An Update on Delayed Cord Clamping, and Thoughts on Internet Expertise
Two years ago, I penned a post entitled “Delayed Cord Clamping Should be Standard Practice in Obstetrics”, which was read by many. Later I gave a grand rounds on the topic, which was viewed by many. In doing so, I contributed to a growing movement towards delaying cord clamping after the birth of preterm and term neonates. This was all well and good. But something else happened as well.
In the eyes of many, I became an “Expert in Delayed Cord Clamping”, worth quoting to others, and even name dropped as some sort of trump card – “Well, Dr Fogelson says….” So let me set the record straight. I am not an expert in delayed cord clamping, if such a person even exists. I am certainly not an activist for the idea, not am I sure that such activism could be justified in the literature.
What I am is this:
1. An educated person with access to the literature and training in interpretation of medical research.
2. A physician with intellectual expertise in maternal health, and first hand experience in its practice
3. A person with a platform where his opinion would be heard.
and
4. A person who chose to express said opinion on that platform.
And that’s it. Does that make me an expert? I say no. Nonetheless, it seems that anyone that chooses to speak in a public forum will be given great respect as an expert in whatever they choose to speak about, if only because they took the effort to open their mouth and be heard. It is this instant “respect to the one who takes the trouble to speak” that makes public speaking so powerful. But let’s not go overboard. I encourage anyone who has read what I have written to investigate the literature, consider the non-data driven logical and physiologic arguments, and then decide for themselves. If you do this, you will be as great and expert as I.
So with that in mind, consider what’s new in the field.
****
Since the 2009 article, several randomized trials have been published, as well as review articles on the topic.
Andersson et al recently published work that demonstrated improved iron stores, lower prevalence of iron deficiency anemia in delayed clamped infants, without evidence of any adverse effects. This data was interesting in that it was produced in a population with a lower prevalence of maternal iron deficiency than the population studied by Chaparro et al in Mexico.
Oh et al recently published data for a randomized groups of 33 very low birth weight infants ( < 1500 grams), which showed higher hematocrits in the delayed clamped infants. They found non significant trends towards improved morbidity rates. Mercer et al demonstrated improved morbidity rates with a sample size of slightly more than double the number of infants studied by Oh, suggesting that Oh may have lacked adequate power to find a difference between groups. It is also possible that Mercer’s data represented an alpha error and overstated the actual benefit of delayed clamping, and that Oh’s data is more representative of reality.
De Paco et al looked at cord gasses from infants of delayed versus immediate clamping, and found minimal differences between the groups.
A JAMA meta-analysis concluded that delayed clamping at term had both short and long term neonatal benefits without apparent downside risk.
*****
So how are we to interpret this and previous work? Firstly, you get to decide for yourself, as I am just one person. Some people with similar backgrounds to myself see it differently. But the following is how I would interpret it.
Delayed cord clamping is more akin to the natural process of birth that we have evolved towards, and to the birth process shared by all land mammals. Immediate cord clamping clearly reduces the amount of blood in the infant in terms of volume, blood cells, and iron content. In my mind, this action removes blood from the infant that the infant was “destined” to receive absent the intervention of immediate cord clamping.
That said, human beings born at term clearly thrive no matter what is done. One only needs to deliver a few hundred infants, clamp their cords immediately after birth, and watch them go home apparently healthy to know this. However, when we measure outcomes at a population level, delayed cord clamping appears to benefit infants. These benefits appear to be clear for iron stores. In preterm neonates, there appears to be a benefit in terms of intraventricular hemorrhage and perhaps sepsis, but we must remain conscious that these data are based on small sample sizes, and are therefore at risk for being the product of statistical error.
Most important in my mind, however, is that there is no real data to suggest that delayed cord clamping is at all harmful to an infant. For that reason, the combination of the underlying physiologic and rational argument with the available data is compelling enough to me to support a policy of routine delayed cord clamping for term and preterm neonates.
But let’s not get ahead of ourselves with this data. Some are supporting delaying cord clamping in an infant that is born distressed in clear need of resuscitation. To me this seems foolish. An infant that is bradycardic from hypoxia is going to have a hard time circulating through its cord. It needs oxygen, and the way to deliver that is through its lungs. If we can devise a way to do this while leaving the cord intact, so much the better, but lacking this lets just be pleased that we have wonderful pediatric staff who can deliver expert care to these infants, and let issues of the cord fall away. Let’s not also hang on the theoretical possibility of placental ECMO, or continued neonatal gas exchange through the cord after delivery. This idea clearly has some physiologic merit, but we have no data whatsoever that would support delaying resuscitation of a infant in jeopardy under the belief that it will self-resuscitate through the cord. Sadly, some have quoted me in support of such a policy, so let me make it clear that I cannot support the idea outside of a research protocol. We are so good at resuscitating infants with proper airway management and ventilation. Let’s not impede our ability to use our strength in pursuit of naturalism. Infants in distress deserve better.
So let’s support delayed clamping and do it whenever feasible. It makes senses and there is data to support it. But holding it up as the one critical moment of an infants birth is more religion that science. And for crying out loud, an infant that is born near lifeless needs to breathe a lot more than it needs an intact umbilical cord. We must remember that if that baby is lifeless, the cord wasn’t doing a very good job up to that point. We’d better give it a break and take over.
I’ve assisted a few homebirth midwives (both DEMs who later became CNMs to be able to practice legally) and they resuscitate with the baby on the cord. It’s definitely doable, but you have to bring the equipment to the baby, rather than the baby to the equipment. The midwives I’ve worked with use a portable resuscitation surface–usually a rigid board with a heating pad on top, wrapped in some sort of towel. They also carry portable O2 tanks, so they can bring the equipment wherever it’s needed.
Resuscitating and leaving the cord intact doesn’t have to be an either-or proposition, but it does mean relearning how to resuscitate without the baby on a separate resuscitation cart (often several feet away from the mother).
How about newborn in distress gets the best of both? http://www.lwh.me.uk/Library/news_centre/Life_Saving_Trolley_Basics_Case_Study.pdf . Surely you have heard of the BASICS Trolley being implemented in UK which allows for complete evaluation and resuscitation of newborn without severing the umbilical cord.
I think the idea of simultaneous placental transfusion with transpulmonary resucitation is a great idea, but is impractical in any delivery room I have ever seen. I have heard of the BASICs cart (trolley), but have never seen one, making it a theoretical idea for me at this point.
While I strongly support delayed cord clamping, I have occasionally heard of women being so adamant about it that they are resisting efforts to provide resuscitation to an infant in need. It concerns me that information I have presented may have been a part of promoting that idea, which I certainly cannot support.
I believe to do neonatal resuscitation with the intact cord appear to be a rather contemporary approach.
Possibly, it is like the simplified version of the EXIT procedure, where we fix the lung while the cord keep the baby well.
Theoretically, intact cord continues to increase the oxygen-carrying haemoglobins while the neonatal resuscitation loads the haemoglobins with oxygen in the lungs.
However, is there any conclusive or ongoing trial showing evidence of this practice?
I appreciate your podcast and reviews of the literature because those of us not affiliated with a university do not have access to the literature beyond what is available through Pub Med. As you know, it is not possible to achieve a balanced view of the literature just reading the journals to which one can afford to subscribe. I see this as a significant barrier to the promotion and implementation of evidenced based practice. I think that this lack of access also contributes to seeing those who speak out as experts. You invite us all to become “experts” but with limited access to the literature, it is simply not possible. BTW, I have resuscitated newborns with the cord attached. Believe me, since I was a NICU nurse before I was a CNM, I am a devotee of NRP and timely PPV!
It would be great if all the peer reviewed journals were open-access, but I’m not sure how that would work. The reason magazines can be distributed far below cost of production (or even free) is that they depend on wide circulation to drive up their advertising rates. Peer reviewed journals have minimal advertising compared to any commercial publication, and rely on high subscription fees for financial support. Its a bit of a catch-22.
Beethoven’s music was on the radio yesterday in celebration of his birthday. Hearing an elegy for a baroness patron who died in childbirth reminded me that that would have been my fate if I had given birth back in the 19th century.
My first son suffered severe head trauma (cephalhematoma) at birth. His developmental delays were evident from the beginning. I did survive to have three more sons. My second son’s birth was even more traumatic (a face presentation). for years I believed he was stillborn, brought back to life after many tense minutes of resuscitation. At 8 pounds 14 ounces he looked fine within a day or two. He had no developmental delays and was precocious in learning to speak. Sadly at age 3 he was diagnosed as having autism. His speech was clear but consisted only of phrase fragments (echolalia).
Who am I, to suggest birth injury as cause of his autism?
1. I returned to school to study biochemistry and neuroscience, and am well-trained in interpretation of medical research, which I have followed for more than 4 decades now.
2. I chose family over pursuing a career in research, and am viewed as just a mother.
3. I have no platform from which to express an opinion that could be taken seriously.
4. However, I will keep trying to point out that ischemic injury at birth affects the brain in a very clear-cut pattern of damage that could interfere with normal language development, and I only hope someday this will be recognized:
In 1959 Ranck and Windle published their surprise finding of subcortical damage caused by “asphyxia” at birth, with most prominent ischemic lesions in nuclei of the auditory pathway. See Ranck JB, Windle WF. Brain damage in the monkey, Macaca mulatta, by asphyxia neonatorum. Exp Neurol. 1959 Jun;1(2):130-54.
In 1962 Kety published results of his work on blood-flow in the brain with the surprise finding that nuclei of the brainstem auditory pathway have higher blood flow than any other area of the brain, which explains their greater vulnerability to ischemic impairment. See Kety SS. Regional neurochemistry and its application to brain function. Bull N Y Acad Med. 1962 Dec;38:799-812. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1804882/?tool=pubmed.
In 1969 Faro and Windle published their finding that brain maturation does not follow a normal course in monkeys subjected to “asphyxia” at birth. See Faro MD, Windle WF. Transneuronal degeneration in brains of monkeys asphyxiated at birth. Exp Neurol. 1969 May;24(1):38-53.
In 1940 William Windle stated, “. . . the rather common practice of promptly clamping the cord at birth should be condemned. Of course this will make it impossible to salvage placental blood for ‘blood banks.’ However, the collection of usable quantities of placental blood robs the newborn infant of blood which belongs to him and which he retrieves under natural conditions.” See Windle WF. Round table discussion on anemias of infancy (from the proceedings of the tenth annual meeting of the American Academy of Pediatrics Nov18-20, 1940) Journal of Pediatrics 1941 Apr; 18(4):538-547.
You point out that “human beings born at term clearly thrive no matter what is done. One only needs to deliver a few hundred infants, clamp their cords immediately after birth, and watch them go home apparently healthy to know this.”
My stillborn son was resuscitated, came home apparently healthy, and appeared to develop normally for about 3 years. However, abnormalities of the auditory system in victims of autism have recently been reported. See Kulesza RJ Jr, et al. Malformation of the human superior olive in autistic spectrum disorders. Brain Res. 2011 Jan 7;1367:360-71.
Clearly most infants suffer no harm from clamping the cord immediately at birth. However, the developmental course of these infants should be followed into the school years, and into their teens. Schizophrenic decline becomes apparent sometimes as late as a person’s 30s, and includes auditory system dysfunction.
I wish my son could have been resuscitated without clamping the cord. I realize now that he was not stillborn, and at 8 pounds 14 ounces had been well nourished and oxygenated from the placenta. Allowing placental blood-flow to continue during ventilation of his lungs would have been healthier, but I realize that in earlier generations we might both have died in childbirth.
Thank you, Dr Fogelson, for continuing to advocate delayed clamping of the cord at birth. I do hope Drs. Weeks’ and Hutchon’s BASICS trolley can soon come into routine use for depressed babies.
Thank you for your comment. I think there are some interesting theories that can be made between immediate cord clamping, loss of iron stores, effects of iron on neuronal development, and subsequent neurological disease. At this point they are just A->B->C->D ideas, with no idea how E-Z come into play. There may be an actual connection, or there may not. Many autistic children have no history of childbirth hypoxia, and many infants with childbirth hypoxic events do not develop autism. Its an interesting idea though.
Help I need to try to get my hands on some info on this topic in SPANISH to present to the Drs in the Dominican republic where we bring students and help with deliveries a few times a yr.any leads ?? Thanks Much Lisa Aman LM dancingmidwife@gmail.com
As an avid reader of cord clamping ‘information’ – literature, articles, blogs and birth stories – I have seen your contributions to social media widely distributed and discussed. However, I have to disagree that (m)any advocates of delayed cord clamping believe this is all compromised infants require. I take your word for it that you have been quoted in this way, however like the posters above me, the discussion and advocacy I’ve come across is concerned with preserving the anatomy of birth so that placental transfusion is still possible – nothing to do with delaying or withholding resuscitation.
I recently wrote to Dr. David Odd (UK) to discuss his work (re: resuscitation at birth and cognition at 8 years of age: a cohort study) and in his reply he stated: “At present we don’t know if early cord clamping is good OR bad for compromised infants at birth: but I am aware of research being planned in this area so we may have an answer in a few years”. Sounds promising.
The implementation of the B.A.S.I.Cs trolley in the UK may be able to begin generating data but it would also be good to have longer term studies that track outcomes.
All the best,
Kate
Kate – I completely agree. Advocates (like me) are not proposing the idea… but some people are hearing that message anyway. I think that resucitation with the cord intact is the ideal situation, and like you would like to see that be made easier to do.
If the cord is pulsing in a compromised infant, it is my understanding that is an indication that the blood is flowing from the placenta to the baby. And even in the absence of a pulsing cord, the flow from placenta to baby is passive, which means if you hold the baby on an equal level or lower than the placenta, the placental blood will drain into the baby. That’s the baby’s blood in the placenta, and especially compromised infants should have all of their oxygenated blood.
Regardless of whether you think the cord has done a great job or not if a baby is born flat, the reality is that the reason that baby grew and lived long enough to be born is because the placenta and the cord did a good enough job.
Another reason to leave the cord intact, besides oxygen and blood stores from the placenta, is that the cord attached to the placenta (which is usually still inside the mother) makes it impossible to remove the baby from the mother, at least not very far. See Dr. Nils Bergman’s work at http://www.skintoskincontact.com for an explanation as to why it is especially important for compromised babies to stay with their mothers: in a nutshell, the mother is the baby’s safe place, and when the baby is removed from the mother’s presence, the baby goes into despair-distress mode, which negatively affects heart rate and oxygenation.
Midwife Thinking’s blog has a post on the topic of resuscitating with the cord intact: http://midwifethinking.com/2010/08/26/the-placenta-essential-resuscitation-equipment/
Also, see this website for photos and description of a baby being resuscitated in mother’s arms: http://www.homebirth.net.au/2008/04/resuscitation-of-newborn.html
It can be done.
Let’s start to assume, as the first rule of medicine requires, that any intervention is harmful until proven safe (First, do no harm). Including the intervention of cutting the cord so you can resuscitate a baby. Use the cord and the placenta, don’t sever them. How long would it take to retrain any one medical professional in resuscitating a baby on a board on their lap or with the baby in the mother’s arms? Strictly technically speaking, I don’t think it would take very long. Skills are the same. It’s the attitudes that need to change.
Cutting the cord at any time should be assumed harmful until proven safe. The physiological process is that the placenta & cord separates from the baby when the cord dries. Let’s put the onus on the INTERVENTION to prove itself, not the other way around.
Mothers of Change is doing a series on cord clamping right now: http://www.mothersofchange.com
That was a really interesting point. Many people confuse the term expert, with educated. However, you have experience which adds to your educated reliability! I would definitely call you a great source of reliable information!