival the time will fly. My health care provider always suctioned during this time as well and usually the baby cried right away or within a minute depending.

      Just lay the baby on the stomach and let the mom hold him!! :-D She’ll thank you for it.

    • Ulrike
      December 5, 2009 at 10:01 am

      A baby with a short cord can still be placed on mom’s tummy and covered to prevent chilling. Babies with average to long cords can be placed at the breast and allowed to nurse if they desire.

      Skin to skin contact is beneficial for baby’s health (facilitating the transfer of healthy, “probiotic” bacteria from Mom to Babe, and regulating baby’s body temperature and breathing), as well as being a bonding experience for Mom and Baby. Nipple stimulation from nursing helps to contract the uterus, decreasing bleeding and expelling the placenta. For squeamish parents, you could wrap the baby in a receiving blanket before passing her along to Mom to hold, but it’s really not necessary. Mom’s going to want a quick shower afterward anyway.

    • March 19, 2011 at 8:34 am

      You could do what most OOH (out of hospital) midwives do, give baby to mom and do nothing until the cord has stopped pulsing (takes 5 – 20 minutes usually). What to do while you wait for the cord to stop pulsing? Stand there drinking in the love while the parents meet their baby. Or repair the perineum if needed or finish your charting.

      With a “silent” baby, ask the parents to talk to and touch their baby.

      • October 25, 2011 at 10:11 pm

        This is all great advice as long as the baby has a good heartrate. If a baby is not crying, one needs to make sure it is pink and and breathing and has a good heartrate of greater than 120. If not, its needs some help, not touching and talking.

    • sarah
      May 22, 2011 at 1:51 am

      Having had 2 lovely waterbirths (one at home) with delayed clamping, the baby was passed to me to cuddle while we waited for the next stage to arrive. it was lovely just to hold the babies while everyone around just stayed quiet – I discovered the sex of my baby myself (I asked the midwives not to tell me) and I was fortunate not to have a doctor present (the reason for choosing midwifery-led care) so that nobody took those first special moments away from me by “tidying up” my babies – they were perfect just as they were. my husband then clamped and cut the cord when it had stopped pulsating and we waited for the placenta to turn up while still holding the baby skin-to-skin in the pool. What a magical experience for all of us!

    • Miguel
      October 25, 2011 at 9:58 pm

      Imagine that your patient is your daughter. Ask her how she feels now that she is holding the baby. Tell her the baby looks healthy and that the baby is adjusting to her new environment. Tell her the baby recognizes the voice of the mother. Tell her some nutrients from the placenta are being transferred to the baby via the umbilical cord and will complete in about 1 minute. If a picture paints a thousand, then surely a baby being born paints a million words.

  17. December 4, 2009 at 3:34 pm

    I’m sure other commenters have opinions on this. I would just hold the baby for a bit and wash him/her off at perineum level then put it on mom’s belly. I’m not sure about whether or not it matters where the baby is being held. Most do it at perineum level but on the belly might be just as good. Certainly for the oxygenation part it wouldn’t matter, as gravity is helping in one direction and hurting in the other, so there should be no net effect on blood flow through the cord..

    I agree that this is much more of an issue for the pretermer. As Dr Mercer said there has yet to be a large randomized trial for term babies in the US, so there will be more data on this in the future.

    As to what to talk about? Guess I’ve never had a problem with that. People say I talk too much not too little.

  18. Ingrid Jakobsen
    December 4, 2009 at 5:20 pm

    Thanks for this article, it’s really great to see an OB/GYN acknowledge that “delayed” cord clamping is the standard that immediate cord clamping has to prove itself better than.

    I’d like to note that the Cochrane analysis does not find any *benefit* to immediate cord clamping, so I think the “but delayed cord clamping only demonstrably helps premature births” argument is misplaced. Additionally, there is a Cochrane analysis (http://www.cochrane.org/reviews/en/ab004665.html) suggesting (limited evidence so far) that placental cord drainage is beneficial.

    This looks to me very much like a second intervention to compensate for the first intervention (immediate cord clamping). Why ever not just let that blood “drain” into the baby? I am not a physician or a midwife, just a biologist with too much time to waste on PubMed.

  19. December 4, 2009 at 5:31 pm

    Interesting that draining the cord speeds time to placental detachment. This makes teliologic sense, as drainage of the cord blood into fetus would also signal that it is time for the placenta to detach, or to be less anthropomorphic about it, allows collapse of the fetal side of the spiral vessels promoting separation.

    The only real concern for delayed clamping at term, as pointed out by a few folks, is that there is a slight increase in neonatal jaundice. Some studies have found this to be clinically significant, others have not. In my mind, we have to ask ourselves if we are honestly going to intentionally drain some blood from the fetal system to prevent this problem. Seems strange to me, but I’d welcome the opinion of some pediatricians or neonatologists. It is possible that I(we) are minimizing the impact of these few extra incidents of neonatal jaundice.

  20. December 5, 2009 at 12:18 am

    To answer the question of where to put the baby and what to talk about, I always place the baby right in the mother’s arms and I agree with Angela that it’s possible with all but the shortest cords. In fact, I’ve never encountered a cord too short for the mother to hold her own baby. I do all assessments with the baby skin-to-skin. I also avoid suctioning in all but the goopiest babies (I’d say my bulb suction rate is well below 5%). If Dr. Fogelson is up for another challenge from the midwife camp, I’d suggest taking on suctioning and/or skin-to-skin next. In the former, you’ll find no evidence of benefit and some troubling surrogate outcomes (pulse ox disruptions), plus many things unmeasured (e.g., effect on feeding). In the latter, well, you’d probably be hard pressed to find anything I care more deeply about, and there’s a ton of literature to support it. See this. Physiologic cord closure facilitates skin-to-skin contact and also may reduce the need (or perceived need, because I really don’t think there is a need in the vast majority of cases) for suctioning, because it pulls fluid out of the alveoli.

    As for jaundice requiring phototherapy, most of the data supporting an excess in delayed cord clamping comes from an unpublished trial that was included in the Cochrane review because it was the PhD thesis of one of the reviewers. From the information included in the Cochrane, it seems like it was reasonably conducted, but we can’t critically assess it without the paper available. Another systematic review published a year prior in JAMA did not find an association between timing of cord clamping and jaundice, and unlike the Cochrane reviewers, these reviewers reported bilirubin levels, which also did not differ significantly.

    • March 19, 2011 at 9:23 am

      Yes! Let’s get the evidence to abandon routine suctioning. I see only negatives with bulb suctioning, including feeding problems, disruption of “bonding”. We do not suction any normal babies and haven’t in years. Granted I own a free standing birth center and have a very low risk cohort. Some of our parents report baby coughing up a big glob about 12 hours after birth. We now know to warn them about this. Back to evolution – there was no way to provide more suction than a mom putting her mouth over baby’s mouth and suck out the goop.

      • March 19, 2011 at 1:45 pm

        Its not an issue that I feel is very important. Suctioning term babies probably isn’t necessary, but there certainly isn’t any evidence that its harmful either. Babies are in water until they are born, and they do need to expel that water to start breathing. Most of that happens in the delivery of course, but what’s the harm in a little help? I’ve seen plenty of babies sputter and spurt until they clear themselves out. Its odd that you can’t see the potential benefit in helping them out.

        To me, this is a classic example of the thing I hate about the natural birth / midwifery / medical birth debate. I feel like natural birth folks just want to eliminate any intervention that isn’t clearly necessary. I can see that to a point, but with something as harmless as removing some fluid from a baby’s oropharynx, why get all up in a knot about it? Maybe this is just a part of OB and pediatric culture, but there are a ton of things that are part of midwifery culture that are equally arbitrary. If you don’t want to do it, don’t! If an OB likes to do it but the mom would rather it not be done, then the OB should just chill and see what happens! It isn’t worth fighting over on blogs, nor is it worth some big campaign. Its just not important enough. Live and let live.

  21. December 5, 2009 at 6:41 am

    Nicholas Fogelson :Interesting that draining the cord speeds time to placental detachment. This makes teliologic sense, as drainage of the cord blood into fetus would also signal that it is time for the placenta to detach, or to be less anthropomorphic about it, allows collapse of the fetal side of the spiral vessels promoting separation.
    The only real concern for delayed clamping at term, as pointed out by a few folks, is that there is a slight increase in neonatal jaundice. Some studies have found this to be clinically significant, others have not. In my mind, we have to ask ourselves if we are honestly going to intentionally drain some blood from the fetal system to prevent this problem. Seems strange to me, but I’d welcome the opinion of some pediatricians or neonatologists. It is possible that I(we) are minimizing the impact of these few extra incidents of neonatal jaundice.

    I think the finding of excess cases of jaundice is an example of an “iatrogenic norm.” Because early cord clamping has been routine for decades, the normal range for bilirubin was almost certainly established in babies who were deprived of a substantial proportion of their blood volume. Some proportion of babies allowed to capture all their blood volume would then read “high” because the curve was shifted lower than it should be. A more familiar example of this is infant growth charts, which, until fairly recently, were based on white, formula fed infants and led to an all too frequent diagnosis of poor weight gain when applied to breastfed babies. Iatrogenic norms are but one of the problems that arise when trying to conduct research within the context of a highly interventive system, the effects of which are rendered invisible by their universality.

    • December 5, 2009 at 6:56 am

      An interesting theory and comment. There may very well be truth to that. I believe the indication for putting a baby under the lights at a certain bilirubin level is based on outcomes research though. Not being my field I am not certain though, perhaps a pediatrician can weight in on this.

    • June 17, 2011 at 12:05 pm

      Henci,
      Yes, yes, and yes!

  22. Linda
    December 5, 2009 at 7:33 am

    Thanks for posting this. I am 32 weeks pregnant and have been doing research into this. I’ve talked to some people about it and I was told by one person that if you delay cord clamping and the placenta detaches too early that the baby could lose blood back into the placenta. Is there any truth to that?

    Thanks so much

    • December 5, 2009 at 8:05 am

      >> I’ve talked to some people about it and I was told by one person that if you delay cord clamping and the placenta detaches too early that the baby could lose blood back into the placenta.

      I don’t think this is a substantial concern. The placenta doesn’t detach right away unless its abrupted, in which case delayed cord clamping probably would not be the right thing.

  23. December 5, 2009 at 7:48 am

    Thank you for publishing this review and I especially appreciate the comment that evidence presented by midwives is frequently ignored due to prejudice.
    In most of medicine, and especially obstetrics, what is “right” depends on the perspectives and belief systems of the people involved. However, what is done should always include the short and long term physical and emotional effects that any action will have on the newborn and the family. Too often, another course of action that is just as correct, is dismissed because it was put forth by the midwife or the well-informed parents.
    ignorance should never be a reason to ignore the dictum: “First, do no harm.”

  24. December 5, 2009 at 8:02 am

    Sarah (the Canadian family doc) as for resuscitation, I am a midwife and an NRP instructor. In 12 years I have only found the need to clamp a cord to move the baby for resuscitation on 2 occasions. It can be accomplished with the baby in mom’s arms or on her abdomen for all but the most critical cases, i.e. those requiring chest compressions. Having the baby in mom’s arms automatically provides warmth and a familiar auditory presence. If we believe that newborns have an emotional presence at birth, then removing them from a familiar environment would increase catecholamine release and make the adjustment to extrauterine life more difficult.
    Usually there isn’t much for the midwife or doctor to say once the infant is born. The parents’ focus will have totally become the baby in mom’s arms.

  25. December 5, 2009 at 2:38 pm

    If the general public just gives up and decide to not fight for something like delayed cord clamping ~ because “we are too far away from seeing this happen as mainstream,” then change will not occur. It is the individuals, families, classes, etc… along with studies who create change in the first place. It’s all about supply and demand, and sadly about money. So if the majority ask and keep pushing, eventually change will occur.

    • December 6, 2009 at 4:57 am

      Honestly I think this needs to happen from the MD side. A few MDs need to talk it up at some major meetings and get a few real thought leaders behind them. A few editorials in major journals later this will all change. That is how change happens in medical practice, and it is what will be required here.

  26. December 6, 2009 at 9:06 am

    Henci Goer :

    Nicholas Fogelson :Interesting that draining the cord speeds time to placental detachment. This makes teliologic sense, as drainage of the cord blood into fetus would also signal that it is time for the placenta to detach, or to be less anthropomorphic about it, allows collapse of the fetal side of the spiral vessels promoting separation.
    The only real concern for delayed clamping at term, as pointed out by a few folks, is that there is a slight increase in neonatal jaundice. Some studies have found this to be clinically significant, others have not. In my mind, we have to ask ourselves if we are honestly going to intentionally drain some blood from the fetal system to prevent this problem. Seems strange to me, but I’d welcome the opinion of some pediatricians or neonatologists. It is possible that I(we) are minimizing the impact of these few extra incidents of neonatal jaundice.

    I think the finding of excess cases of jaundice is an example of an “iatrogenic norm.” Because early cord clamping has been routine for decades, the normal range for bilirubin was almost certainly established in babies who were deprived of a substantial proportion of their blood volume. Some proportion of babies allowed to capture all their blood volume would then read “high” because the curve was shifted lower than it should be. A more familiar example of this is infant growth charts, which, until fairly recently, were based on white, formula fed infants and led to an all too frequent diagnosis of poor weight gain when applied to breastfed babies. Iatrogenic norms are but one of the problems that arise when trying to conduct research within the context of a highly interventive system, the effects of which are rendered invisible by their universality.

    Thanks for this comment, Henci, I consider this along the lines of the current infant growth charts in use, based on growth rates for formula fed babies in the ’70’s. Just like it might be high time for the growth charts to be re-evaluted, so might it be time for the charts used to determine normal bilirubin be reassessed?

  27. December 6, 2009 at 9:29 am

    The large body of research over 5 decades shows beefits from delayed clamping of the umbilical cord, but there are conflicting reports of potential rise in rates of jaundice.

    I believe the conflict in these reports is a result of the variations in conduct of third stage.

    The practice of delayed cord-clamping does not mix well with oxytocics given as part of “active third stage management”.
    Under normal physiologic conditions, the uterus remains in quiet tone for a few minutes while the baby receives the “correct” amount of blood remaining in the placental circulation.
    If oxytocics are given with delivery, the early uterine contractions may result in an over-infusion of blood to the baby, polycythemia, and elevated risk of jaundice.

    In my region, the understanding of the association of increased risk of jaundice with the practice of “pitocin with the shoulders” was the major reason for the abandonment of this routine in the 1980s.

    I think a wise policy is to allow normal third-stage umbilical transfusion by clamping after the cord goes flat under most circumstances. But when pitocin is used then the cord should be clamped within 30 seconds.

    Midwives and doctors who follow this policy report rare incidences of neonatal jaundice, and extremaly rare need for phototherapy.

    regarding ‘what to do with the baby while waiting”… Let MOM deal with the baby!
    In almost all cases, the cord is long enough to allow the baby to be held on mom’s abdomen (and in her arms). There is no need to keep the baby at the level of the intoitus: in fact, this is not physiological. It is normal instinctive behavior for mothers to want to hold their babies at birth; in evolutionary terms, this means mothers hold babies while the cord is still intact!
    The maternal abdomen may be considered to be close enough to the level of the placenta that gravity is not likely to impact either under-infusion or over-infusion, unless the woman has given birth while standing (and this is unusual in our culture)

    (On a personal note: I’ve been a midwife for almost 40 years and can attest that babies do extremely well with a policy of delayed cord-clamping! I think they transition to extra-uterine life more easily, and breathe more quickly and deeply with a lower incidence of “gunky lungs” or TTN. And their intact cord allows them an additional life-line in the rare instance when they require assistance.

    Immediate cord-clamping is a very new development in human history. The routine evolved as a method to reduce the neonatal load of maternal medication when births were conducted under general anesthetic.
    Those days are LONG past, but this old routine still remains!
    We;re having a heck of a time getting rid of the silly thing!

    see: JAMA. 2007 Mar 21;297(11):1241-52.
    Late vs early clamping of the umbilical cord in full-term neonates: systematic review and meta-analysis of controlled trials.

    Hutton EK, Hassan ES.
    CONCLUSIONS: Delaying clamping of the umbilical cord in full-term neonates for a minimum of 2 minutes following birth is beneficial to the newborn, extending into infancy. Although there was an increase in polycythemia among infants in whom cord clamping was delayed, this condition appeared to be benign.
    PMID: 17374818
    (note nearly a 1000 babies in late-clamping study)

    also check out PMID: 16567393
    PMID: 15510946

    PMID: 18624002 — describes additional benefit of increased alveoli perfusion and recommends a minimum of 3 minutes delay

    PMID: 11783688

  28. December 6, 2009 at 11:05 pm

    One important remark: please stop speaking about “delayed” or “late” clamping. It’s high time to pass on to the concept of NATURAL CLAMPING (induced by natural process, hormones and so on…).
    On the other hand “premature” or “early” clamping are adequate.

    Sigismond, author of “Placenta, clitoris, foreskin, same fight against violence!”

    http://circabolition.multiply.com/journal/item/345/Placenta_clitoris_foreskin_same_fight_against_violence

    • December 7, 2009 at 9:16 am

      PoTAEto PoTAto. :)

      • June 7, 2010 at 7:06 am

        As a doctor surely you know the importance of language. I don’t think you should be so quick to dismiss the power of semantics. If you and other doctors begin to referring to premature cord clamping as such, it will really make other doctors stop, ask “what do you mean?” and maybe THINK instead of just doing the same ole routine.

  29. Tsedef Hadar
    December 7, 2009 at 6:14 am

    I am a birth educator and doula in Israel, the hospitals here clamp pretty quick but I have been working with a midwife who does homebirths and she clamps hours after and I have seen the difference in the way the baby accepts his/her new environment, a nonviolent procedure, disconnecting when it’s time like saying hello to the new and being ready to say goodbye to the old, it also makes sense and I am not a nurse or a doctor that the blood that still is pulsating in the cord from the placenta is meant for that new life every ml of it. I hope this changes soon, LISTEN TO THOSE LITTLE HUMANS AND THE MOTHER”S REQUEST TO HAVE IT CLAMPED LATER!!!!NATURE IS PERFECT WHEN IT”S LEFT ALONE!!!

  30. Tsedef Hadar
    December 7, 2009 at 6:25 am

    I Just wanted to add, the less interferring at birth and being there with all the technology “just in case” would make a whole lot of difference for the mother and baby whom should be born into a loving caring and supportive society! Unfortunately man believs he created nature so he has the right to meddle with it, Does it really suprise you that there are so many angry sorry and unhappy people running this world afterall violence was the key of entering this world, and forgetting how much we have to learn and study nature itself and maybe realise when to use the knowledge needed to save a life and not before.

  31. Tsedef Hadar
    December 7, 2009 at 6:28 am

    Thanks for writing about your research, I forgot to say that, it helps for all of us that believs that clamping should be delayed!

    • December 7, 2009 at 9:19 am

      Not my research – just a review of what is already out there. I don’t want to take credit for others’ work here.

  32. December 7, 2009 at 9:18 am

    I appreciate all your comments. While I appreciate the different ways of supporting this issue, what _I_ care about is the DATA that supports the practice. I don’t feel terrible about the conceptual nature of allopathic medicine. I just want to do, and think others should do, what the data supports.

  33. December 7, 2009 at 11:21 am

    Honestly I think this needs to happen from the MD side. A few MDs need to talk it up at some major meetings and get a few real thought leaders behind them. A few editorials in major journals later this will all change. That is how change happens in medical practice, and it is what will be required here.

    ++++++++++

    Change in obstetric and midwifery practice is so much more complex than this. For example, the research evidence (not all RCTs, but solid scientific investigations on the physiology involved) for spontaneous and directed pushing (and particularly coached breath holding, valsalva etc…) has been available for decades. And yet it is hard to shift practice. It is not just a question of being in the right or having the editorials in the right place.

    The history of changing fashions for episiotomy is instructive in this respect – the science was the same, the access to the science was same, but practice changed at a very different pace on different sides of the atlantic.

  34. December 7, 2009 at 6:31 pm

    Honestly, I don’t think it is much more complex than this. System wide pattern changes, in my experience, often stem from one or two prominent articles that “go viral” throughout the community. The WHI is a great example. David Grimes article “Magnesium: It’s Time To Quit” also had a dramatic impact in a short period of time, despite the fact that it brought no new data to the field. The large trial on magnesium neuroprotection spun it back in the other direction a few years later.

    Like any group of people, OBs respond to a respected leader that directs change. Right now, there is no respected leader pushing for delayed/physiologic cord clamping. If there were, we would see a big change. An ACOG committee opinion article would have a large impact as well.

  35. December 7, 2009 at 7:46 pm

    I work for a large company that owns many hospitals across the state I live in. They work hard to look at the research out there and implement what it suggests. As of recently, they are working with their OBs to start clamping the cord later. The research you mentioned has also been brought up as examples as to why we should do this. So, the word is getting out that is would be good practice.

    • May 7, 2010 at 4:15 pm

      Rachel, can you say where you are and which large company you work for? I have had many people contact me for info but don’t always know the outcome. This is very exciting that a whole hospital system is taking this on. I too feel that the research is adequate to support delayed cord clamping and placental transfusion but still most babies in the US are having their cords clamped immediately. My colleague, Deb Erickson_Owens and I are present a workshop on cord clamping/placental transfusion at the American College of Nurse-Midwives convention in WDC in June and would like to mention your system. Would also like to hear more about their methodology. Thanks for sharing this.

  36. December 7, 2009 at 8:38 pm

    That’s kind of a circular argument though (i.e. Research done -> Article published -> Practice changes, ergo article must have been influential/writer was respected). There are scores of counter-examples. It’s also easier to amend the obstetric formulary (like dropping magnesium sulfate for tocolysis, especially when there are other tocolytics still in the formulary) then make changes that impact the culture of birth. Cord-clamping practice is related to skin-to-skin (promotion or otherwise), third stage management – and a lot of people resist it because they are concerned about not being able to ‘control’ the situation (witness discussion above about where to put baby etc….)

    Why are women still encouraged to give birth in supine positions despite the evidence that this is not the optimum position? Induction for suspected macrosomia? Routine/universal use of cEFM? Restriction of oral fluids/eating in labour? Who would be the ‘respected leaders’ who could take up these issues and make an impact?

    • December 8, 2009 at 7:33 am

      I guess my point is that things change in big bursts, not slowly over time. Often times a key article or editorial is the impetus for that change. Just as easily it could be some other stimulus. I believe strongly in the idea of “The Tipping Point”, as described by Malcolm Gladwell, which describes how a few small stimuli lead to systemwide change.

      As to who? Could be me, could be you, could be anybody. It would just take some concerted effort by that individual, or group of individuals, to initiate that cascade of change. Not to say that anyone could definitely make it happen, but that it won’t happen without a concerted effort. This blog post and its resultant discussion has already had some effect (see two comments up)

  37. December 9, 2009 at 7:39 am

    I guess my point is that things change in big bursts, not slowly over time.

    ++++++++

    I totally agree. I just don’t entirely recognise your description of change in medical practice (particularly obstetric practice!) being entirely an internal affair. My perspective may be different because I’m outside the US context, but the experience in the UK has been one in which pressure for change from the service users has been pretty important over the past 2-3 decades.

  38. December 9, 2009 at 7:50 am

    I don’t know if you’ve come across this book?

    You might enjoy it.

  39. Jeffrey Ahmed
    December 11, 2009 at 1:27 am

    Great article, but extremely odd that you feel the need to reference creationist theory in a scientific review of evidence!

    • December 11, 2009 at 7:06 am

      Just trying to be respectful of all views….you can imagine where I stand on that one.

  40. Beth
    December 11, 2009 at 7:47 pm

    Not mine to control, but you would be an excellent addition to the science-based medicine blog. Much better than the dreck about OB being written over there right now.

  41. Danae Steele, M.D. (MFM)
    January 19, 2010 at 1:18 pm

    I just this morning presented to the Ob-Gyn committee at my hospital about the benefits of delayed cord clamping for premature babies. I’ve been doing delayed clamping term (and “termish”) babies (and putting them directly on the mother’s belly) for years, but have still been immediately clamping preterm babies so they could be moved to a warmer for evaluation and resuscitation. I was really surprised to come across all these articles about reduced rates of IVH (as well as other benefits) and my immediate reaction was that we have NO excuse not to be doing this for our preterm babies. I was expecting some opposition from our neos, but there was not one peep. People were very supportive. And one of the nurses in admin had printed your blog and gave it to me, which I found SO encouraging! I am not the only Ob-Gyn who thinks we need to get the word out on this! Thank you!

    • January 19, 2010 at 8:51 pm

      I’m happy that your department is starting to look at this, and that my blog was able to play a part in that! Thanks for looking, and please come back! Remarkably this blog post has been a catalyst for change in a number of places, which is more than I ever expected. I will be speaking at the REACHE conference in Seattle, WA in April about delayed cord clamping and other topics, also due to this blog post.

      Thanks for reading!

    • May 11, 2010 at 4:55 am

      I’m a doula and childbirth educator with a great deal of experience but without a medical degree. I have a client who is being given the argument that the baby must be kept below the level of the placenta until clamping in order to prevent the flow of blood from the baby back into the placenta – and this is from a very new doctor.

      Can you or Dr Fogelson direct me to some literature that explains how the umbilical cord works after birth that would help a doctor understand why delayed cord clamping/physiologic third stage and immediate skin-to-skin are not incompatible?

      From what I’ve heard over the years, not to mention the comments on “My OB Said What?” this is a common concern of medical professionals. It’s being used to persuade women to allow immediate clamping in order to facilitate skin-to-skin. They’re essentially being told they have to pick one or the other, not both.

      • May 11, 2010 at 5:19 am

        I’m not sure what reference I can refer you to, as I don’t think this has been definitively studied. However, the studies that have looked at delayed cord clamping did have the baby at or below the level of the placenta during the delayed clamping period.

        There are two issues:

        1) oxygenation of the fetal blood – this should not be affected, as the blood is being pumped up and back by the fetal heart. If the baby is above or below the placenta the net difference in pressure will be unchanged, as while the blood going one way has to fight gravity, the blood going the other way has the benefit of gravity. As fluid will continue in a straight line without gap, pulling the fluid behind it, the net pressure will be the same.

        2) As for volume of transfusion, she is correct that putting the baby up right away would effect how much of the placental blood would get to the baby. Placental blood vessels do not have any musculature to them, so the net transfer of blood would be affected by the position of the baby relative to the placenta. That being said, I certainly don’t think it is dangerous to put the baby on mom’s belly right away. It might interfere somewhat with transfusion of placental/cord blood into the baby, but I don’t think it is in and of itself harmful. Millions of mothers do this after delivering babies, and it seems to work out ok. But if one specifically wants to delay cord clamping so the baby gets the cord and placental blood, to me it makes sense to keep the baby at or below the level of the placenta while you are waiting.

        Ultimately, though, I don’t believe this has been studied. Nobody has looked head to head at keeping the baby below the placenta versus up on mom’s belly. My opinions above are based only my knowledge of physics and fetal/placental physiology.

  42. Danae Steele, M.D. (MFM)
    January 20, 2010 at 2:34 am

    Where are you located? I’m in Green Bay, WI. My co-fellow in MFM fellowship was Vincenzo Berghella (chair of MFM at Jefferson in Phila, and pretty well-published guy, and well-connected), and I’ve asked him to think about what he can do to get the word out about this and he is all over it. He is also working on a free on-line compendium of evidence-based recommendations for pregnancy and perinatal care.

  43. January 20, 2010 at 4:19 pm

    Columbia, SC presently, previously in Honolulu, HI and Charleston, SC before that.

  44. January 23, 2010 at 5:22 am

    I agree in the delayed cord clamping, eventhough cord blood banking is also a great opportunity for future cell therapies. Eventhough collection of vol of blood is directly related to the amount of cells (CD 34 cells), each cell counts because the numbers are usually low. Science today is only moving forward with technologies on the proliferation of those cells, as well as the use of the cord tissue (Wharton Jelly) as another source of stem cells (mesenchymal).

    My question reading your references is what have seen so far is in preterm which I agree provide much needed blood flow for further vital functions. Are there any studies related to delayed cord blood in normal term babies and its benefits?

    • January 23, 2010 at 5:51 am

      You make a great point, which I think came up in the comment thread before. Delayed clamping does preclude cord blood collection for future use. Clearly if you are going to save cord blood for banking, you would want to clamp right away. As you mentioned, the efficacy of a banked unit of cord blood is directly related to the volume of cord blood collected.

      As preterm babies are less likely to have enough cord blood to make a good donor unit, and they have the most to gain from delayed clamping, it makes sense to me that delayed clamping should be the standard.

      There is data with term infants that shows a decreased incidence of iron deficiency anemia in babies born to iron deficient mothers. There is not yet a large randomized trial of of immediate vs delayed clamping in term infants, though one is either underway or in design now.

      I noticed that you represent a company that does private cord blood banking, and as such you clearly have a financial interest in preserving immediate clamping as a standard in term babies. I am a huge supporter of public cord blood banking, based on a strong track record of success. I do not recommend private banking to my patients, based on the incredibly high cost per unit used, which in randomly donating families is in the hundreds of millions of dollars per unit. That is of course based on current technology, and most likely in the future the use of privately banked stem cells will increase, so that cost per unit used will fall as that happens. But based on current use the value private cord blood banking is selling is science fiction, not science fact. If my patients are willing to spend the money based on the vanishingly small likelihood that they will use the cord blood, or the potential that future use will increase, I’m happy to collect it, but I do try to temper the claims of the various storage companies with the evidence so far.

      At my last position, we were able to collect blood for public storage, which we did quite often. As we were in Hawaii, we actually did a great service for the public system as we added a lot of units that were ethnically dissimilar to the overall banked population, and as such did a lot of good for the southeast asian and pacific islander population around the world.

      It is my hope that public cord blood banking becomes the standard around the country. When that happens, we will be able to have a very good discussion about the merits of delayed cord blood clamping vs immediate clamping for public donation of cord stem cells, as they will be mutually exclusive options.

      This is a good topic for a future blog post. If I do one I’d certainly appreciate the side of the private cord blood banks in the comment thread!

      Thanks for your comments!

      • March 19, 2011 at 9:42 am

        “Delayed” cord clamping and cord blood collection ARE NOT incompatible. Grrrrr. I see claims nearly every where stating that you have to immediately clamp in order to collect for storage (whether it be donation or paid banking). I can tell you unequivocally that one can get an adequate sample out of the placenta with “delayed” cord clamping.

        I am a CNM running a free standing birth center in FL. A number of our clients have donated their cord blood over the years (although recently the private companies appear to have suspended their donation programs). Because our policy is to clamp once the cord has stopped pulsing, I was curious if we could maintain that policy and still collect cord blood.

        I was not going to ask the baby to effectively donate his/her blood.

        Once the cord stops pulsing, we clamp and dad or mom cuts. We then wait for the placenta. We take the placenta out of the room and collect the remaining blood in the cord.

        I was pleasantly surprised to find that I was able to collect more than the minimum sample. So, we did the same thing for all the other families who chose to donate or store cord blood. And this has been our experience:

        We have ALWAYS gotten at least the minimum amount for collection.

        There are lots of people who say it is impossible to have a physiologic 3rd stage and collect cord blood, and that makes me mad, because it sets up, essentially, a war between advocates of natural 3rd stage and cord blood harvesting advocates.

        If a family is collecting due to a family medical history, we do clamp a little sooner. Basically, we are hyper vigilant to clamp as soon as pulsing slows.

  45. January 23, 2010 at 7:13 am

    Dear

    I agree with you, we collect donations also, unfortunetly the cost of processing (we process with AXP and Bioarchive system same as all Public Cord Blood Banks such as NY Cord Blood Bank, MD Anderson , Duke, Utah and others), testing (related with the volumen of cords to process) and not much funds makes the public practice of collection difficult. Cord Blood Banking is an essential practice that should be the standard of care, covered by health insurance, for the benefit of your loved ones and the general public. With new cell therapies available every day these cells could be an extra opportunity for several diseases.

    Like Monoclonal Antibodies became a very useful tool in many therapies (as humoral response) so does the cellular response and the ability of the body to repair itself.

    Check clinicaltrials.gov search box cord blood stem cells to see what the future may look like.

    We believe in mixed banks private and public therefore we decided to go for the latest technology and invest on it as the only private bank doing it.

    We give the choice and try to accomodate donations as well as private banking.

    I agree costs should go down, hopefully all providers and the awarness will make this an affordable choice.

    Thanks for your feedback !!!

  46. Tsedef Hadar
    January 26, 2010 at 6:22 pm

    I was wondering if cord clamping has anything to do with all the coctails and different drugs a mother might recieve during labor? Are there more drugs going to the newborn if the cord is cut later or has that already passed through so cord clamping early really doesn’t have any impact on if the baby will be drugged more or not. I would be interested to know> Thanks

    • January 28, 2010 at 6:22 am

      I think the baby will get whatever narcotics the mother gets in pretty short order, so I don’t think it matters much. That being said, I don’t think that maternal narcotics are particularly harmful to neonates. Throughout my career, I’ve never seen a baby substantially depressed from maternal narcotic exposure, despite thousands of women who have gotten narcotics either parenterally (IV) or in an epidural.

  47. LH
    February 3, 2010 at 10:44 am

    Sorry about that, apparently my arrows were interpreted as html and some things got lost… what I meant to post:

    **NewMoonBirth: I have also, always said, (as a strong believer in evolution) that if the cord was meant to detach right away after birth, it would, all on it’s own!

    Nicholas Fogelson: We should not assume that what is natural is necessarily the best way. […] You could easily say “If we were meant to survive a placenta previa, we would have higher hemoglobins in pregnancy!”**

    The analogy doesn’t work to support your assertion, given that in one case we’re talking about normality and in the other abnormality. Of course it makes sense to intervene when something goes wrong. It does not follow that the normal physiological process needs to be “improved” by obstetric management.

    **Nicholas Fogelson: While I appreciate the different ways of supporting this issue, what _I_ care about is the DATA that supports the practice. I don’t feel terrible about the conceptual nature of allopathic medicine. I just want to do, and think others should do, what the data supports.**

    Studies don’t get done and data don’t get gathered until people look at a situation critically and observe a logical discrepancy. Reason first.

    **That being said, I don’t think that maternal narcotics are particularly harmful to neonates. Throughout my career, I’ve never seen a baby substantially depressed from maternal narcotic exposure,**

    Perhaps there are other harms besides being “substantially depressed” that you aren’t privy to, not spending significant time with the mother and baby post-birth and (I’m guessing) not being terribly familiar with a completely undisturbed process and therefore truly normal mother-baby behavior.

    • February 3, 2010 at 11:40 am

      Thanks for the comment. We probably have some fundamental differences in thought about things, but that’s ok. That being said, our thoughts are probably closer than you think.

      When it comes to the narcotics in labor, I don’t agree. Babies born to mothers that have some narcotics in labor are not harmed from it. Mothers clearly benefit from the pain relief, if that is their desire. I strongly believe that pain relief in labor is the right of women. If women choose not to have that that is fine, but I will not withold it based on metaphysical ideas of “natural” or “normal” labor. Natural and normal labor is painful, and some(most) mothers would like to avoid that. Probably in your selected clientele that is not true, but believe me in my patients it is very true. Given a complete lack of evidence to suggest any significant harm in giving mothers narcotics in labor, it would irresponsible of me to withold that based on some theoretical idea about baby bonding, activity, or whatever.

      “..and therefore truly normal mother-baby behavior”

      Again, normalcy is not what I am going for. Best outcomes is what I am going for. Normalcy/naturalism is the best way in some cases, but in some cases it is not. We use what data we have, followed by what logic we can muster, to figure out when it is time for normal and when it is time for not normal. Differing preconceptions about intervetion/naturalism/physician roles etc.. may change where we fall on these individual issues, but ultimately each patient and caretaker have to make those decisions individually.

      Thanks for the comment!

  48. Jacqueline
    March 19, 2010 at 1:38 pm

    I suggest it at every delivery but no one seems to be interested and they think I’m a flake… one day I’ll be a senior on the service though and I’ll be teaching it to my medical students. Evidence-based obstetrics is coming in my generation of obstetricians, I’m committed to it!

  49. Angela Horn
    March 22, 2010 at 5:04 am

    I was delighted to find this thoughtful and well-informed blog. Great to see one which is written, and commented on, in a polite and respectful manner, too.

    There have been a few articles published in the British Medical Journal about the potential risks of early cord clamping – for any readers who’ve not come across them, this editorial is a good place to start:

    Umbilical cord clamping after birth – Better not to rush, by Andrew Weeks.BMJ 2007;335:312-313 (18 August), doi:10.1136/bmj.39282.440787.80

    http://www.bmj.com/cgi/content/extract/335/7615/312

    Responses to above : http://www.bmj.com/cgi/eletters/335/7615/312

    The BMJ has published quite a few letters from Dr David Hutchon, a UK consultant obstetrician who has taken an interest in the timing of cord clamping. He has explained why he feels immediate clamping is particularly risky in babies who may be compromised, eg by a tight nuchal cord. He has updated his caesarean section protocol to allow resuscitation with an intact cord. See for instance the following:

    http://www.bmj.com/cgi/eletters/333/7575/954

    http://adc.bmj.com/content/93/5/451.2.extract

    Next there is part of a presentation given by Dr Hutchon, which includes plenty of references and some interesting graphs:

    http://www.nepho.org.uk/uploads/eid177_Cord%20clamping_David%20Hutchon.pdf

    I do find it counterintuitive that the blood loss for the term baby arising from immediate cord clamping is generally considered insignificant. Thinking merely in absolute terms – if one approach to management of the third stage for the mother resulted in an average of 100mls additional blood loss compared to another, there would be considerable pressure to adopt the approach which conserved her blood volume. For instance, if I recall correctly, the Hinchingbrooke trial of active versus physiological management of the third stage of labour found an average of around 80mls blood loss prevented by active management. Yet, as a proportion of total blood volume, 100mls is far more significant to the neonate.

    [The Lancet, Volume 351, Issue 9104, Pages 693 – 699, 7 March 1998
    Active versus expectant management of third stage of labour: the Hinchingbrooke randomised controlled trial
    Original TextJane Rogers BA a, Juliet Wood BSc a, Rona McCandlish RM b, Sarah Ayers BAxs b, Ann Truesdale BSc c, Dr Diana Elbourne PhD]

  50. April 27, 2010 at 1:01 pm

    Thank you SO MUCH for this post!!!! I love that you are an OB who believes in this, and that you posted all the scientific information about it.
    I have taken Neonatal Resuscitation and in it learned the importance of delayed cord clamping/cutting especially in cases where the baby is in distress (as long as the baby can be safely resuscitated on the mothers abdomen.)

    Thank you, thank you, thank you! :)

  51. April 27, 2010 at 1:03 pm

    Oh, and I can’t remember where I read it, but I have seen some information about delayed cord clamping AND saving blood for banking….I’ll have to find the article.

    • April 27, 2010 at 2:25 pm

      Thanks for the comment. I’m not sure what article that would be, or how that would work. Stored cord blood depends on volume for potency and graft effectiveness. Delaying cord clamping intentionally removes cord blood volume into the baby. The two ideas are mutually exclusive, assuming you want to freeze a useful cord blood.

      Given the relatively little effect delayed cord blood banking has at term, I would encourage any mom that wants to store cord blood to clamp right away and store every drop they can.

      As for whether or not random mothers should bother to store cord blood… that’s another story. In short: its very expensive, and the chance of it being helpful is extremely small. Its basically buying science fiction.

  52. April 28, 2010 at 1:36 am

    I have to admit, that the lack of education to fill the gap between the enormous amount of research and the clinical practice, makes assumptions about the use of cord blood that are not true. Please I invite you to see clinicaltrials.gov and in the search box put stem cells , or cord blood and just see how many clinical trials and the diversity of applications that is being tried today. The capacity of the body to regenerate and fix is natural, is not invented. Educate, educate before making statements and misleading people. only may be 2-5% will make from the total of trials going on, and that still is a very good number. The applications go beyond blood related diseases. It can be a complement treatment in some cases.

    • April 28, 2010 at 8:50 am

      As you are a PhD in these issues, I’m sure I am not educating you here, but for my readers:

      There is certainly a lot of promise in future uses of cord blood and other stem cells, but at this point it is still primarily a research entity. There are very few conditions that can are being successfully treated with autologous cord blood derived stem cell transplants in actual practice, in 2010. There are many many areas where this technology is developing, but for now the use is very limited.

      Women are being advertised to by private cord blood banking companies with taglines “its like an insurance policy.” This is hard to call an insurance policy, given that most insurers pay back at least 85% of what they take in. As the dollar amount that any individual can expect to get back is more like 0.005%, a lottery ticket would be a better analogy. As of a few years ago, only about 50 units had been used out of several hundred thousand cord bloods that were banked from random private donors up to that point, leading to a per-use cost of around 10 million dollars (and over $1 million dollar per quality-of-life year saved). Given our current health care crisis, that’s a near unethical use of health care dollars. Your own company’s tagline of “Your cells today, your chance tomorrow” is fair, but the chance is quite small given the cost required today.

      That being said, people have the right to spend their own money on health care (at least they do until this right gets taken away with upcoming legislation). If they want to spend $1500 – $2000 and $100 a month to store cord blood for the future, under the fully informed consent that it is extremely unlikely it will ever be used, that is their right, and I’m happy to collect the cells for them. But if patient asks me if I recommend it, I say that it is not a cost effective way to spend health care dollars at this point, and this likely this will remain the case long into the stem cell technology laden future.

      On the other hand, I strongly support public banking. There are a number of hematologic conditions that can be successfully treated with donated cord blood that is HLA matched to the recipient, and the larger the number of samples that are available in public banks, the greater likelihood that children and adults will be able to be treated this way. As the likelihood that any one unit will be used is very low, public storage also provides nearly 100% of the benefit of private banking, as there is a very strong likelihood that any given individual’s cord blood will be available for autologous use if the need should arise. The downside of course is cost. Public banking, though, does allow more distributive cost structure that would focus the cost on the recipient of the blood rather than the donor. Personally I would like to see the development of a nationally supported public cord blood banking system, autologous (no pun intended) to the American Red Cross blood banking system.

      Of course in specific families that might have a good chance of needing the privately banked blood (ie Fanconi Anemia families), private banking makes more sense.

      This is all worth greater discussion on another post at another time. Perhaps a pro-con debate between you and myself would be a good read.

      I am amazed at the work of researchers in this area, and will be happy to support random private cord blood banking once we can support it in current technology rather than future potential. I can see how someone who is deep in the stem cell field or works for a storage company would see storage as a no-brainer, but from a population level we’re just not there yet. There’s too many other things we can more justly spend our healthcare dollars on.

  53. April 28, 2010 at 9:03 am

    I will be glad to continue privately and find the right forum for it, actually will help to understand and educate. I agree in both public banking and private as well, people though actually should know the truth about the cost of retrieval of a cord blood from a public bank (is actually not free) vs private use. The funding from Federal sources and the trend from this industry. I am not speaking as a supporter of banking but as a scientist. Yes, you are absolutely right, healthcare have more urgencies than this one, but is not science fiction is in some cases and applications 2-3 years away.

    • April 28, 2010 at 9:14 am

      >> I agree in both public banking and private as well, people though actually should know the truth about the cost of retrieval of a cord blood from a public bank (is actually not free) vs private use.

      But if one individual spends, for example, $30,000 to retrieve and use a cord blood sample from a public bank (much of which would need to be spent to use a private sample as well), they are spending that money for a specific need. This is quite different to spending $2000 for some potential future need. One is buying healthcare. The other is buying some potential future healthcare.

  54. April 28, 2010 at 10:44 am

    I think I’m rather annoyed with someone who works for a cord blood company comes in and hijacks a discussion about delayed cord clamping.

    I happen to also have read a lot of the research on stem cells. And I feel pretty confident that by the time we have mainstream applications for stem cells, there will be alternative sources of stem cells rather than just cord blood. After all, the vast majority of individuals were born before cord blood was collected, or did not have parents and circumstances where cord blood collection was possible or affordable. Pluripotent adult stem cells are one of the more active areas in stem cell research, as far as I can tell.

    On the balance of probabilities, I think any parents can feel confident that their newborn’s cord/placental blood will do more life-long good inside their child than in a freezer somewhere.

    • April 28, 2010 at 2:08 pm

      I don’t have much problem with cord blood banking from a scientific point of view – there certainly is a lot of promise in it, and I can imagine a future in our lifetimes where a lot can be done with these cells. However, I can also imagine a future where we still don’t know what to do with them. I have a hard time recommending something that is expensive to do with no real ability to predict how it will impact future health potential. Even if stem cell therapies blow up, still the vast majority of people won’t need those therapies, making the cost per cord blood used very high.

  55. April 30, 2010 at 6:55 am

    I agree with Ingrid, I don’t want to interphere in your discussion. It will be very productive to initiate a Cord Blood pros and cons today, there is a lot of data out there that would be good to know,
    http://www.marrow.org/PHYSICIAN/images/nmdp_transplants_b1.jpg you can see how cord blood is replacing bone marrow

    Let me know when you are ready… would love to provide info.

    • April 30, 2010 at 7:15 am

      Cord blood tranplantation is indeed on the rise, but it is my understanding that the vast number of these transplantations are not autologous samples from privately banked cord bloods, but from allotransplantations from publically banked samples.

      I am not at all against storing cord blood, as there is quite clearly a big future in it. Am am against private banking of cord blood, at least not without clear disclosure of the mathematical unlikelihood of using it ever being used.

  56. April 30, 2010 at 10:03 am

    Nicholas I enjoy this discussion a lot… Let me just add that allogeneic data is more available because comes from public banks, but there are many trials in autologous use, juvenile diabetes at University of Florida, Palsy at Duke University, and bladder a new from Case Western, helping to vascularize tissue, etc, this is all TODAY, imagine in a few years !!! Public banking depend on federal money that is very short, the solution to that is to generate mix banks public/private so private can pay some of the expenses of the public.
    The other major point is why banking, well stem cell grow older too… telomeres get shorter, mutations acumulate. http://www.nature.com/nrm/journal/v8/n9/abs/nrm2241.html

    This reminds me to the aspirin story, aspirin has been around for decades, as a pain reliever, today is much more than that and can save lives, who could imagine that. Cell therapies have been around a lot, blood transfusions are simply cell therapies…

    Actually I provide CE courses around this area…

    • April 30, 2010 at 10:08 am

      >> the solution to that is to generate mix banks public/private so private can pay some of the expenses of the public.

      Yes this is probably a good solution. I was recently reading and learned that a person cannot retrieve their own sample from a public bank because the identifying information is expunged once it enters the bank. This seems foolish to me, but it is what it is for now.

      A system where privately banked units are catalogued and made available for public use, as well as for private use, makes sense. It would be fair that if the unit is used publicly, the recipient pay the expenses that the original donor paid for storage.

      This is a good discussion but lets save future discussion for another post. We can work on it in the near future.

  57. May 7, 2010 at 4:41 pm

    Interesting discussion. There is no long term data to show that the recent intervention of immediate cord clamping is safe and has no long term effects on infants and children. In fact, there is a very interesting article that fully explains the potential that receiving the cord blood offers to the infant. If these cells are so precious and so valuable, why would one think that they were not intended to be in the infant’s body? We do not know the cause of any of our newborn diseases including cerebral palsy, hypoxic-ischemic encepalopathy, etc, yet we assume that blood volume has nothing to do with them! How do we know that that little boy who was on NBC because of his improvement in CP after he had his own stem cells returned to his body, might not have developed CP if the stem cells had not been removed at birth? We have no evidence that this was not so.
    I have recently attended some births where 5 oz of blood was collected from two different babies – they probably donated over 1 billion stem cells in total. One baby at 4 minutes of age was in the warmer shivering violently as any of us would with that amount of blood removed. It made me very sad. His parents had no idea and were congratulated on the “large donation.” Unfortunately, cord blood harvesting is big business at the expense of our infants. All of Betsy Lozoff’s work should give us pause about creating anemic infants! I refer you all to a new article that just came out and will try to put the reference here in the next post. I am going to support the idea of banking the cord and placenta which are rich in stem cells. Also, researchers are begining to harvest menstrual blood to collect stem cells – much better to donate that than to rob one’s baby of his intended endowment of stem cells.

  58. May 7, 2010 at 4:46 pm

    Reference is: Mankind’s first natural stem cell transplant. Jose N. Tolosa, Dong-Hyuk Park, David J. Eve, Stephen K. Klasko,Cesario V. Borlongan, Paul R. Sanberg. In J. Cell. Mol. Med. Vol 14, No 3, 2010 pp. 488-495. If I knew how to attach the pdf, I would for all of you to read. Researchers need to learn how to make small populations of stem cells expand so that it will be worthwhile to save small amounts of cord blood.
    In the study we are designing, we are going to follow infants for 24 months in the first round with developmental follow-up. This should help answer some questions. It has not been done before.

    • May 27, 2010 at 4:28 am

      Dr Mercer – I’ve read that paper recently, and it is a very speculative opinion piece. I think there may be a lot of truth in there, but at this point there is not adequate evidence to support the ideas that are presented there (which they admit in the article). It will be interesting to see what the future research shows, and how many of Dr Tolosa’s ideas are proven out.

  59. May 9, 2010 at 3:57 pm

    >> Researchers need to learn how to make small populations of stem cells expand so that it will be worthwhile to save small amounts of cord blood.

    Yes this would be an important advancement. We do have a number of immortalized lines of stem cells, though I think they are of embryonic origin rather than cord blood cells. That being said, it doesn’t make sense to immortalize every child’s stem cell lines. Perhaps, though, one could freeze just a bit of blood and regrow it in the future once its needed.

  60. May 10, 2010 at 5:34 am

    It is coming, other cell populations are available in that small amount of blood that have great potential.

  61. Jen
    May 10, 2010 at 2:13 pm

    Very happy to find this blog post and all the linked research! As a mom having my 2nd baby and researching many of these issues I really appreciate all of this data!

    One question: Why do you think most of the research that HAS been done on delayed clamping has been with preterm infants? Why not term infants? (I AM happy to read – from the comments dating back to Dec. 09 – that one is planned.)

    Thanks – and glad to see that the discussion is still going on.

    • May 10, 2010 at 2:23 pm

      Oh the reason is clear, and it has completely to do with the mathematics of the research.

      Bad outcomes are relatively common in premature infants, and as such if delayed cord clamping were to have an impact on those outcomes, the number of babies you would need to study would be far fewer than you would need to study to find the same change in the much lower prevalence term population.

      It is the norm in research to try an intervention in a group that already has a high prevalence of the outcome you are trying to study. As term infants tend to do well no matter what you do, it would be very hard to find a meaningful difference in outcomes in a study looking at them. This is because it would most likely take many hundreds if not thousands of patients to identify a difference, if one exists.

      What we are talking about here is the idea of “power”, which is the ability of a study to find a difference if in fact it does exist. When prevalence of the studied outcome is high, power will be relatively higher than it will be when prevalence of the studied outcome is low. The studies on preterm infants were able to find a difference with only 75 patients studied because 1) the prevalence of the studied outcome was high and 2) the intervention had a fairly large impact on the studied outcome.

      I think its important to understand that while it makes sense that term infants would benefit from getting the blood they were destined to get, outside of differences in iron stores there has been no published data that suggests that delayed clamping is helpful, or for that matter that immediate clamping is harmful.

      Dr Mercer has said they are working on a term delayed cord clamping trial. I would be interested to see the results of their pre-study power calculation, which would have calculated how many babies need to be studied. I suspect its quite a lot.

  62. Angela Horn
    May 27, 2010 at 12:36 am

    Just in case you haven’t seen this – it’s a new article focusing on the issues surrounding cord clamping, including stem cells:

    http://hscweb3.hsc.usf.edu/health/now/?p=12765

    Early clamping may interrupt humankind’s first “natural stem cell transplant,” the researchers report

    Tampa, Fla. (May 24, 2010) –- The timing of umbilical cord clamping at birth should be delayed just a few minutes longer, suggest researchers at the University of South Florida’s Center of Excellence for Aging and Brain Repair.

  63. May 27, 2010 at 5:34 am

    Dr. Fogelson, while this paper does not represent one study, I think they have done a fairly good job of substantiating many points. There is very good mulitple animal studies on the benefits of human stem cells after a variety of brain injuries. These are most impressive. Also, it is important that they be given to the animal quite a brief time after the lab -induced injury. Meanwhile, in spite of the fact that we have no idea what causes HIE, persistent pulmonary hypertension, neonatal stroke, cerebralpalsy, autism,etc, etc., we usually deny infants this valuable cord blood. We have no evidence that immediate clamping of the cord is safe as there are no studies of long term follow up of these infants. It is time to think outside the box as we have made no progress on preventing most of the newborn diseases in years. More later.

  64. May 27, 2010 at 7:53 am

    I am a big supporter of delayed cord clamping, but have to play the devil’s advocate here, as I feel like you are making a lot of assumptions here.

    >> Meanwhile, in spite of the fact that we have no idea what causes HIE, persistent pulmonary hypertension, neonatal stroke, cerebralpalsy, autism,etc, etc., we usually deny infants this valuable cord blood.

    We have no idea what causes these things _AND_ we often deny babies cord blood that _may be useful at term. The connection between these two statements is not clear. There is no evidence at this point that cord blood prevents these outcomes. There is also no evidence for negative or positive long term outcomes from delayed or immediate cord clamping at term. The data for pretermers is fairly compelling (your data), but at this point there is little data to suggest anything about term timing of cord clamping. I look forward to seeing your term randomized trial and what it shows.

    >> We have no evidence that immediate clamping of the cord is safe as there are no studies of long term follow up of these infants.

    Safe? There are tens of millions of children out there that had immediate cord clamping and have done just fine, and no evidence that the development of some of these conditions in an unfortunate few had anything do with whether or not they had autotranfusion of cord blood.

    >> We have no progress on preventing most of the newborn diseases in years.

    And cord blood stem cells is a worthy thing to study regarding this. This doesn’t change the speculative nature of these ideas, at this point. The fact that you can have some impact on an iatrogenically injured animal with contemporaneously injected stems cells does not mean that retention of cord blood is going to have an impact on these outcomes. I think we can both agree that while it is certainly worth studying, the data isn’t here yet.

  65. June 6, 2010 at 6:10 am

    Thank you for this blog. This is a topic I raise with my student midwives as they are most often taught in clinical practice to clamp and cut the cord immediately, although a recent trial took place in one of our main clinical practice areas. In the university setting I try to get them to ask why do we do this, and like you I can see no benefit and in some cases harm.

  66. birthfriend
    July 26, 2010 at 2:40 am

    You know you have a strong admiring midwifery following, right? :)

  67. July 27, 2010 at 4:06 pm

    I’ve heard :)

  68. VW
    July 28, 2010 at 10:18 pm

    My daughter was born with an APGAR of 3 after a 2 minute shoulder dystocia. She also suffered a collapsed lung, although it’s unclear to me whether this was as a result of the shoulder dystocia or the resus efforts. At the time of her birth, I was told that the cord needed to be cut right away even though I had stated a preference for delayed cord clamping (and this is a relatively accepted practice where I live).

    I’m wondering how a patient should communicate with her care providers to have the baby put on the chest and avoid immediate cord clamping unless chest compressions are required. At the time of my daughter’s birth, everything was happening very quickly and it’s clearly not the time to interrupt people’s routines, but at the same time, I felt like they cut the cord immediately because the resus equipment/table was bolted to the wall on the other side of the room.

    I’d like to be able to address this issue with my care providers for any future pregnancy, and was wondering if you had any suggestions how I could do so most effectively, esp at the time of the actual birth?

    Thank you!

  69. August 10, 2010 at 7:25 am

    Wow – I hope your daughter did well after this difficult event.

    >> I’m wondering how a patient should communicate with her care providers to have the baby put on the chest and avoid immediate cord clamping unless chest compressions are required.

    I appreciate the idea, but I just don’t think it is realistic.

    There are some people that have pushed delayed cord clamping to the point of resucitating a depressed infant on the mother’s belly, but that is very uncommon (I have only heard of it never seen it). It does make sense, but to do this would require a system wide change in the way that neonatal resucitation is performed, both in mind and in equipment.

    An infant with an apgar of 2 is near lifeless, and the most important thing at the time it is born is reoxygenating the infant’s brain as soon as possible. We can theoretically say that pumping blood through the cord would be a great way to do that, but at this point its purely a theory which has never been studied in this setting. On the other hand, we have extensive experience with reoxygenating the child through ventilation with a bag mask or endotracheal tube. Given the critical nature of the situation, I would go with the proven methodology over the theory every time. Given that the baby’s heart is beating less than 60 times a minute, the level of reoxygentation one would get through the cord may not be enough.

    Neonatal resucitation requires a coordinated effort between many people. These people do follow a routine, as you mentioned, that would be very messed up by trying to do it all on mom’s belly. Many of the physical tasks that are required would be much harder away from the resucitation bed, particularly endotracheal intubation.

    Perhaps there is a neonatalogist out there that would like to try to pilot an idea of resucitation on the mom’s belly, but at this point it seems unlikely.

    • Cara
      September 18, 2010 at 10:42 am

      Not on the mother’s belly perhaps, but surely with the baby laid (still attached) on the same surface the mother is on is possible, in many cases. Unless the mother is incapacitated she could sit up and keep her own legs out of the way. Yet another problem of the “trapped like a beetle” on a narrow hospital bed supine birthing position I suppose?

    • Kate
      April 29, 2011 at 1:15 am

      I can’t help but feel like this blog article and the associated comments belong somewhere last decade?

      In Australia literature is provided by some hospital antenatal classes to women so they can make informed decisions about physiological birth and third stage. My most recent birth plan was explicit about NOT touching or cutting the cord, no synthetic oxytocin, no suctioning (without prior discussion) etc.

      You might be uncomfortable with the baby being reoxygenated via the placenta – but I can tell you from a mother and baby’s perspective which I would prefer!

      I have experienced one child’s cord being cut many minutes before his shoulders were born and the critical resucitation that ensued (only cut because of nuchal cord, no other issues). You can probably imagine why my birth plan was so explicit on this issue next time around!
      I can compare this experience with my next hospital birth where my baby was born into my own hands, gently, cord intact. This baby quitely and gently turned pink, while looking around the room and gazing at me. He did not cry. Because he was so quiet I leaned closer to his face and gently blew near his nose, upon which he inhaled slighly louder and I completely relaxed.

      I can imagine an OB may not have witnessed hospital births like this, and after reading this post I now have a better understanding of why women I encounter from America feel very disempowered.

      BTW – how can not cutting the cord upon the request of the mother being ‘humouring’ someone? If this is their body and baby, surely not complying with this is assault?

      There were many other comments about premature cord clamping, resucitation, suctioning and blood banking that I am bursting to respond to, but I think I would do a better job of responding by linking this comment to an Australian researcher and esteemed midwife.

      http://midwifethinking.com/2010/08/26/the-placenta-essential-resuscitation-equipment/

      http://midwifethinking.com/2010/10/09/the-curse-of-meconium-stained-liquor/

      http://midwifethinking.com/2011/02/10/cord-blood-collection-confessions-of-a-vampire-midwife/

  70. October 3, 2010 at 2:00 pm

    Many thanks for this details. It is very appreciated! Cheers.

  71. November 19, 2010 at 10:53 am

    Thank you for this post! As a doula and childbirth educator, it’s so nice to hear an OB’s thoughtful (and not hostile) perspective on these types of matters.

  72. November 27, 2010 at 6:30 am

    Thanks mate. Great article you got going on here. Got some extra sites to link to which have more info?

  73. January 31, 2011 at 6:53 am

    Dr Fogelson,

    Just seen you your Grand Round lecture on cord clamping and was very impressed by the presentation. You are absolutely right that immedaite or early cord clamping is the intervention which needs to be proved both effective and safe. As Andrew Weeks says in his BMJ letter few weeks ago until this is done we need to withdraw the intervention.

    There are two more recent publications which help to build up the evidence on cord clamping practice. First the BJOG paper by Farrar et al (Farrar D, Airey R, Law G, Tuffnell D, Cattle B, Duley L. Measuring placental transfusion for term births: weighing babies with cord intact. BJOG 2011;118:70–75.) They repeated the work of Alice Yao using accurate weighing equipment and showed the placental transfusion can be over 200mls. Then there is the paper by Wiberg et al (Wiberg N, Ka¨lle´n K, Olofsson P. Delayed umbilical cord clamping at birth has effects on arterial and venous blood gases and lactateconcentrations. BJOG 2008;115:697–703.) The more important data in this study was the considerable amount of oxygen in the in the cord vein blood for at least 90 seconds after the birth of the baby. Many people think the placenta just stops functioning after delviery of the baby. In addition there were 3 babies with significant acidaemia indicating significanthypoxia in labour, with abnormal CTGs and one with a low one minute APGAR, but all three recovered without any intervention; I say without any intervetnion ie no cord clamping, no ventilation, no attention by the neonatologist – and they were all fine.

    In Liverpool we are developing a BASICS principle resuscutaire (Bedside Assessment and Stabalisation with Immediate Cardiorespiratory Support) which is simple enough to allow a baby to be resuscitated close to the mother with the cord intact at normal devivery, assisted vaginal delivery and caesarean section. Trials should start later in the year.

    It has to be remembered that immediate or early cord clamping is routine, given to every baby, so any effects will not be obvious. If immediate cord clamping was responsible for some neonatal deaths if would not be obvious. I clamped the cord immediately on 20 babies yesterday and they were all fine. Is it really speculative to consider that a baby with moderate hypoxia and 200mls of blood less than the same baby would have after a physiological 3rd stage.

    All the trial so dealyed cord clamping have excluded babies who were perceived to need resuscitation and as a result automatically had immediate clamping.

    Thanks again for the lecture which I will send around to colleagues. An RCOG conference on umbilcal cord function is schedules for 1st June this year.

  74. March 2, 2011 at 9:50 am

    Thanks for your detailed comments and information!

  75. Rebecca
    April 11, 2011 at 9:36 am

    I’m anticipating a battle with my OB over including delayed cord clamping in my birth plan. Most of the studies you cite are of preemies or in “developing” countries. are there any studies on full-term infants in “developed” countries? (I hate the terms “developing developed,” but you know what I mean about some physicians only seeing studies done in the U.S. or Europe as legitimate.) What one or two studies (preferably from widely recognized journals) would you suggest that would be most useful in persuading a garden-variety OB to sign off on this in a birth plan?

    • April 11, 2011 at 10:53 am

      There aren’t any randomized trials in term babies in fully developed countries. Still, I wouldn’t think your OB would be that opposed. If so, I might look for a new OB.

  76. May 21, 2011 at 12:48 am

    There were never any randomized trials before early cord clamping was introduced.The current practice of early cord clamping was introduced to save hospital linen long ago when there were much less efficent laundry systems. Not very scientific is it? How has a ‘science based’ profession continued to practice such nonsense without question in spite of seeing babies scream and shudder when their cords are amputated? Additionally read the utter nonsense that has been written about third stage, declared to be ‘truth’ and then blindly practiced to the determent of both baby and mother. I think that this issue is the bases of widespread health problems for the entire community and that we are in the grip of its generational harm to the human organism. The obvious damage to the major organs being deprived the essential blood and nutrients is staggering. What an imprint! Then we have the very clever idea of blood banks! Really spare me the vampire aspirations of the $$$$ focused companies that are selling such superstition. How many clever little people have enrolled in promoting them?
    The second edition of ‘Lotus Birth” will be released soon. It is full of sound information that reveals the further damage that early cord cutting has caused.Contact me for your copy.

    • May 21, 2011 at 3:55 am

      And herein lies the biggest reason that campaigns in support of delayed cord clamping meet resistance. Instead of providing solid scientific evidence, the failed campaign will rely on wild rhetoric, and thus be ignored by the real scientists of the world.

  77. May 21, 2011 at 8:14 am

    Nicholas,
    I really admire the way you are responding to everyone’s comments. You are right that we need solid scientific evidence, but of course the original move to immediate or early cord clamping was a “quiet campaign” so strictly speaking it should take a campaign to reverse it. However can you explain why “real scientists” continue to support and teach an non-sensical description of physiology. I will give everyone the example of Ganong which has very recently been updated.
    The physiology textbook Ganong’s Review of Physiology states on page 584 that “At birth, the placental circulation is cut off and the peripheral resistance suddenly rises.” This is the first sentence in the description of the changes implying that it is the first change to occur after birth. There is no explanation for the sudden “cut off”. Later on in the description the author tries to claim that even with this cut off there will be a placental transfusion. In Asaki’s Pediatrics the text simply states on page 286 that systemic vascular resistance rises subsequent to “obliteration of the low resistance placental circuit”. There is no explanation why this obliteration takes place. !!

    Then in Asaki’s Pediatrics the text simply states on page 286 that systemic vascular resistance rises subsequent to “obliteration of the low resistance placental circuit”. There is no explanation why this obliteration takes place.

    In Heart Disease, A Textbook of Cardiovascular Medicine, which describes the physiological changes at birth on page 1512, the following statement appears; “Systemic vascular resistance rises when clamping of the umbilical cord removes the low resistance placental circulation”.

    How does this fit into the solid academic scientific description of a physiologicial changes which we should be passing on medical students, postgarduates and midwives? Can you really say that these are pure physiological description of transition at birth or are they (possibly campaign like) cover stories for what is common practice. No-one want to accept that these are not physiological descriptions. It is a subtle attempt, possibly even subconscious on the part of the author to include cord clamping as NORMAL.

    For those that want to check the textbooks.
    Barrett KE, Barman SM. eds. Ganong’s Review of Medical Physiology. McGraw Hill Medical. New York. 2010

    Mc Millan JA. Ed. Osaki’s Pediatrics. 3rd Edition Lippincott Williams and Wilkins, Philadelphia 1999

    Braunwald E, Zipes DP, Libby P. eds. Heart Disease, A Textbook of Cardiovascular Medicine 6th edition Saunders Philadelphia. 2001

    David Hutchon

  78. May 21, 2011 at 11:52 am

    I think you’re right. There’s plenty of data out there to support delayed cord clamping, and basically none to support the concerns that people have about it.

    That said, it isn’t some kind of conspiracy. The vast majority of OBs currently in practice trained at a time where immediate cord clamping was standard, and never thought to question the practice. Shown the data, most OBs will change. My hospital has almost entirely changed over after my grand rounds presentation, and the entire residency has become somewhat passionate about it.

    The problem in my mind is that most of the data is published in pediatrics journals that OBs don’t read.

    The other problem, alluded to in the previous reply, is that there are a whole bunch of very passionate folks out there that present the issue with near religious zeal completely devoid of actual data. These folks are well intentioned, but don’t realize that this type of presentation shuts the mind of any scientist almost immediately. Attaching cord clamping to autism or other number of mysterious diseases is similarly degrading to the cause, and draws parallels to all manner of bizarre anti-science beliefs and conspiracy theories. The connection is 100% theoretical and worthy of study, but to pretend that it is proven is to reveal oneself as a person that does not respect the scientific method.

    The data needs to be presented in a way that will be well received, and in the journals that are read by the target audience. Fortunately, the world is picking up on this more recently. There was a nice new article in the Green last month, along with a major editorial predominantly in support.

  79. May 21, 2011 at 10:39 pm

    Nicholas,

    Alarming statements with no evidence certainly do not help credibility when some more substantial evidence becomes available. I do not think there is a conspiracy but a whole genereation as you say who have been taught ICC and because of the “physiology” teaching deep down think cord clamping is necessary. Those of us who are familiar with pulsating arteries at surgery would never just clamp off a major artery. We know the end organ depends on it for its blood supply. For the cord however we are conscious of the blood being pumped out by the baby and perhaps not so conscious of it coming back! Perhaps we almost think we are stopping the baby losing blood? Just a thought.

    Can you give us a reference for the “Green” article I presume you mean Obstetrics and Gynecology.

    There is no conspiracy ut there is a strong reluctance to be critical of the authorities or established textbooks like Ganongs Physiology. Here in the UK things are changing but very slowly and the National Institute for Clinical Excellence (NICE) is not going to change its Intrapartum care guideline advising early cord clamping as part of the active management of labour for about 3 years! As a coauthor of two Cochrane reveiws I know there s no evidence to support immediate or early cord clamping as part of active management.

    One area where immediate cord clamping is ? ?justified is when there is fetal distress and the need to resuscitate the baby on a remote resuscitaire. We have just won an innvovation award to be presented in London on June 6th, for a BASICS resuscitaire (Bedside Assessment, Stabilisation and Immdediate Cardiorespiratory Support) which can be brought right up to the mother The baby does not need to be separated from her baby and the cord does not neeed to be divided.

    Here in the UK women complete a birth plan which is followed by her careres whe possible. I hear of many women who include delayed cord clamping in their birth plan but at the hospital they very often do not get it. Cord clamping is such a quick action, irreversible adn reflex with so many obs and midwives.

    It perhaps does not need a campaign but it does need leadership which you have shown Nicholas. Our immediate RCOG past president has also made statements and the current president ensured taht all RCOG memebers got allerted to the change in our greentop guidleine on PPH pointing out that immediate or early cord clamping is not necessary for the prevention of PPH and thre may be benefits for the baby. It is the removeal of immeidate or early cord clamping from the triad of active management of the third satge of labour which woudl change OB’s practice more than anything and the American College needs to follow the lead of the RCOG.

  80. May 22, 2011 at 2:40 am

    Editorial: Increasing the Placental Transfusion for Preterm Infants
    Bell, Edward F.
    Obstetrics & Gynecology. 117(2, Part 1):203-204, February 2011.

    Milking Compared With Delayed Cord Clamping to Increase Placental Transfusion in Preterm Neonates: A Randomized Controlled Trial
    Rabe, Heike; Jewison, Amanda; Fernandez Alvarez, Ramon; Crook, David; Stilton, Denise; Bradley, Robert; Holden, Desmond; for the Brighton Perinatal Study Group
    Obstetrics & Gynecology. 117(2, Part 1):205-211, February 2011.

  81. Alexandra Goss
    May 22, 2011 at 3:05 am

    Surely the long overdue onus is on professionals, practising to an evidence base, to show that EARLY cord clamping is benificial for the baby and the mother. Or is there already evidence supportiing the intervention?

  82. May 22, 2011 at 3:07 am

    Couldn’t agree more. There’s no evidence to support early clamping. Most docs are unaware of the data in support of delayed cord clamping.

  83. May 22, 2011 at 8:36 pm

    As long ago as 1967, Professor Peter Dunn demonstrated the adverse effects of early cord clamping, and he has published a long list of research papers subsequently. In 2004, in an attempt to inform women, AIMS asked Professor Dunn to write an article for the AIMS Journal explaining in lay terms the implications of this intervention.

  84. May 22, 2011 at 9:14 pm

    Beverley Beech knows the history behind the intervention of cord clamping as well as anyone and she has tirelessly worked through AIMS to inform women of this and other routine obstetric interventions which can be harmful to mother or baby.

    In my introduction at the RCOG conference in London “The Underrated Umbilical Cord:Physiology, Pathology, and Pracitce” on June 1st, I intend to credit the numerous people who over the years have tried to allert the rest of us to the implications of cord clamping. Peter Dunn will be one of these. It was his work and correspondence with him since that maintained the subject in my mind almost every day for the last 5 years.

    The conference is aimed at obstetricians, paediatricians and midwives. Eminent speakers include Dr Heike Rabe, Professor Colin Morley, Professor Sir Sabaratnam Arulkumarin, Dr Hora Soltani and Dr Diane Farrar. If it has half the impact of Nicholas Fogelsons’s lecture I will be satisfied. (There are still places available so it is not too late!) It will also interest lay people with an interest in maternity and neonatal care especially resuscitation.

    The Medical Futures Innovator award winners (presentaion on June 6th in London) with the BASICS trolley (Bedside Assessment and Stabilisation, Immediate Cardiorespiratory Support), Andrew Weeks, Andrew Gallagher, Susan Bewley and myself are all involved in the conference. For more information email me at djrhutchon@hotmail.co.uk

  85. april Grayson
    May 23, 2011 at 10:56 am

    There is a paradigm shift here just on the brink of happening

  86. May 27, 2011 at 10:12 pm

    Dr Fogelson – forgive me if this has been mentioned already, but when did immediate cord clamping become the accepted standard? I’m just curious. :-) I thank you for all your work on this.

    • May 28, 2011 at 12:37 pm

      I don’t know specifically, but I suspect it was around the time hospitals started having pediatrics or pediatric nurses at every delivery.

  87. May 29, 2011 at 11:42 am

    The history is quite complex. From ancient times mankind stopped times mankind stopped chewing through the placenta and started using sharp instruments.Tying was the first “clamp” but was inevitably a long way from being quick. The first autoclamp was devised and publiscised in the LANCET about 110 yeas ago. It was essential diviced to stop bleeding from the placental end whihc made a mess of the bed sheets.

    With instrumetns becoming more and more available clamping become easy. In the 40’s and 50’s it was realised that quick clamping resulted in more blood in the placenta and this ws useful for reseach and using the blood for transfusion.

    When active mangement and the RCT’s were completed there may have been some commercial drive for early clamping. For some reason those doing the Cochrane reveiw promoted immediate or early clamping as part of “active management” althoug it was not justified from the trial protocols.

    Teh rest is history. Impatience on the part of attendants, need for neonatal resuscitaion especially after maternal narcotic analgesics in the 50’s and 60’s. Then today a more subtle drive for stem cell bankng keeps the myth alive.

    David

  88. September 4, 2011 at 8:54 am

    Hmm..I’m a doctor in Nigeria and we pretty much aren’t done with dealing with all the issues we have like PPh and maternal mortality..poor 3rd stage interventions and what have you..
    We’ll be a long while in joining this debate unless some senior person picks interest in it.
    Funny enough I came across this blog while trying to find answers to my stage 1residency exams practice questions.
    Just wondering about the possibility of increased fetal pulmonary hypertension with delaying cord clamping and the increased blood volume thereafter.that’s question 51c

  89. Shane Marsh
    September 4, 2011 at 2:51 pm

    Dr Samsie, you have found a wonderful resource here.

  90. Doug Hepburn M.D.
    October 2, 2011 at 9:08 am

    Nicholas your grand rounds were superb. I am going to suggest the S.O.G.C. invites you to our next annual meeting as a keynote speaker. I am planning to change my practice but i still worry about the Cochrane review that shows relative risk of .6 with early clamping towards phototherapy. I think this negative impact would depend on how often phottherapy is needed in one’s own population. I also agree with you that the benefits of private cord banking are minimal and I suggest to my patients that spending $500 on safety proofing your house is a much better investment.

  91. October 2, 2011 at 9:45 am

    Dear Dr Hepburn,

    We have been doing delayed cord clamping in Darlington and also in Worcester for several years and have not had any increase in the need for phototherapy. Even if it were true the increase in absolute numbers is very small. However most of the increased use of phototherapy came from one unpublished study, the paediatricaisn were not blind to the cord calmping group and there was no consistent level of bilirubin used to prescribe the phototherapy. Inevitably there were some babies who had severe hypovolaemia as a result of the early clamping. These babies would have been in poor condition and birth and excluded from the trial analysis. All babies needing resuscitation in these trials were excluded. The Farrar et al study in the BJOG showed that potentially a baby can lose 204mls of blood trapped in the placenta by immediate cord clamping.

    You should get Nicholas Fogelson to be your keynote speaker at the next SOGC meeting, and he may well tell everyone the same. By avoiding the hypovolaemia of immediate or early cord clamping, we may be preventing a lot more disability. Here is the announcement of the BASICS trolley, which could be available commercially within a few months.

    In addition to Nicholas why do you not invite Professor Susan Neirmeyer to speak at your conference.

    David Hutchon FRCOG retired obstetrician

  92. October 2, 2011 at 9:54 am

    Dear Doug,

    Please see the letter from Mercer and Erickson-Owens which is to the side under “Comments” on the Cochrane initial page. I could send it in as a pdf if I knew how! Anyway, I would put more stock in the article by Hutton and Hassen in JAMA 2007. I have recently read the thesis on which these results are based and the information surrounding the infants is minimal. No report of blinding of neonatologists or pediatricians and no scale to decide when to put infants under phototherapy. No other study has reported an increase in jaundice in infants with delyed cord clamping of times varying from 1 to 5 mins or more. Think you will find the information in our letter interesting.

  93. Rachele
    October 12, 2011 at 12:28 pm

    I’m currently 26 wks with fraternal twins (first pregnancy) and I am definitely going to tell my Dr. that I want to delay clamping in my birth plan. But how long should I suggest? I’m not sure if 3 minutes is good or until I deliver the placenta. With the possibility of them being born before 40 wks I want to give them as many health advantages as possible.

    • October 12, 2011 at 10:46 pm

      The data published to data is for delayed clamping for only 30-45 seconds. It does make sense to go for a few minutes if the infants are vigorous, in my opinion.

  94. Miguel
    October 25, 2011 at 9:20 pm

    Hello Dr. Fogelson,

    My wife is about to give birth to our 2nd child by ceasarian section very soon. To cut a long story short, our first child suffered fetal distress during birth and was delivered by ceasarian section.

    This time our new family doctor and Ob/Gyn knows what happened about our first child and planned for a scheduled CS one week before due date for this coming 2nd child.

    We will meet our Ob/Gyn for the last time before the scheduled CS and we want to know the best way on how to persuade her to do delayed cord clamping in a ceasarian section.

    My wife mentioned DCC to our family doctor and his reaction was “you’ll be in shock” because it is a CS.

    Dr. Fogelson, is it possible to cut the umbilical cord AFTER the baby has cried/breathing for 20-25 seconds or maybe longer??? Or, maybe, is it possible to do DCC in a CS???

    We will meet her in about 9 hours from now and I printed your article and an article by Dr. Morley and will burn to a CD your DCC grand rounds video to give to her. I hope she has an open-mind and the time to read and watch the materials. Thank you Dr. Fogelson.

    • October 25, 2011 at 10:07 pm

      Miguel –

      Delayed cord clamping is entirely possible during a cesarean section. I do it all the time. The infant is delivered onto the operative field, and one just doesn’t cut the cord for 60 or more seconds. No problem.

      Your family doctor’s reaction is common for someone who is not familiar with DCC, and is not accurate.

      • Judith Mercer
        October 25, 2011 at 11:40 pm

        The other alternative for C/S is to milk the cord 4 or 5 times towards the baby. We have a paper coming out on this soon. This can also be done when the baby at a vaginal birth appears distressed. It is quick (10 to 15 seconds) and gets the blood in the baby. Many doctors are afraid to do this so maybe our article will help.

  95. Judith Mercer
    October 25, 2011 at 11:46 pm

    Miguel – you should print out Hassan and Hutton (2007) for her. It is a meta-analysis of many studies with full term infants with delayed cord clamping. It is published in JAMA – Journal of the American Medical Association, a well respected journal, and is an excellent article reviewing all of the latest important literature. One other study has been published about follow-up of the infants in Argintina and also found higher ferritin levels at 6 months of age in infants with delayed cord clamping. Ferritin represents iron stores and is a good indicator of the baby’s iron reserve.

  96. December 8, 2011 at 1:47 pm

    A friend linked me to this: delayed cord clamping is reaching the mainstream media: http://www.economist.com/node/21540226.

    I also wanted to mention, as an evolutionary biologist and now the mother of an eight month old, how curious I found it that all the baby books and child health nurses were adamant that a child’s first non-breastmilk (or formula) food should be iron-fortified rice cereal. It’s rather a specialised product, and not something babies would be likely to eat, in most of the world or for most of our evolutionary history.

    So we may not have a lot of scientific studies proving that immediate cord clamping leads to potential iron deficiency in four to six month olds in the Western world, but baby health care and the baby food industry take it for granted that iron deficiency is a common problem at that age, and it seems to me that immediate cord clamping is the most likely cause for its frequency.

    (Yes, the birth centre we used had delayed clamping as standard practice, and my baby’s cord was clamped perhaps 15 minutes after birth. It was certainly white and still by that stage.)

  97. January 18, 2012 at 7:41 am

    Thank you!

  98. July 6, 2012 at 1:37 pm

    This blog makes my heart sing. I’ve been teaching about this for decades! Dr Fredrick Le Boyer ‘Birth Without Violence’ made it very clear that cord clamping was against the interests of the child in the 1970’s. My book ‘Lotus Birth’ first published in 2000 and the second edition 2012 has information that you will find compelling. We’ve had Lotus born C/section babies and the results are very good. See the research by Dr Sarah Buckley also. As mentioned in an earlier post clamping the cord was introduced to save the hospital linen. In the production line obstetrics of the 40’s and 50’s as cords were being cut before the placental transfusion occurred of course there was a lot of blood to be spilled, up to 50% of the baby’s total blood supply. The solution was clamps. It also causes an implosion in the mother’s uterus and then of course we have escalated the likelihood of PPH! What clever little fellows they are! Mother nature does know what she is doing. Do no harm……..Remember? There is no such thing as delayed cord clamping all cutting is precipitous.

  99. August 1, 2012 at 8:22 am

    I love this. I’m curious as to how it’d be accomplished with twins…I’m preggo with b/g twins, two placentas and would like to delay the cord clamping. My doc says that a 30 sec delay is taking time away from baby b…any advice?

    • Judith Mercer
      August 1, 2012 at 8:28 am

      You could ask your doctor to milk each baby’s cord 5 times rather than delay. If your babies are relatively equal in weight, then there is no reason to worry about any cross transfusion. Baby B can wait a few minutes! Are you having them by C/S or vaginally?

  100. August 1, 2012 at 4:18 pm

    In the ‘Lotus Birth of the Malcolm Twins’ the placentas stayed with the babies.
    http://www.lotusbirth.net

  101. August 12, 2012 at 5:50 pm

    “Teaching the world that rushing to cut the cord is not a physiological necessity would have a number of practical implications. One of them would be to eradicate neonatal tetanus, a major cause of deaths in developing countries. Neonatal tetanus is a complication of early cord clamping. If the cord is kept intact for several hours it becomes thin, dry, hard, and bloodless. Then, It can be cut without any need for cord care practices. The risk of neonatal tetanus is eliminated.” Dr Michel Odent in the forward to the 2nd edition of “Lotus Birth”

  102. August 23, 2012 at 3:40 pm
  103. Susie Tean
    November 15, 2012 at 1:59 am

    Actually, there’s plenty of evidence that it’s harmful to breastfeeding as it interfers with the suckling and rooting instincts.

    Nicholas Fogelson :
    Its not an issue that I feel is very important. Suctioning term babies probably isn’t necessary, but there certainly isn’t any evidence that its harmful either. Babies are in water until they are born, and they do need to expel that water to start breathing. Most of that happens in the delivery of course, but what’s the harm in a little help? I’ve seen plenty of babies sputter and spurt until they clear themselves out. Its odd that you can’t see the potential benefit in helping them out.
    To me, this is a classic example of the thing I hate about the natural birth / midwifery / medical birth debate. I feel like natural birth folks just want to eliminate any intervention that isn’t clearly necessary. I can see that to a point, but with something as harmless as removing some fluid from a baby’s oropharynx, why get all up in a knot about it? Maybe this is just a part of OB and pediatric culture, but there are a ton of things that are part of midwifery culture that are equally arbitrary. If you don’t want to do it, don’t! If an OB likes to do it but the mom would rather it not be done, then the OB should just chill and see what happens! It isn’t worth fighting over on blogs, nor is it worth some big campaign. Its just not important enough. Live and let live.

    • Judith Mercer
      November 15, 2012 at 2:38 am

      Actually, if you look at our paper “Mercer, J, Erickson-Owens, D, Graves, B, Mumford-Haley, M. Evidence-based practices for the fetal to neonatal transition. Journal of Midwifery and Women’s Health, 2007;52:262-271.” you will see that there is some evidence that suctioning is harmful.

      There is never going to be an RCT with long term outcomes on this issue! The problem is that it gets to be a habit and people are rough even with those bulb syringes. It makes the babies bubbly and then the person just keeps suctioning the baby = more bubbly = more suctioning = baby not nursing for 24 hours.

      Sometimes we just need to get over ourselves. This issue is just not “granola” practices of midwives but what actually supports the fetal to neonatal transition.

      The only thing I like about bulb suctioning is that it keeps the “must do something” people from cutting the cord immediately!!!!

    • November 15, 2012 at 3:22 pm

      Actually, Nicholas Fogeison, it is extremely important that this issue be brought into awareness and debated. The imprinting that occurs at birth has life long ramifications. Much of the health issues that the community is burdened with now can be related to birth. So called ‘panic attacks’ are usually activated birth trauma. Do you think that the practice of feeding babies sugar and water whilst keeping them from their mothers for the first 24+hrs in communal nurseries as was the practice in the 40’s 50’s and even the 60s in some places, may have something to do with the epidemic of eating disorders, obesity and diabetes? These mothers were told by doctors that their colostrum was worthless. 90% of those babies were formula fed. What we are seeing now is generational trauma. No other mammalian species would act so foolishly. I suggest that you become familiar with the research that Dr Michel Odent has available on the Primal Health data base. http://www.wombecology.com and also APPPAH the Association for Pre and Peri -natal Psychology and Health. http://www.birthpsychology.com Let them live and thrive not just survive

      • November 23, 2012 at 11:29 am

        There is a lot of interesting work on prenatal origins of adult disease, which I think is what you are referring to. The idea that panic attacks are related to birth trauma is a new one for me. I am a bit skeptical that this has been shown in any rigorous way, given the vast number of confounding factors that would be present in any attempt to show this. I suspect this is more of something that someone has chosen to speculate on and then present as fact. If not, please share the reference that leads you to believe this.

        >>Do you think that the practice of feeding babies sugar and water whilst keeping them from their mothers for the first 24+hrs in communal nurseries as was the practice in the 40′s 50′s and even the 60s in some places, may have something to do with the epidemic of eating disorders, obesity and diabetes?

        I have no idea. Your argument seems to be of the type -> could X be related to Y? (and because I ask this in a particular way… it must be!!) It could be, but I don’t think we have data on this. Personally I think that the epidemic obesity has more to do with the generally bad diet that most of us consume, and a general lack of physical exercise in most people’s daily lives. Compared to these major issues, I find the likelihood that 24 hours of sugar water or loss of colostrum having a major impact to be very low. That said, I certainly support breastfeeding for its many benefits, including the benefits of colostrum.

        I have read some of Dr Odent’s work. I find some of it moderately compelling, but the occasional well thought out ideas are so mixed with massively speculative and non evidence based ideas that I find him in general to be a little woo for me. I don’t think of him as a hard scientist.

        ***

        I think birth issues are important, but not as important as a huge number of larger public health issues, like immunization, education, diet, excercise. I am most concerned that we deliver healthy infants and that women feel good about their birth experience, in that order. I am not worried that some sort of deficiency in the modern birth process is leading to long term health consequences. But that’s just me.

  104. vhim
    November 22, 2012 at 7:52 pm

    Thank you Dr. Fogelson its a great help for I myself conducting a local study of delayed cord clamping in the newborn

  105. vhim
    November 22, 2012 at 8:09 pm

    Hi Dr. Fogelson as i presented my study in delayed cord clamping in newborn i showed them the significant difference in the hematocrit level of the newborn compared to the immediate clamping, but i received few negative comments does it makes a difference ? since the immediate clamping group still in the normal level of hematocrit? and one comment of a pediatric hematologist, most of the neonatal anemia is more on physiologic so whats the significance on delaying the clamping even though it can increase the level of iron stores according to her infants does not need it. also the complication of congestion ? please do comment on this, thank you

    • November 23, 2012 at 11:09 am

      I think you have identified the gamut of what people say about delayed cord clamping, as part of an argument on why we shouldn’t do it.

      I think it is primarily a matter of perspective. It is seems to me that we are physiologically evolved to have the full complement of our cord blood, as that has been the standard post natal state for nearly 100% of our evolutionary life as humans, and is the standard process for all other mammals at birth. Given that idea, it seems to me that to immediately clamp the cord is to electively remove somewhere around 20% of the infants blood volume.

      Given that perspective, it seems to me that the burden of evidence is not on one to show that delayed cord clamping is better, but rather to demonstrate that the intervention of immediate cord clamping is safe.

      The data we have now would suggest that delayed cord clamping increases iron stores, which would clearly be useful in infants born to iron deficient mothers. Given that iron is important for early neurological development, early iron deficiency may be something we want to take efforts to avoid.

      Several studies have shown that infants that have delayed clampings do have higher bilirubin levels, but none have shown an increase in adverse outcomes. In some studies delayed clamped babies are treated with light therapy more often, however. I think in this situation one must consider than normative levels of neonatal bilirubin are most likely set with sets of immediately clamped infants, which is clearly a group of infants with lower bilirubins than a similar group that had delayed clamping. As such, normative levels are probably shifted lower, and may lead pediatricians to consider infants to be pathologically high in bilirubin who actually are not.

  106. Irina
    December 9, 2012 at 4:59 pm

    Dear Doctor Fogelson.
    We are searching Doctor in New York for natural birth and delayed cord clamping. My daughter has normal pregnancy 33 weeks. Her Doctor told: ” There are no benefits and only risk”. Could you recommend us Doctor or Midwife in New York who believe in delayed cord clamping and can assist natural birth.
    Thank you.

    • December 11, 2012 at 3:47 pm

      Dear Irina, please be aware that it is within your rights to decline consent for umbilical cord clamping. Rather than “ask” for delayed, decline to consent to immediate clamping. It is best if you discuss this with your care providers in advance, explain you take responsibility for your decision, document your decision, and also discuss situations where cord clamping may be necessary (ie issues with placenta, cord) or the need to relocate the baby for more advanced resuscitation. You can still ask for your baby to be held below the placenta if born pale and without tone, and for cord milking prior to clamping in c-section or emergency. Kate

  107. Judith Mercer
    December 10, 2012 at 1:48 am

    The Midwives at most of the hospitals and those that do home births will do delayed cord clamping.

  108. Irina
    December 10, 2012 at 5:31 pm

    Thank you for you help.
    This is first pregnancy and my daughter and her husband not sure do this at home.
    How we can confirm delayed cord clamping with Hospital? Who is the person we have to contact?

  109. Judith Mercer
    December 11, 2012 at 8:54 am

    Most all of the hospitals have midwifery services. You don’t have to have a home birth to get a midwife.

  110. December 11, 2012 at 5:16 pm

    Since being actively involved with this issue since the 90’s with the publication of Lotus Birth in 2000 and 2010 I am amazed at how people continue to make allowing the baby to receive its full complement of placental transfusion questionable . The placenta is an organ that is still functioning and all the baby’s major organs are awaiting the blood that it will deliver as nature has designed. The entire organism is compromised if that does not happen. I suppose most clinicians have never actually seen a totally healthy infant. The compromised infant has become the norm. How ridiculous is that? Goodness knows how much the community’s overall health has been affected for the past 2-3 generations.
    For parents it can be simple. FACT: There is no medical reason to cut the cord.
    I advocate good relationships with caregivers and echo the advice given in this ongoing excellent post about establishing rapport with them as to what you want before hand however if you meet objections there are two strategies that work.
    “If you cut that cord I will sue you” As they seek advice from higher management the placenta does its work and all is well.
    The second is it to represent the practice ( this is particularly successful with Lotus Birth) as part of your spiritual observance. It is quite extraordinary how ‘solid scientific dogma’ melts in the light of ‘supporting diversity’. We have had numerous C/section Lotus Births in hospitals.

    Our latest research has identified the cranial reflex impulse (CRI) present in the placenta until the time that the cord comes away naturally 2-7days after birth. This suggests that the organ is alive and doing something. As an intuitive I have no problem in understanding this energetically as the process of the baby’s auric field becoming fully established. I would certainly welcome someone with the resources to take this research further.
    You only have to watch a baby still attached to its placenta to ‘see’ that all is very very well.

  111. Laura Lee
    January 12, 2013 at 11:06 am

    So how can I present this to my OB and midwife without insulting their intelligence?

  112. Kimberly Staker
    March 11, 2013 at 8:50 am

    My daughter was born at home @34week upexpectedly … I delivered her on the bathroom floor. Cord obviously still attached. My other older daughter went for help at age 4. .. Julissa was born still inher birth sac.. She was purple and i was able to get her to breathe. It was a good 20 minutest before paramedics got there. And another few minutest before they could clamp off the cord and cut it. My daughter Julissa has mild cerebral palsy now.. But after reading this i wonder if Julissa was saved now by us being attached for so long…. It was a great story to hear. Thank you for writing it.

  113. March 22, 2013 at 9:17 am

    Please let me know if you are looking for a article writer for your blog.

    You have some really good articles and I think I would be
    a good fit. If you ever want to take some of the load off, I’d absolutely love to write some content for your blog in exchange for a link back to mine. Please drop me an e-mail if interested.
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  114. Judith Mercer
    March 22, 2013 at 10:40 am

    For Rachana Shivam: What is the cranial reflex impulse and is this information published any where?

  115. April 6, 2013 at 2:11 pm

    Reblogged this on KARMAwaves Blessings Roll Call and commented:
    Heres an informative read regarding delayed cord clamping for MotherBaby. A must read for all birthworkers and expecting mamas.

  116. June 11, 2013 at 10:02 am

    I do trust all of the concepts you have introduced to your post.
    They are very convincing and will definitely
    work. Still, the posts are too short for beginners.
    May you please prolong them a little from next time?
    Thank you for the post.

    • Shane Marsh
      June 11, 2013 at 3:45 pm

      Debra, see the Grand Rounds talk, which is much longer. Available on podcast, free on itunes. One of the posts above may give the details of how to find it.

    • August 5, 2013 at 3:21 pm

      Shane, Debra is a fairly well disguised spammer.

      • Shane Marsh
        June 20, 2014 at 3:26 pm

        Thanks, Nicholas.

  117. June 11, 2013 at 6:47 pm

    CRI is the cranial rhythmic impulse. It is a ‘pulse’ with a slower rhythm than the arterial respiratory rhythm. . Its frequency is around 8-10 oscillations a minute and can be found in all living tissue . In Italy Dr Luca Daini has identified and measured CRI present in the placenta of his lotus born child in the days after the birth until the cord came away at the navel.
    What this means to the infant and the benefit of having this energetic connection continue until it ceases naturally is a subject for ongoing research. We have repeated Dr Daini’s results in a lotus born baby in Melbourne. The mother’s osteopath measured and recorded the strength of the CRI each day. It was found to match the child’s CRI on day one and it gradually diminished until the cord came away from the navel. This would suggest that it is still ‘alive’ in some way. Our knowledge of subtle energies lags behind other cultures health systems where it’s strength or otherwise is an indication of one’s health status.
    We are pioneers of this subject. In our culture the placenta has been treated very differently to how human beings have traditionally treated it. Most cultures have most specific practices that show respect for this extraordinary organ. The Japanese dry it and grind it into a powder that is used as the person’s medicine when they are ill.
    Last week scientists in Western Australia announced that they had evidence that plants make sounds and communicate with each other. It is a time of a paradigm shift. Placental awareness is part of this development.

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