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.)

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.

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.

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.

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

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

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

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.

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.

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.

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

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/