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Delayed Cord Clamping Grand Rounds
I recently gave Grand Rounds on Delayed Cord Clamping. If you have an interest and a spare 50 minutes, take a look!
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Academic OB/GYN 
Thanks again Nicholas. This lecture is a great resource and I will be using with our Masters of Midwifery students. I’ll also link to it from my blog post about the importance of placental circulation during neonatal resus. Very clear explanation of the relevant research!
I’d be interested in your opinion of the function of the cord during waterbirth. I’ve noticed that placental circulation continues for much longer than on land ?effect of warm water. This gives the baby time to gently transition from placenta to lungs. In contrast, at a birth I recently attended the water was pretty cool and we didn’t get it warmed up in time for the arrival of baby. The cord stopped pulsing pretty quick – before the baby had really established her breathing = required some ‘tactile stimulation’ which I rarely have to do. Do you think this may be linked to the water temperature?
Rachel
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Rachel, German Midwife Cornelia Enning has done research on this subject. Briefly: yes. Water temperature greater than 95 degrees Fahrenheit is associated with a slower transition. You can probably find Ms. Enning’s work through Waterbirth International or Midwifery Today.
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Thank you Nicholas for a great lecture!!!
I just posted the link on the FB-group Leaving A Baby´s Umbilical Cord To Stop Pulsating (Delayed Cord Clamping)
http://www.facebook.com/delayedcordclamping#!/delayedcordclamping
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Thank you for these lectures. Until the newborn baby’s lungs are fully functional, ongoing placental respiration is essential. My full-term 9 lb baby was rushed across the room after birth to be resuscitated, which took too long. We were relieved that his motor and early speech development were right on time, but by the age of 3 his speech was “echolalic,” meaning his speech consisted of phrase fragments used out of context. He was diagnosed as autistic.
Look at pictures of how the brain is damaged by a brief period of asphyxia at birth, in Windle WF. Brain damage by asphyxia at birth. Sci Am. 1969 Oct;221(4):76-84. The inferior colliculi in the midbrain auditory pathway suffer severe injury. The inferior colliculi have higher blood flow than any other area of the brain.
See my website http://www.conradsimon.org/ for more on how auditory system damage interferes with normal language learning. Many people contacted me and asked how soon my son’s umbilical cord was clamped, and clearly it was before his lungs had taken on respiratory function. On my website are also results of my research on the history of cord clamping. Traditional textbooks taught that pulsations of the cord should cease before ligating the cord. By the mid 1980s this advice was totally forgotten, and immediate clamping became standard practice. This was the beginning of the autism epidemic.
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Eileen – thank you for your comments. I’d like to point out to the readers that there is no known connection between cord clamping timing and autism. While cord clamping timing does affect iron stores which likely has some impact on brain development, the nature of autism remains unknown. The increase in diagnosis is clearly influenced by an widening of the diagnostic criteria over the last twenty years (ascertainment bias). Birth asphyxia may be related, though the timing of cord clamping has no measurable impact on birth asphyxia – the acid base status of the infant does not seem to be affected by the timing of cord clamping. While cord clamping may have some influence on future autism rates, this connection remains theoretical at this time.
While I am completely in support of a system wide change to delayed cord clamping, in supporting this it is important to stay within the bounds of what we can prove. Given the rapid propagation of ideas on the internet, it is important to distinguish from what is evidence based and what is idea-based. The connection between cord clamping timing and autism is the latter.
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Great lecture, Nicholas. Thank you for sharing…
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Dr. Fogelson – Thank you for responding to my post above. My ideas about autism resulting sometimes from clamping the cord too soon are based on evidence I have found in my tireless effort to understand what happened to my son: (1) He was resuscitated at birth, and his first feeble cry was very delayed. (2) Ischemic brainstem lesions, most prominent in the auditory pathway, were found in monkeys subjected to asphyxia at birth, by delivering the head into a saline-filled sac and clamping the umbilical cord. (3) The monkeys did not develop cerebral palsy, but were delayed in achieving motor control. (4) Hyperacusis is exhibited by many children with autism. (5) Developmental language disorder is the core handicap of children with autism.
Clamping the cord before the first breath is dangerous, and can lead to difficulty establishing pulmonary respiration, and asphyxia. Capillaries around the alveoli must be filled with blood before the lungs can become functional. This is a desperate emergency, and blood may be drained from the brain and other organs to jump-start the lungs. This is not healthy. The first signs of trouble with my son were his multi-organ problems. Most scary was his collapsing trachea.
I may be wrong, but auditory system impairment from apnea at birth should be investigated. I have tried to point this out to members of the Interagency Autism Coordinating Committee (IACC) but their response is stony silence. Clamping the umbilical cord at birth is dangerous, and certainly not the healthiest start for any infant. I do hope you can be instrumental in getting obstetricians and midwives to understand this, and stop using a clamp on the umbilical cord.
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I appreciate your comment, and your dedication to understanding what went on with your son. I wish you both the best!
I have to say though, that to me your conclusions are still a bit speculative. To me you have hypothesis is worth investigating, not yet a conclusion. But that is certainly where all research starts!
I do of course really support delayed clamping, and if it does have an impact on future autism rates, that will be a wonderful thing.
(This comment was edited after original posting)
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I am an ethnopediatric anthropologist—my research focuses on birth and infant-care practices cross-culturally and historically. Thank you for posting your presentation– it was very informative and I will be sharing the link with my friends and colleagues. It is refreshing to see an American OB-GYN who is open to researching ‘alternative’ birthing practices.
During the first segment/video it would have been nice to see a video clip of humans giving birth without cord clamping, so that your audience of OB/GYNs and “lay-people” could visualize what birth could look like without immediate cord clamping and whisking the baby away for testing. Instead your clips of animal-birth were contrasted with ‘human-birth’ involving immediate cord clamping/cutting– as though it was a species-wide norm, when in fact it is an unusual practice considering the rest of the world, even in the post-industrial/Western world.
Again, thank you for sharing your presentation and research—I hope that it has a positive impact on American hospital-birth practices. Someday I hope our infant and maternal mortality rates become closer to that of the countries of Western Europe and less affluent countries… who have midwifery model of birth and homebirth as the norm for healthy, low risk pregnancies. (https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html)
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>> Instead your clips of animal-birth were contrasted with ‘human-birth’ involving immediate cord clamping/cutting– as though it was a species-wide norm, when in fact it is an unusual practice considering the rest of the world, even in the post-industrial/Western world.
Good point! Every presentation could be better.
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Great presentation. Timely and academically rigorous. Let’s hope that the content and the value of delayed cord clamping spreads. Have you thought of going on the lecture circuit? There have been some anecdotal accounts of premies staying clamped during resuscitation (simply because they were in a remote, rural location) and the incubator wasn’t available until 1 hour later during transport. The results were impressive. We need to study these types of cases some more. (without the radioactive iodine of course 🙂 )
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I would have like to hear the questions, if there were any. What kind of response did you get from your peers on this subject?
I also noticed that you didn’t show a human birth in which the cord is not clamped. There are certainly examples all over the internet some of which you could have gotten permission to share, i would guess. But perhaps you know your audience best.
Thank you for doing this. I listened with great interest to the whole presentation.
Susan Peterson
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Peer response has been uniformly positive, and the residents seem to have taken up the practice with enthusiasm!
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Hearing that residents (hopefully attendings, too?) have taken up the practice of delayed cord clamping is the greatest news! I do hope the practice spreads with increasing awareness (representing a return to “normal” practice).
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Agreed. I would have liked to hear discussion from the pediatricians in particular. I think this is very interesting, and I think your introduction involving bloodletting is poignant, if excessively charged considering. I would agree that clamping came about for convenience, and so as standard practice has no standing until demonstrated beneficial. However, I would like to see something on, as one poster mentioned, aspiration and other complications. A baby who is early and struggling to breathe is one thing. A baby who has been injured in some way is another, and I would be hesitant to agree that treatment should be delayed for these neonates.
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Neonates who are compromised require their placental circulation and full blood volume even more. Resuscitation can be carried out better with the support of placental circulation. When I worked in hospital this is how I resuscitated newborns. The resuscitaires are on wheels – bring them to the mother. I suspect the separation of baby from mother is for the benefit of the practitioner not the mother/baby. Mothers can be involved with a resus and have less anxiety if they can see and touch their baby at this time. Delayed cord clamping does not mean delayed treatment.
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I wish I would have known about delayed cord clamping before I had my son who is now 19 months. He was delivered via emergency cesarean- he aspirated meconium and his first Apgar was a 2. Not sure how much it would have helped him with that but any help would have been great. My future pregnancies (if any) I will request this. Thanks for the knowledge and well done! BRAVO!!!
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I posted a question about caesarian section and possible delayed cord clamping. I would be happy to receive updates about that, too, if there are any. So many fields of research still to do in even “natural” or “normal” birth.
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Dr. Fogelson – Thank you again for your ongoing responses. Like Karen B above, I wish I had known about delayed cord clamping before I had my children, or anything about use of a clamp. I trusted my doctors would do the right thing.
My third son was my healthiest birth. After an hour or so of monitoring I was told I was not in labor (and had a long tight cervix). I got up to get dressed to go home, then suddenly went into second stage labor, and my son, Matt, was born before the doctor could get scrubbed or do anything about the umbilical cord. I am eternally grateful for this accidental natural childbirth. Matt is my pride and joy, recently married but I think afraid to start a family for fear of having to deal with autism.
Thank you for speaking out against umbilical cord clamping, and for your willingness to respond to concerns of those of us who more than anything else in life want healthy children. Discarding the clamp will give all children a healthier start in life I am sure.
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Enjoyed your lecture.
In Scotland when I trained,,almost 40 years ago,I was taught not to cut the cord until it had stopped pulsating.
This was common practise in the hospital where I trained.
One of our consultants who was nearing retirement used to “milk” the cord prior to cutting for the same reasons you have talked about.
This was not the norm, and many other obs and midwives were against it as they felt that it led to a higher incidence of jaundice in infants.
I would be very interested to hear your views on this.
Thank you.
Dawn Laverty. (practicing midwife)
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The data so far suggests that milking the cord does lead to a more rapid transfusion of blood, but minimally affects total transfusion volume. One study showed a higher rate of laboratory diagnosed polycythemia with milked cords in comparison to passive delayed clamping. I’d recommend a 1-2 minute delay (or longer if you like), no milking.
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I love this!! Thank you so much for it! I got interested in delayed cord clamping because my daughter was diagnosed with an e-coli blood infection at 11 days old. They technically don’t know how she got this infection but they say a possibility is that the scissors used to cut the cord weren’t clean… (This was a hospital birth) I got to thinking that if the blood was no longer flowing into the babe that it would probably reduce the risk of bacteria getting to the baby, even if the cutting device isn’t properly cleaned… thus protecting the baby. Any thoughts on this?
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Wow. Hard to know how that happened. E coli is part of vaginal flora, to which the baby is very exposed to in delivery. I think a colonization and infection from labor is far more likely that getting something from a scissor that came out of a sterile delivery pack.
That being said, there is data that delayed cord clamping reduces the incidence of delayed onset sepsis, which may be mediated through improved neonatal oxygenation and possibly through increased number of available immune cells.
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I find the discussion here on immediate cord clamping as a possible cause of autism very interesting.
This study showed a very high prevalence of iron deficiency in autistic children.
http://www.ncbi.nlm.nih.gov/pubmed?term=autism%20iron%20anemia
and as we now know, many studies show that delayed cord-clamping reduces the risk of iron deficiency and anemia.
http://www.ncbi.nlm.nih.gov/pubmed/15005961
Hopefully this will bring the interest among researchers to explore the relationship between immediate cord clamping and ASD
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This was a really great presentation; thanks so much! I will definitely be bookmarking it for any doula clients that may be interested. I’m glad that we had researched this before my daughter was born, and that my husband reminded the attending doctor of our wishes.
Dr. Folgelson, you’re kind of funny! I love the orangatan (sp?) birth. Really cool stuff.
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I wonder what, if any, difference delayed vs immediate clamping has on Vitamin K levels? Perhaps babies with immediate clamping have more need for Vitamin K injection after birth?
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Watched all 50 minutes…(whether I had those minutes to spare is another question ;-).
In the end, I was struck (once again…no surprise) by how elegantly designed our system is — naturally. I smiled at the data around where the infant was held with respect to the placenta. Turns out, when the baby is below mom or on her chest for those first moments (45 seconds, was it?), the transfusion was optimal (or at least, minimally reversed). I can’t help but think in the natural order of things moms generally have their babies below them (hands and knees, squatting, lunging) for that time frame before they pick their little ones up. (Even on mom’s chest — while mom is prone — is a bit out of the natural order of things). Go figure, a pretty elegant design, indeed.
I was sorry to see the Q&A period was not included in the webcast. What was the general take from the audience?
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The Q and A was very supportive, and there were good questions. I don’t have releases from the various folks to post them on the internet, so I didn’t post that part.
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Kristy, on this point I disagree. The pressure of an intact cord is SO MUCH greater than gravity. Literally, when newbie practitioners clamp and cut inelegantly, the blood from the cord will hit the ceiling. The key is the delay, not the position. Also, in my experience, most standing or squatting moms drop down to the toilet, birth stool or floor, and clutch their babies to their chest anyway!
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That’s a lovely sentiment, but it doesn’t really mean anything.
I presume there are more interventions that may be required than just resuscitation?
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I think in this context resucitation would be inclusive of anything that would done for a distressed newborn
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I’m not being sentimental. A healthy full term baby is fairly resilient (thankfully considering what is done to them routinely). A baby who is compromised due to prematurity, hypoxia or congenital abnormality is not so resilient. The support of ongoing oxygenation via placental circulation during their transition to breathing assists any resus administered externally. Allowing them to have their full blood volume = increased red blood cells = increased oxygen carrying, increased white blood cells = protection against infection, increased stem cells…. etc etc. I think Nicholas has covered this.
By resuscitation I mean inflationary breaths, IPPV, even cardiac massage and intubation can be done whilst baby is attached to their placenta. See here to understand where I am coming from: http://midwifethinking.com/2010/08/26/the-placenta-essential-resuscitation-equipment/
If you would prefer not to take the writings of a mere midwife into consideration there is a link at the bottom of the post to an article by Dr Moreley about the importance of the placenta during external resuscitation.
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WhatPaleBlue –
There’s a difference between discourse and pure skepticism. Can you explain what you think is not right about what midwifethinking is saying? What she is saying is not only rationally based in physiology, but also in data.
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That being said, there is data that delayed cord clamping reduces the incidence of delayed onset sepsis, which may be mediated through improved neonatal oxygenation and possibly through increased number of available immune cells.
I’d love to see this data on this can you reference the study?
Thanks
Tracy
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Pediatrics. 2006 Apr;117(4):1235-42.
Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial.
Mercer JS, Vohr BR, McGrath MM, Padbury JF, Wallach M, Oh W.
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Hi, I saw this presentation via Science and Sensibility and really appreciated it – especially as a new mom who asked her OBs to delay clamping and they refused because “it doesn’t make a difference”.
Anyway, I wanted to point something out (I mentioned this in the S&S comments too) – you said that Darwin probably noticed the effects more because of the nutritional status of the moms, whereas these days that’s not an issue so the outcomes are subtler. But I have to point out that today’s OBs (I’m Canadian, so maybe it’s different there) have zero contact with mom or baby after the placenta is delivered. They can’t observe effects on the baby without seeing it right?
Specialization is important, but it can and, I think in this case, create a disjointed and even myopic system of care that doesn’t benefit the patient.
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You’re right OBs have little contact with the baby, after birth, other than seeing it a bit while in the hospital and if they’re lucky enough that the patients bring the baby in to visits. Moms, though, also have trouble seeing a difference, as they only have one baby and nothing really to compare to.
That said, since I’d started doing delayed cord clamping its pretty obvious that when one delays the baby is much pinker, and perhaps more vigorous as well.
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Yay! Glad you see it, anecdotally, as well. It’s sharing THIS kind of stuff, as much as the evidence (sigh) that will convince your colleagues….
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Nicholas, please could you tell me what the condition is called if a baby is born (with the cord around the neck twice) then removed before shoulders born and the baby’s face is deep blue/purple/black in colour? Would you expect that, without cutting the cord until it had stopped pulsing, the baby would recover without any ill effect, or what effects, if any, if no other resus measures were taken, might there be?
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This is called a nuchal cord (‘NU-KEL’). Most nuchal cords can be pulled off the baby’s head to allow the baby to deliver, and in other cases the baby can be delivered through the loop of cord. In either of these cases, the cord would still be intact. In some cases the neck is wrapped tightly enough that the cord needs to be clamped and cut to allow the infant to deliver.
In some of these cases, the baby will be significantly affected by having had its blood flow interrupted during the labor and delivery. If so, usually the priority is going to be getting the baby enough oxygen via its lungs, rather than delaying cord clamping. If one could do both, that would be great, but most delivery rooms are not set up with this in mind.
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I wouldn’t be game enough to cut and clamp a tight nuchal cord. Five obs in the US have been successfully sued for doing this before a shoulder dystocia occurred. You can use the ‘somersault manoeuvre’ instead if the cord is really tight enough to prevent the baby descending once the head is out. Most of the time even a tight cord will not prevent birth. If the baby has been compromised they need their placental circulation afterwards to re-balance their blood volume + oxygenation. I have a lovely photo story of this occurring at a waterbirth I attended. The baby is born fairly ‘stunned’ due to a multiple tight cord, but the placental circulation resuscitates the baby. No need for anything else.
Best to leave a nuchal cord well alone.
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Certainly there is no need to cut one if the baby will deliver, but occasionally it is really holding the baby in there. In over 1000 vaginal births, I’ve probably seen one that tight 3-4 times.
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I agree with Dr. F that it CAN happen that cords are too tight to deliver through. In my 1,000 births or so I’ve never had to cut but I’ve seen cases that I agreed with its necessity and a few per thousand is probably right on. Remember 38% of babies have nuchal cords! I don’t know how the fast-to-cut-providers breathe after that cord is cut!
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example of a home (!) breech (!!) waterbirth (!!!) with x2 nuchal cord (!!!! 🙂 ), needing resuscitation, where it is done in the mother’s arms: http://www.homebirth.net.au/2008/04/resuscitation-of-newborn.html
Midwife Barb Herrera describes her resus equipment herehttp://midwifethinking.com/2010/08/26/the-placenta-essential-resuscitation-equipment/#comment-158 and has pictures here http://navelgazingmidwife.squarespace.com/navelgazing-midwife-blog/2010/8/26/resuscitation-board.html
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Appreciate the comment.
Please note that as a physician I do not endorse all the views noted in these links, and have issue with several.
1) breech homebirth is likely associated with statistically increased rates of neonatal death, though we do not have specific data. I am personally aware of two neonatal deaths from head entrapment related asphyxia in breech homebirths.
2) mouth to mouth breathing is not likely to achieve fetal oxygenation as well as using a bag mask. Breathing across the infants face will not improve its oxygenation.
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I am very comfortable with newborn resuscitation, have done many, many both in and out of hospital. I feel that mouth to mouth can be as effective, if not more effective in some cases, than bag and mask. The “feeling” of appropriate pressure just can’t be duplicated by tools. And, in cases of waterbirth, standing birth, etc – have a lot more control without the need to cut the cord. These days our bag pop off valves are far too sensitive for what mmHg the initial inflation sometimes requires. Obviously, if the need for support is ongoing the need for 02 necessitates bag and mask. But even the world of NRP is more and more questioning the routine use of oxygen and I think soon the recommendations for initial resus will include NO O2… On the “blowing in the face” – this is NOT the same as PPV when truly needed but WILL inspire respiration in a lot of babies. Heck, try it even on a one year old! Blow in her face and she’ll gasp (then laugh). I admit it is my first step in encouraging respiration if stim does not work, and it’s VERY successful. Try it, doc!
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of course, wouldn’t expect you to without the data. I linked to them as examples of what is possible even in “extreme” situations such as the first one.
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Wow, two quite different types of recommended care. The baby in question was one of my children, born at home in Sydney thirty years ago. We had a very attentive trio of midwives (one just happened to be just passing on her way home after another birth). When the head was born, the midwife unwound the cord then the rest of the baby was born. They left the baby on my belly for some time until she returned to a normal colour. I don’t recall how long after the whole baby was born that the cord was cut but, judging by the photos, it was some minutes, at least. I breastfed her as soon as possible while we all drank champagne and ate cake. I don’t remember how long the placenta took to come out, either. My daughter is now a happy adult, with no significant apparent health problems and a university education, but we do sometimes wonder what would have been the case if she had had the usual intervention of immediate cord clamping and whatever else a hospital team had thought appropriate.
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Dr. Fogelson,
I found your blog via myobsaidwhat.com
I’d just like to say that, based on what I’ve read thus far, I quite enjoy your blog. I may not agree with you in every instance, but I have great respect for your use of professional knowledge, openmindedness, common sense, and willingness to engage in reasonable debate. You’ve definitely found yourself a new reader, although I am a layperson (hoping to become a doula, and perhaps a midwife eventually.)
Speaking of midwifery:
What are your opinions, professionally and personally, re CNMs vs CPMs. Also, what would you reccomend by way of training? Would you consider a nursing degree (RN or LPN) followed by training at a school of Midwifery sufficent, or would you solely rec. a nursing degree plus a Masters in midwifery (via a traditional university)? I’d love to hear your take, as a traditional MD, on this.
Off-topic, I know. Sorry! Sometimes, my enthusiasm gets ahead of me. 😉
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Amber – I’ll leave that one alone here since its a bit off thread.
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Thank You very much for your presentation. I do not know much about the situation n the US. Here in Germany private companies advertise nuchal cord blood banking in an aggressive manner. Parents sometimes feel they are letting their children down if they do not pay for the storage of cord blood. The positive effects of a more natural treatment of the nuchal cord (=delayed cutting) is downplayed. This is understandable from a profit oriented company, but this is done by doctors and even midwifes too.
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Public cord blood banking seems to be a useful thing and has benefited many, though at the expense of potential benefit that blood might have had for its donor. My personal feeling is that private cord blood banking is a little ahead of its time, and in most cases the companies are making claims based on potential future uses rather than current proven technology. You’re right that cord blood storage companies downplay delayed clamping, as it is an anathema to their business model.
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Thanks for sharing Grand Rounds!
Just thought you might be interested to know…. we donated our daughter’s blood to a public cord bank AND delayed clamping at least 10 minutes. So it is a possibility….
The company I found sent me a kit and my midwife took the sample for us. I was very interested in delayed clamping and also in public banking (I was skeptical about paid storage). So I had researched this and contacted the company to confirm I could delay. When I got the kit I was also able to read the instructions and it specifically mentioned a delay and only that the cord blood had to be collected before the placenta was delivered. I know our midwife had no problem getting enough for our donation- she just stated that she could not guarantee a sample (which we were fine with) and she’d have to see at the time because it was not something she had done often. Her standard was delayed clamping and she did very few cord collections- so she was interested in the possibility of both, too.
Obviously, I’m not as familiar with the mechanics of this as a midwife or doctor would be (maybe you can shed some light into this). I would love to know more about the mechanics of the blood and oxygen transfer at birth and more about exactly what happens- how pressure is regulated, what it means when the cord stops pulsating, and what is still transferring hours after birth (as proponents of extended delay would mention). There does seem to be this huge misconception that gravity and all will make the baby get too much blood and that clamping very quickly is necessary- to get a sample- both which seem untrue.
Also, the value having the placenta still attached while the baby is first learning to breath is something that needs to be front and center- I’m so glad you squeezed it in there at the end..
BTW, I couldn’t find enough info on how common it was to have a problem with collection size, but the providers that were familiar with collection seemed to think it was _not_ common. Also, it sounded like once they were more used to collection they had a better sense of things and would be able to milk the cord or use gravity to get the collection. (I wonder if it would be possible to wait till birth and make a better decision about if it was necessary to rush to clamping or not??) . And there are those that strongly believe there is benefit to even further delay and caution that even collecting after the cord has stopped pulsating is interrupting benefit to the baby.
Now, for a family with a known condition- it would definitely be a harder decision to make. I also wanted to note that these families should also check out public banking because when I was looking at this I found statements that public banks allowed families with certain conditions to store cord blood for free and that it could be reserved for them (again, if they met the specific guidelines)
IMO, double shame on the private paid storage co’s, though.
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Thanks for your comments. To answer a few of your questions.
1) Gravity seems to have minimal effect on fetal transfusion, as long as the baby is not too far above the placenta. Up to 20 cm above the placenta seems to not change things very much. Holding the baby far above mother does. There was a chart presented in the grand rounds that discusses this.
2) There seems to be continued blood flow between baby and mother for at least as long as we feel pulsation in the cord, which is anywhere from 30 seconds to 2 minutes or so. There is probably some passive flow of blood into the baby even after pulsation has stopped.
Extended delayed clamping / lotus birth is a cultural ritual without any physiologically plausible benefit.
3) My sense is that if you are going to collect blood for donation or storage, it doesn’t make sense to delay cord clamping. The success of engraftment for a transfused cord blood unit is most dependent on the volume of the transfusion. There is a ‘minimal volume’ below which the cord bank will accept the unit, but that doesn’t make that minimal unit as good as a bigger one. I think a lot of folks are not familiar enough with cord blood transplantation and think that the ‘minimal’ volume is just as good as a more fully sized unit, which just isn’t the case.
I am not a particular fan of private storage of cord blood, as it seems to be very expensive relative to the potential benefit, not to mention that one is then immediately clamping the cord (assuming one wants the best unit one can have.) The private companies don’t want to take a stance on delayed cord clamping, because they don’t want to give medical advice. They say officially that they are compatible. One has to understand that they are in the business of banking cord blood, and it matters not to them if your unit is big or small – the dollars are the same. If you talked to a hematopathologist who specializes in cord blood banking and transplantation I think they would say one wants the biggest unit one can get.
4) I’m happy to hear that there are public banks that allow units to stay identified. My understanding was that all the public banks completely de-identify the cord blood units and that they are not retrievable by a specific donor.
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Hi ! I work for a cord blood bank and can give you the facts behind the over-promotion. See http://cordadvantage.com/cord-blood-blog/2011/5-straight-facts-about-cord-blood-viacord-viacell-and-cord-blood-registry-wont-tell-you/ to find 5 Straight Facts About Cord Blood ViaCord / ViaCell and Cord Blood Registry Won’t Tell You.
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Thanks so much for posting this! I teach Brio CBE classes and have advocated for delayed cord clamping for some time. You blog post on this topic and now these videos will go out to all my students so that they have an evidence based academic resource with which to advocate for themselves when they have a care provider who is hesitant to wait a few minutes before clamping.
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I have always believed, since my first Bradley class, that delayed cord clamping is important. Now as a midwife, I am sometimes torn. Sometimes I feel like I should be obtaining cord gases. What I would really like to know, and I haven’t been able to find the answer in a journal or from a person, is if I delay cord clamping, does this affect the cord gas content? If I delay for 3-5min, I think there would still be enough blood to be able to obtain a sample, but would it be accurate?
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There’s nothing to keep you from getting blood from an umbilical vein and then using a hemostat to clamp off the tiny hole that is left behind. Both goals reached.
If you wait 3-5 minutes to get the cord gas, you would be sampling the acid/base status at the time when the umbilical arteries stopped pumping (45-60 seconds), so it wouldn’t be quite the same, most likely a little better than at delivery.
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OMG–I never thought of that. I think I will try it next time. Thank you!
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A Swedish nurse has invented a tool that facilitates the acid base sampling from intact cord ..
She has now patented her invention and the product will be sold worldwide.
In this clip from Swedish TV4 News today you can see how it works.
http://www.tv4play.se/nyheter_och_debatt/nyheterna_stockholm?title=nu_uppfinning_skyddar_skoterskor&videoid=1271849
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Practical management of acid-base sample at delayed cord clamping (my own free translation from the Swedish National Guidelines for Cord Clamping) :
“The cord is clamped temporarily with the fingers. The umbilical artery is punctured and 1-2 ml of blood is aspirated. The venous sample is taken in the same way. When the samples are taken the manual tourniquet is released and the syringe removed. In most cases, no leaks or only a minimal amount of blood. Would there be a major leak, insertion site is compressed with a gauze for a few minutes.”
This method is practiced in most hospitals in Sweden. Only those hospitals situated geographically close to the National Cord Blood Bank ( we dont have any private cord blood banks in Sweden) are taking the acid base sample from immediate clamped and cut cord .
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I watched all three segments and really enjoyed. Thank you. To me, the evidence is obviously important but it’s truly a case where the proof is in the pudding. Babeis with delayed cord clamping just do SO much better… pinker, more alert, heartier, bleed better for their PKUs, I see less jaundice, not more. The hard part is, in my part of the country, NO OB or neonatolgist believe you even enough to read the evidence.
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Its interesting how we look at the evidence from a different perspective. I’d say its the data that is the pudding, not our anecdotal experience 🙂 But I’m a data geek.
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Ya’ll should listen to the upcoming Podcast Episode 31 – its a discussion of the Mercer cord clamping data with Mercer herself.
PS – though I am not a Southerner, I recognize the introduction of “ya’ll” to the English language as the single greatest contribution of this region of the world.
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Hi Dr. Fogelson,
I have a client birthing with a CNM at a facility that practices active management of third stage, per the WHO guidelines. The midwife said that pit would be administered via IV if one is placed or IM if not, after the head is delivered. My client is interested in delayed cord clamping for the benefits to her baby. Her question to me, and mine now, to you, is what effect does this admin of pit have on the continued pulsing, exchange/delivery of blood to the baby, and timing of the sep of of the placenta. I see that the most benefit of the delayed clamping is received within the first 3 minutes, if I understand correctly. Does this admin of pit affect that? If she wanted to wait to clamp until pulsing has ceased, how might this be affected by the medication?
All of this, of course, is in the absence of risk factors for PPH and in a normal, low risk mother, attempting a VBAC with one low transverse prior incision 20 months ago.
Thanks in advance for your comments and response.
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Sharon –
I’m not aware of data that specifically addresses this question, but I suspect that a lot of the women in the term trials published so far got postpartum pitocin. I would consider the data already quoted as applicable to a woman getting pitocin.
At a logical level, the pitocin would shorten the time period required to move blood from the placenta to the infant, as it would effect a net increase in uterine compression on the placenta.
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Thank you so much for this valuable information, I am pregnant with my first child, due in 7 weeks and will be requesting that the doctor waits until the cord has stopped pulsing before being clamped. I am also doing hypnobirthing to create a calm environment to labor and deliver my baby. My pure interest in both of these are you don’t see animals wailing their heads off giving birth and like you said another animal running over and cutting the cord lol.
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Thanks so much for posting!
Quick question re: part 4 at 6 min 55 sec — are cord blood stem cells really pluripotent (able to differentiate into all nearly all cells) or multipotent (lineage-restricted)?
I’d also like to solicit some advice — I’m planning to deliver in ~10 weeks at a hospital with a reputation for being incredibly strict about following ACOG guidelines (which I’m fine with) – and for active management of third stage labor this includes 1. uterotonic administration w/ delivery of anterior shoulder 2. immediate cord clamping and 3. controlled cord traction. The more I learn about delayed cord clamping, the more it strikes me as a good idea. My question is: what is the best approach to requesting that the delivery team follows WHO/FIGO 3rd stage labor management guidelines (includes items 1, 3, and delayed cord clamping) instead of ACOG guidelines? I ask because anecdotally I’ve heard of someone requesting delayed cord clamping, and then the OB clamped in <20 seconds anyway (and no, I'm not interested in or able to go to another hospital). Thanks for any advice.
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According to this study active management is associated with a seven to eight fold increase in postpartum haemorrhage rates for women at low risk of postpartum haemorrhage , compared with holistic psychophysiological care in the third stage labour .
http://www.ncbi.nlm.nih.gov/pubmed/20226752
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Thanks, I’ve seen lots of similar data, and I’m 100% in support of active management of 3rd stage. The issue for me is whether to follow ACOG’s active management guidelines (includes immediate cord clamping) or the WHO & FIGO’s active management guidelines (includes delayed cord clamping). There is excellent evidence in support of uterotonic administration and controlled cord traction for 3rd stage.
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The study is retrospective and not randomized, bringing in huge selection bias. Patients who have bleeding issues are more likely to receive uterotonics , which pushes them into the active management group in this study.
Randomized prospective trials have shown the opposite result of this study, that active use of pitocin or other uterotonics decrease postpartum bleeding relative to expectant management without uterotonics.
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Nicholas and Evamarie, what is your opinion of these quotes by Michel Odent
“Having been in charge of more than 10,000 ‘non-managed third stages’ of labour in the French state hospital of Pithiviers. I cannot see any reason to interfere with the exchanges of blood between the newborn baby and the placenta. “
Excerpted from Dr. Michel Odent – Notes on Birthing
http://www.waysofthewisewoman.com/dr-michel-odent-notes-obgyn-studies.html
“It is only when an hour has passed after the birth—if the placenta is not yet delivered—that I dare to disturb the mother in order to check that the placenta is at least separated from the uterus. With the mother on her back, I press the abdominal wall just above the pubic bone with my fingertips: if the cord does not move, it means the placenta has separated. In practice, the placenta is always either delivered or separated an hour after birth, and bleeding is minimal, if the third stage has not been “managed.” I have never had to inject a uterotonic drug to control the bleeding.”
Excerpted from “Putting an End to Women’s Global Slaughter: Bleeding to Death http://www.midwiferytoday.com/enews/enews1202.asp#main
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I guess my opinion is that these are the opinions without the benefit of evidence. The statement from Dr Odent seems to be in accord with evidence we have, the statements in the second quote are not consistent with the results of randomized trials on the effects of active management of the second stage.
I would also say that I tend to discount the views opined in a publication titled so dramatically, as such a publication rarely is of much quality.
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Let me clarify the last point –
A lot of us feel very strongly about whatever view we hold, no matter what our educational background is.
I have trouble with publications that choose to push their point with a title that is emotional and dramatic, rather than just titling the publication as what it is and letting the reader decide. If the publication has data that is rigorous and compelling, that should be enough. My experience is that publications that title themselves dramatically tend be more opinion based and data-poor.
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Nicholas, that is an interesting comment, #67 (great idea, numbering system) re active management. Please could you post some references re the RPTs that show that active pit decreases PP bleeding?
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Dear Dr Fogleson,
Congratualions on your excellent and compelling lecture. Interesting that so far the blogs all seem to be form midwives. Here in the UK there are also a few obstetricians and paediatricians who have realized that routine interfering with physiological transition at birth is not a good idea. The evidence is that the system has developed over millions of years and if anyone thinks they can improve on it then it is up to them to provide the RCT evidence. Until that comes available (and I very much doubt it ever will) we have to rely on physiology. When there is a routine procedure and the baby does not breathe then we can never really know whether or not the routine prociedure was to blame. There is some evidence from your part of the world from the a randomised study done on preterm babies in the 60’s. They found that many more babies in the quickly clamped group needed resuscitation. The paper was therefore criticised for not being properly randomised and having more asphyxiated babies in the quickly clamped group. (I can’t get the reference straight off NEJM I think).
However much more recent and reliable evidence comes from the recent paper by Wiberg et al in the BJOG. They showed just how much oxygen is in the umbilical vein and showed that 3 acidotic babies recovered fine without any “resuscitation” just using the maintained placental circulation. This paper is very informative. They study did show that the pH in the cord blood falls while f the placental circulation remains intact. Their explanation for the fall was a release of trapped lactic acid within the baby’s circulation. If this is true then leaving the circulation intact will allow the baby to distribute the lactic acid into the blood volume of the baby and placenta rather than just the reduce d blood volume of a quickly clamped baby. A low pH can adversely affect the blood brain barrier.
The other recent paper by Farrar et al also in the BJOG agrees with you that an oxytocic has no effect on the volume of the placental transfusion. They also showed just how variable the volume can be. Although we do not know the baby’s weight, we can ask ourselves what the baby that had a transfusion of 200mls would have been like if it had had immediate cord clamping!
There is a lot of stubborn confusion within the academic colleges. Here is a transition from a radio interview I did at the end of last year.
5 live Breakfast
Thu, 11 Nov 2010
SF Now a retrired medic is urging fellow obstetricians and midwives not to clamp babies’ umbilical cord straight after they are born. Dr David Hutchon whose warning has been published in the British Medical Journal says its time for the UK to follow guidance from the World Health Organisation to wait a few minutes before cutting a babies cord.
DH 160 mls of blood can be potentially trapped in the placenta and this could represent 35% of the babies total blood volume. There’s never really any need to rush to clamp the cord and face a baby with a blood loss of 35%.
SF Well lets talk to consultant obstetrician Patrick O’Brien form the Royal College of Obstetricians and Gynaecologists. Good Morning Do you agree there is never a need to cut the cord?
PO David Hutchon makes a good case for sort of routine delaying clamping of the cord, I think that as a good case, but I think whats holding people back is that there are certain situations where delayed clamping of the cord is an issue, so for example at caesarean section when the mothers womb is open and therefore bleeding if you delayed for two or three minutes that could lead to the mother losing another couple of hundred mls of blood which could make a difference to the mother. Or for example a baby that is born very preterm very premature, often these babies need resuscitation quite urgently and therefore obviously delaying would make quite a difference to that baby as well.
SF And when it comes to guidelines on this is it down to the discretion of the clinician whether it is someone like yourself or the midwife, in a normal delivery I mean, is it down to the discretion of you or a midwife or are there set guidelines?
PO The guidelines specify really this package of delivering the placenta which is clamping the cord early, giving some medicine some hormone to help the placenta to come away and sort of pulling on the umbilical cord quite early. Now the whole package of that is designed to reduce the amount of bleeding the woman has, and we know that that reduces the women’s chance of bleeding by about two thirds. But there’s no doubt that if all is well and the mother’s not bleeding and the baby’s well, I think Dr Hutchon’s point is well made and it is perfectly reasonable to wait at that stage.
SF And what about in the developing world organisation advises this often in the developing world, isn’t it, is that because of the benefits to the baby?
PO I think thats right. In situations that anaemia of the baby is a big issue then delaying clamping of the cord becomes more important particularly in developing countries also very premature babies who are at an increased risk of anaemia.
SF Thanks for talking to us this morning, Consultant Obstetrician Patrick O’brien.
I just wish we could have a lot more logical debate and discussion from obstetricians and paediatricians – they are the ones that are largely doing or promoting early cord clamping. I am a co-author of the recent Cochrane review which showed that the timing of the oxytocic has no effect on the efficacy of “active management of the third stage.” After almost 40 years in obstetrics, some in developing countries, I have my doubts that active management of oxytocic, cord clamping and controlled cord traction really has much benefit in preventing PPH. I am also the co-author of an as yet unpublished Cochrane review of the timing of cord clamping and there is a suggestion from the data that cord drainage (ie DCC) leads to less blood loss. It certainly shows that early cord clamping is not a necessary element of active management.
It may seem logical to whip the baby over to the resuscitaire when it is not breathing at birth and it is certainly the only way the baby may get some oxygen if the cord is clamped. However there is no evidence that there is any need to remove the baby is the cord is left intact. There is no RCT evidence that a baby benefits from resuscitation (mainly PPV) rather than doing NOTHING – and when I say nothing I mean NO interference with the cord. Once the neonatologists realise this they may look on immediate cord clamping in a different light. I too am passionate about EBM but it must be doing something for which there is evidence of benefit not continuing to do something until someone shows it is a good or bad thing. If there is no RCT evidence that an intervention is beneficial we should not do it, no matter how traditional it may be.
Here is the program for the RCOG conference. We want to see as many midwives and paediatricians as possible.
Wednesday 1 June 2011
9.00am REGISTRATION AND REFRESHMENTS
9.30am Welcome and introduction
Mr David Hutchon, Consultant Obstetrician, Darlington Memorial Hospital
Session I: Cord pathologies
Chair: Dr Susan Bewley, Consultant Obstetrician, St Thomas’s Hospital, London
9.40am Abnormal cord insertion: prediction, prevention, and management of
complications of velamentous insertion and vasa praevia
Dr Christos Ioannou, Clinical Research Fellow, John Radcliffe Hospital, Oxford
10.00am Medical management of intrapartum cord compression
Professor Sir Sabaratnam Arulkumaran, Head of Obstetrics and Gynaecology,
St George’s, University of London
The evidence base for third stage interventions to prevent post-partum
haemorrhage
Dr Hora Soltani, Reader, Sheffield Hallam University
10.40am Discussion
11.00am REFRESHMENTS
Session II: Physiology of Neonatal Transition
Chair: Professor Sir Sabaratnam Arulkumaran
11.30am Measurement of redistribution of blood during third stage
Dr Diane Farrar, Research Fellow, Bradford Institute for Health Research
11.50am New strategies for supporting transition and resuscitation at birth
Professor Colin Morley, Retired Professor of Neonatal Medicine, Royal Women’s
Hospital, Melbourne, Australia
12.30pm Discussion
12.50pm LUNCH
Session III: Influence on Practice
Chairs: Dr Andrew Weeks, Senior Lecturer in Obstetrics, Liverpool Women’s Hospital
1.50pm Clinical experience in a unit with a policy of clamping at three minutes
Dr Andrew Gallagher, Consultant Paediatrician, Worcestershire Royal Hospital
2.10pm Is there a place for cord milking? Implication of the timing of cord clamping on
the premature neonate
Dr Heike Rabe, Consultant Neonatologist, Honorary Senior Clinical Lecturer, Brighton
and Sussex University Hospitals NHS Trust
2.30pm Timing of cord clamping: implications for the obstetrician
Mr David Hutchon
2.50pm Discussion
3.20pm REFRESHMENTS
Session IV: The Future Implications of Timing and
Documenting Cord Clamping
Chairs: Mr David Burrowes MP, Member of Parliament for Enfield Southgate
Professor Peter Braude, Head of Women’s Health, Kings College London
3.50pm The political and moral economy of cord blood banking
Dr Laura Machin, Research Fellow, University of York
4.10pm Current and future challenges in cord blood stem cell transplantation
Professor Alejandro Madrigal, Professor of Haematology, Royal Free Hospital, London
and Scientific Director, The Anthony Nolan Trust Research Institute, London
4.30pm Discussion
5.00pm CLOSE
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Thank you for your comment and information! Good luck with the meeting!
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Thank you Nicholas, for clarifying and for your kindness to respond my questions .
I am very glad that you gave Grand Rounds on Delayed Cord Clamping and that you did it so brilliant. I´m sure you have convinced many of your colleagues.
I myself have been advocating delayed cord clamping since the 80:s , and was first applying the tentative method for many years. But it was not until I changed method and became emotional and dramatic that I finally succeeded in pushing through guidelines for cord clamping here in Sweden, which were introduced in October 2008.
My next goal is Neonatal Resuscitation with the cord intact. I still use the emotional and dramatic method, and now I’m starting to see the first signs that it yield results.
I no longer work in maternity care, but I do this out of moral reasons
as a private individual. So I have nothing to lose and can therefore afford to be quite cocky 😉
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Dear Dr. Fogelson,
I would like to ask one specific question and then I would like to add couple of thoughts.
Do you have any thoughts on the cord clamping vs. cord blood banking? Your video is the first time I see research that shows statistical data proving that waiting to clamp the cord could offer significant benefits. I have read and heard previously that one should wait to clamp umbilical cord, but it was not clear how much of a benefit it would create. Previously, I was told by health care professionals that one cannot have both: waiting until the umbilical cord stopped pulsating and banking the cord blood; one had to make the choice on what would be more beneficial. Considering the research on the benefits of waiting to clamp the umbilical cord, what would be your opinion on whether in such case it is ever “worth it ” to do the cord blood banking? (I must note that to me the cord blood banking seems to be similar to an “insurance,” you do not know if you need it, and likely you would not, but if you do, and do not have it, the outcome could be fatal)
I think someone hav expressed similar opinion but I still would like to say that I am very impressed to see an American OBGYN, who is open to changes in the common practice and who accepts the evidence from the research, even if its means less intervention (and use of a more “natural” approach).
I think that America, unfortunately, has gone the wrong road with active labor management, rare use of midwifes (8% is the national average) and doulas (3% is the national average). It is a great place to be for women who have complicated pregnancies and deliveries, but for others – the birth experience becomes a horrible one, all when a woman is quite capable of remembering quite painful labor as one of the best days in her life.
I cannot understand why, when statistics and research support natural child birth, American doctors continue to “manage” uncomplicated labor. Why, for example, are women not only not educated that supine position during labor is the worst one to be in, but also are forced to labor in such position?
I hope that your will continue to research the other aspects of labor and birth practices used in U.S., to promote the evidence-based approach to labor, and I hope that your voice, as a voice of professional OBGYN will be heard by other professionals across the U.S.
Thank you for the work you do!
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In short, delayed cord clamping and cord blood banking are mutually exclusive. Banking requires a maximum amount of blood be stores, delaying clamping aims for a a maximal reduction in residual placental volume. Banking may provide some benefits in the future, but preserving stem cells in the infant at birth may also be important in preventing future diseases. Its all a bit theoretical, but in my mind delayed clamping and placental transfusion makes the most sense.
I appreciate your compliments, but have to defend American obstetrics a bit. We have a very high take rate for epidurals, which then leads to active management and supine positioning. Active management wasn’t invented here either – its acceptance comes from trials originating in the UK. These trials showed a decrease in cesarean section rate with the use of active management over expectant management of labor.
Everybody has a different view of pain. Birth seems to be the only case where a subset of people view pain as a good experience. A large subset are happy to have birth be a pain free experience, and see the provision of such an experience as a beneficial evolution of medical care.
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I appreciate your reply. And your opinion/adivce about the cord blood banking vs. cord clamping. I have to agree that now it seems to make somewhat more sense to wait with clamping the cord
As far as the pain and epidural rates. I agree that once a woman has an epidural the active management is inevitable. But should epidural be available for normal labor? Would you prescribe a narcotic to someone who has nothing abnormal with their body?
From what I heard and read women are not educated about the negative effects of epidural and its risks (of course there are general statements, but nothing like statistics showing increased labor length, increased cesarean rates, increased rates of episiotomy and tears, baby distress, etc…), further the image of birth that is given – is that it is pain and intolerable pain; further the women are given no skills and no preparation to cope with such pain.
I think no matter how hard men try, it is impossible for a men to imagine what the birth feels like. The comparation that you make of birth being the only painful experience that is good is not really a good one. All other painful experiences are because something goes wrong, the birth – is the normal experience for the body. I hope you understand what I mean.
From the way birth is presented in our society women have nothing but fear of it, it is something they want to get done as fast as possible. And I cannot blame them. The image is to blame and society as a whole, but not an individual woman, who when in labor and with no skills and no help to cope with labor, agrees to epidural that is strongly offered by a nurse.
I know that my personal experience was that because of the research I read about I wanted to try to have a natural child birth, but I also was very afraid of the labor pain, because the image I received from others was that labor was Pain, terrible Pain you’ll want to forget. The reality was different.
Of course, epidural is a great invention. If for some reason a woman has 2 day labor, she would be exhausted and epidural main give some relieve, and help such woman avoid cesarean section.
The labor is not this terrible pain that you can compare to kidney stones or something. When the labor is allowed to go naturally and when the woman is in the supportive relaxing environment (and I have to say this is vital) the woman does not feel the pain in the same way. The endorphins secreted by the body are great at “pain relief”. You feel the strong pain and yet you head is “fuzzy”, and the emotions when the baby is born are much stronger, just as is the attachment to the baby. (I remember reading an article, sorry I have no citation for it, that when cats were given epidural it seemed they failed to recognized that just born kittens were theirs, they either abandoned their kittens right after birth or ate them).
I think the first thing that should happen in order for majority of women in US to give birth “normally” is for OBGYNs to be able to comprehend and recognize that it is not terrible to feel the pain of labor, and that labor pain can be managed without drugs very well; so that OBGYN can in turn empower women.
I think something to consider is the statistics of C-sections in other countries, the statistics of home birth and births with midwives in European countries.
“These trials showed a decrease in cesarean section rate with the use of active management over expectant management of labor.” I am sure there was such study, but I hardly believe that its results actually represent reality. From everything I have read, the cesarean statistics is much higher with active management.
I do not defend the “natural childbirth” simply because of the word “natural”, I believe in research, and evidence. But just as you reasoned that waiting to clamp the cord to get full benefits of cord blood made more sense then cord blood banking and its potential to offer treatment for some deceases, I see more logic in allowing the labor to proceed naturally, and obtaining all benefits of it (emotional, less tearing, faster labor, less chances of cesarean, less chances for baby distress and other baby having other problems, faster recovery, less tearing, easier breastfeeding start) vs. seemingly “pain free” epidural birth with use of drugs, high chances of tearing, more pain (because of supine position) and thus need to use oxytocin with its risks for stronger contractions and baby distress, and consequently leading to stronger epidural, higher chances or prolonged labor, c-section,…
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Thanks for your comments. Your ideas are shared by many, and represent one particular view of labor and delivery. Plenty of folks see the pain of labor as a negative experience that they would be happy to avoid. One of the toughest things I have found in life is to accept that not everybody things like I do 🙂 That fact that you see the pain of labor as a good kind of pain is your view. As an OB, I really don’t care if someone wants an epidural or not. I’m not the one feeling the pain. The demand is from the patient, not the OB.
As for the study – I’ve never seen a mom with an epidural not realize her child was hers, not had a mother try to eat her child. We’re not cats.
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Having birthed naturally twice and planning another natural birth, I may be able to explain the pain thing.
First, let me say I have fibromyalgia, which perhaps paradoxically gives me both a low pain threshold and a high level of pain tolerance. I feel pain early, but since I put up with it so often, my ability to tolerate pain over time may be higher than many people. That said, I do reach for pain relievers for injury, illness, dental work. Drilling my teeth? Knock me out. Childbirth? Nope.
But I don’t reach for narcotics or ask for an epidural if I’m trying to do something physical, even if it hurts. The idea of trying to run a race numb or dopey would be crazy. I find it uncomfortable to walk right now due to pelvic pain in pregnancy, but an epidural or stadol wouldn’t make walking any easier.
My first child’s birth, I was languishing at 4-ish cm, when my mother dragged my whiny self out of bed and got me walking, rather than listening to me asking for something to “let me sleep”. 2 1/2 hours later my baby was born. Drugs wouldn’t have helped the way tromping around the hospital did, and I wouldn’t have been able to stand within moments of the birth and move the doctor out of the way to be able to see my baby on the (totally unnecessary) resuscitation table.
My second child’s birth, at home, in water, was extremely painful, due to a 14.5 inch head with craniosynostotis and a congenital issue that made the crowning diameter closer to 13 cm than 10. The head did not mold. But because I was not numb, or my cognitive or motor functions inhibited, I was able to feel exactly what I was doing, know that pushing on land (upright, squatting, toilet, many different positions) wasn’t working at all, get into water, allow my pelvis to open, and push that baby out anyway.
The other issue is that pain meds seem in many ways to delay discomfort. Sometimes in obvious ways, and sometimes in subtle ways. If a baby doesn’t have a well-coordinated latch due to IV narcotics, then I may be trading hours of “taking the edge off” for days or weeks of nipple pain, worry about weight gain, etc. If I have an epidural, and my knees are ratcheted so far back that it overstretches my pelvic ligaments, or there’s a leak and I get a spinal headache, I could be looking at months worth of pain. If either intervention causes heart rate issues for the baby or breathing issues for the mother, and a c-section is needed, then we’re trading that temporary pain relief for a few hours of labor for a much longer surgical recovery.
I’d rather put up with normal pain in labor, even severe pain in labor, and be able to get that baby out and be DONE after, than deal with longer-term potential consequences of pain relief. That’s not illogical, that’s using my higher functions and applying the concept of delayed gratification.
Even having pain after pushing my second out due to how far my pelvis had to open to get her that way, I at least knew that it wasn’t because I’d had pain medication that I was feeling that way.
Not to mention that while labor wasn’t exactly fun with my first, pushing her out was one of the high points of my life, and the hormonal “rush” of that normal delivery is something I will never forget. Delayed gratification. The reward is there.
I understand why women ask for epidurals. That second birth HURT. It was just extraordinarily painful. But given how many benefits we were able to get from NOT having medical intervention, I will never regret birthing her naturally and letting that cord stay.
As for me… my placentas both delivered exactly the same way. I declined to lie down after the baby was out, and had an urge to stand up about 5 minutes after baby was born, and the placenta fell out, surprising my attendants. The look on the nurses’ faces was priceless that first time. The last thing I want as a mom is someone messing with me during that time.
My first had her cord clamped within seconds and was anemic within 4 months of birth. I’m still angry about that, as delayed cord clamping was important to me. It’s a huge part of why I birth at home, because it was the only way I could guarantee that my priorities at birth would be respected.
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Thank you for addressing all of my comments. I appreciate that you acknowledge my opinion, and most importantly that there are many holding such opinion. I understand that each person has a right to have an opinion and beliefs.
Such discussion can go forever, it seems, but I would like to make the last comment – you may not be demanding the patient have an epidural, but not all OBGYN are the same way. I switched providers for exact reason that OBGYN only accepted the “birth” in the way he saw it proper, and part of “proper” was a “c-section,” or at least with an epidural, when a mother is calm, watching TV, looking through magazines.
As far as the kittens are concerned :), I was not really thinking – “mothers eating their babies”- when I wrote that, we humans have a little more intelligence than cats 🙂 so mothers are likely to understand better that babies actually belong to them 🙂 But in my opinion, there is definitely some truth to it, and the level of attachment mom has is affected.
Thank you, and while I may disagree with you on some ideas, I sure hope that there will be more OBGYN in U.S. who share your research-evidence based approach to labor.
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Dr. Fogelson, could you pretty please comment on the discussion about cord clamping and oxygenation on this recent post at the Skeptical OB? http://skepticalob.blogspot.com/2011/03/watch-how-and-why-homebirth-increases.html
It is probably nearly halfway down the page. They are discussing a video of a homebirth, including a baby needing resus. There’s some confusion about the benefit of delayed clamping, vs. performing resus correctly and swiftly. Thanks so much, if you get a chance to comment!
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Erk! I’m not going to let that blog do bad stuff to my blood pressure. *findahappyplace*
I think it’s the alter ego of Dr.Fogelson –
By day – affable, evidence-based, progressive clinician;
By night – arrogant, manipulative, reactionary harpy – and as such he will be unable to comment. He may say that collegial etiquette prevents it, but I think it’s a Jekyll and Hyde scenario.
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Ah.. I don’t have the time to be Dr Fogelson AND Dr Tuteur. Just being me is tiring enough.
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PLEASE Dr. Fogelson,
I would love to hear YOUR opinion of Dr Amy’s “cord clamping and oxygenation” post.
Quoting her:
“Why don’t we ask Dr. Fogelson whether he thinks you are accurately representing what he says? Do you promise to abide by his assessment of whether or not you are “educated” on this or any other topic?
I assume not, because he would rip your self-regard to shreds.”
This comment from her was made following my (Kim L. Mosny, CPM) post:
“Listen to Dr. Nicolas Fogelson speak SPECIFICALLY about oxygenation in the first minutes after birth… [fast forward to 11:20 on this video] Certainly listen to the whole lecture, but the point is that leaving the mother/baby/cord/placenta undisturbed immediately after birth is beneficial and is biologically and naturally what would happen if others would not interfere.
His points are made that fetal-to-neonate circulation (the fetal-neonatal cardio-vascular transition) is a gradual change and the neonate DOES benefit from continuing to receive oxygenated blood from the placenta (yes, his/her heart is the pump that brings that blood into the body from the placenta) in those early seconds to minutes after birth.
[fast forward to 11:20 on this video]
Natural Birth Advocates support delayed cord clamping because to interfere is not biologically appropriate nor intellectually sound.”
Please let us hear your opinion.
Thank you.
Kim L. Mosny, CPM
Home Birth Midwifery Service
Midlothian (Richmond), VA
http://www.RichmondMidwife.com
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I wonder if the active management of third stage has effectively skewed our existing data on ‘natural’ neonatal vitamin K levels. Rather than delayed cord clamping creating a requirement for less vitamin K,as queried by a reader earlier, could it theoretically negate the need for it altogether?
I don’t have huge issues with vit K administration, but I can’t help but wonder why nature would have had us evolve to be ‘deficient’ in something – maybe our obstetric practice has shifted a physiological norm into a pathological deficiency.
Also, if I was benevolent dictator of everywhere, we wouldn’t be using the word ‘delayed’ because to me it has connotations of being abnormal or tardy. Can we think of a better term? Lets, go a step further, logic dictates that a non-pulsating cord will have no effect on neonatal blood volume, so do we even need to clamp and cut the cord at all?
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What do you suggest? Shall we leave the cord and placenta on the baby until it rots away? I suppose some think that’s a good idea, but sometimes there’s too much of a good thing.
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Well, lotus birthing (see, I’m all about terminology!)is a valid choice, although admittedly not a common one. The placenta is rubbed with sea salt and essential oils, then stored in a bag until the cord rots away and drops off, so there is no more mess than the conventional way. And after all, a clamped cord necrotises just the same way.
But seriously, I suppose my thinking is more along the lines of “why the rush to clamp and cut before the placenta is even delivered”. I don’t have a preference, but I’ve had placentas appear before I’ve had time to clamp and cut. Is there a clinical indication for an optimal timing?
And how about vitamin K?
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Link to an article on Lotus Birth by Dr Sarah J Buckley:
http://editor.nourishedmagazine.com.au/articles/lotus-birth-a-ritual-for-our-times
Dr Buckley is a family physician, with qualifications in GP-obstetrics. Her passion for birth, delayed cord clamping, breast feeding and mothering has been fueled by her personal experiences with her own children, who were all born at home, with Lotus Birth.
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I think ‘ritual’ is a very good word for lotus birth.
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Duhhhh! What a wonderful presentation of evidence to support what nature does already (LOL) I am a CNM who was involved with resident training and had a devil of a time convincing MDs that delayed cord clamping was at least not harmful and in fact beneficial. Despite presentation of studies to that effect, had a hard time changing the mind of OB’s who “had always” clamped immediately and somehow thought that justified the practice.
BTW – not to be critical, but in future presentations, I have two suggestions. 1. OB’s, Family Practice, AND CNMs deliver babies in this country and 2. you sound alittle condescending of us “naturalist” types. I have been a CNM for over 10 years and believe that I provide evidence-based practice and support women in informed decision making. Pregnancy and childbirth are “natural” processes.
Thanks again for a very interesting and informative summarization of the data. Hope your OB collegues take note.
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I know a bit of the talk came across that way, it wasn’t my intention. The audience was all physicians. I think people think that laypeople refers to non-OB providers, when it doesn’t. As for being condescending to naturalist types, take it as you will. I’m a science based physician, and have great respect for anyone that practices in a way based in science, evidence, or at least a true understanding of physiology. When someone practices based on a near religious belief in the natural process, I have less respect for that. The bad things that can happen in pregnancy are also natural.
A lot of my colleagues have changed practice, and almost all the residents have adopted the idea. One of my residents took it on herself to setup a meeting with the nurses to pass the idea on. Going viral! The youtube video has been seen a few thousand times as well.
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Fascinating blog! As someone with a (non-medical) science background, I get frustrated with the lack of scientific understanding in many online discussions about labor and birth and I look forward to exploring your site further.
I’m an O+ mom with three type B kids and my second and third babies dealt with ABO incompatibility jaundice. One of my doctors mentioned that immediate cord clamping can help in this case by reducing the number of maternal antibodies that make it into the baby. What is the current thought on this issue — I presume that this would outweigh the benefits of delaying cord clamping?
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That is an interesting point that I had not considered. Its rare, that we know what the blood type of the infant is going to be, however. If you were O and the father AB, then there would be a certain possibility of short term ABO hemolysis. Delayed cord clamping may very will impact this to a greater extent for this reason.
I’m working on a randomized trial in preterm neonates, maybe we’ll look at this idea. It wouldn’t be so hard to do and it would be interesting.
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The heart is the first organ to begin functioning in the embryo, and the anatomy of the heart during gestation is totally different from what it must become after birth. The fetal heart has two valves (the foramen ovale and ductus arteriosus) that ensure blood flow to the placenta as the respiratory organ. At birth these valves must close to redirect blood flow to the lungs. As long as pulsations persist in the umbilical cord, these valves have not completed their closure. Clamping the cord while fetal circulation to the placenta is ongoing after birth is dangerous.
Merkle and Gilkeson have reported finding remnants of fetal circulation in people in their 40s and 50s (Merkle EM, Gilkeson RC. Remnants of fetal circulation: appearance on MDCT in adults. AJR Am J Roentgenol. 2005 Aug;185[2]:541-9}. Could so many reports of sudden death of teen-aged athletes be related to failure of the heart to change its anatomy at birth?
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Um, your fetal physiology is incorrect. It is perfectly normal for the ductus arteriosus to remain patent for weeks, although it should be mostly closed within 24 hours. That’s why the paeds don’t get het up about a murmur in an otherwise normal neonate until after 24 hours.
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There’s a lot more to the transition from placental to pulmonary circulation that just the DA and the FO. The cessation of blood through the cord is because of constriction of the umbilical arteries in the cord, not the closure of either of these cardiac structures. The umbilical arteries come off of the internal iliac arteries in the mature fetus, far downstream of the heart.
Everyone has remnants of fetal circulation. I see them every time I do laparoscopy – the urachus is the remnant of the umbilical vein and I identify obliterated umbilical arteries with every retroperitoneal dissection. Sometimes these vessels are still open in adults to some extent. As for the relationship between this and young athlete sudden death? There isn’t any that I am aware of, or any physiologic reason to believe there would be. Most of these kids have hypertrophic cardiomyopathy, I thought. Not my field though.
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Modern obstetrics is rife with rituals. They are hidden because they are underpinned with authoritative knowledge and are therefore considered ‘functional’ ‘rational’ and ‘scientific’ despite a lack of evidence supporting these assumptions. Immediate cord clamping is a ritualist practice.
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Really? I think of a ritual as a set series of actions that people ascribe some meaning to. Immediate cord clamping has no meaning. Its just a habit people got into.
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Ritual is ‘an established or prescribed procedure’. The function of a ritual is to create a sense of order during life transitions and to transmit and reflect cultural values. Check out the work of Robbie Davis-Floyd re. US obstetrics and rites of passage.
I’m currently writing a thesis using ritual theory to explore midwifery practice during birth.
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So is any ‘established or prescribed procedure’ a ritual? Seems a bit of a broad definition to me. I tend to shower every morning, but I wouldn’t say I have a ritual. Its just something I do, for the individual purpose that it serves.
Ritual is a good word for lotus birth, because for those that practice it, it is reflecting some sort of cultural value. Whatever benefit it provides is its is promotion of that culture value, and can’t really be objectively measured. Some find it desireable, and others would find it culturally unappealing, like various other rituals.
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The definition of what constitutes a ritual is open to debate (just written a few pages on it!). Lotus birth is a ritualistic and noticeably so because the cultural values it transmits are ‘alternative’ to the authoritative cultural values of current Western birth knowledge. Until recently shaves and enemas were ritually administered to women. Not only did the practices have no rationale to support them – they also served to transmit the cultural messages of the woman as ‘unclean’ and were part of the admission to hospital rites which transferred ownership of the body (via practices, gowning, hierarchical interactions etc.).
There remain many rituals surrounding birth – most hidden because they reflect the dominant cultural values.
‘Behaviour in hospital is not always as rational and scientific as it would seem. Much that occurs in obstetrics is heavily ritualised… We do not regard the practices surrounding childbirth in our society as ceremonial or ritualistic, but may the ritual be hidden from us only because we are so hypnotised by the apparently rational assumptions behind them that we do not even begin to seek further explanation?’ (Lomas 1978, p.174)
What messages are being transmitted by immediately separating mother and baby and handing the baby to a gowned up hospital representative to clean and assess?
Happy to share the findings of my research but because it is a qualitative study the findings are not considered as valuable within our culture as quantitative research with its claims of objectivity 🙂
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Chimpanzees practicing “lotus birth”.
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I prefer ‘choice’. If it does no harm, and the alternative proffers no benefits, then why not offer it?
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Have you seen this YouTube – “The natural caesarean” ?
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Dr Fogelson, I would like to know your opinion on randomized cord clamping trials; Do you consider it ethic to apply non evidence based interventions (which early cord clamping is) on babies, particularly when the researchers already are aware of that previous studies show it is harmful (Doctors swear to, “First, do no harm…” ) and when they withhold the parents this information, and additionally deny them to opt delayed cord clamping. This is actually the case with a recent study here in Scandinavia. “Crazy Scandinavians” you know 😉
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> Do you consider it ethic to apply non evidence based interventions …. when they withhold the parents this information
1. We are already doing immediate cord clamping nationwide in the vast majority of deliveries. Its standard of care, even if its wrong.
2. research is by its very nature applying a non evidence based intervention, usually compared to another intervention that is more standard. If the evidence were there we wouldn’t need to do the research.
3. I don’t think docs are withholding anything. A lot of docs are unaware of the data, however.
So far, the randomized trials have supported delayed clamping, but they are still few and they are small. Its going to take more work to change practice nationwide.
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Thanks for answering my questions..
I refer mainly to the Scandinavian study I mentioned earlier. These doctors were actually withholding parents the already known cons, and they even denied them to renounce immediate cord clamping.
Honestly, isn´t it enough with all these studies that have already been conducted over the years?
And is it really necessary with randomized studies, where children and women are used as guinea pigs? Why not studies where nobody is sacrificed , cohort studies for example?
Given the overwhelming research about the potential harms of early cord clamping both WHO and FIGO have dropped the practice from their guidelines. But it is still widely done, in most developed countries.
It really is a mystery why they can´t just STOP doing this unethical premature cord clamping, which quack doctors started once upon a time.
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I think you’re getting a little over the top here, and being a bit offensive as well. The immediate clamping of cords started as an evolutionary process as part of a lot of different pediatric interventions. It was done without a lot of thought, and probably is the wrong thing to do, but is hardly quackery. Thoughtlessness perhaps.
There is not overwhelming evidence that immediate cord clamping is harmful. In fact there is hardly any evidence at all. There is _some_ evidence that delayed cord clamping is better, not enough yet to convince a world of physicians that the practice should be standard. The vast majority of docs still think it just doesn’t matter. They are probably wrong, but that’s where we are for now.
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Dr. Fogelson, thank you for responding to questions and comments. You are engaging in conversations, which is so helpful. I have many questions, but first on that posed by Linda Morge on randomized control trials. Standard care is now to clamp the cord immediately after birth, but this has not always been the case. When it was first pointed out to me that my son’s resuscitation was begun after his cord was clamped, I immediately went to the medical library (at Harvard) and pulled first one then another and another old textbooks off the shelf. Up to the 1950s they all taught that the cord should not be clamped until pulsations had ceased.
Then Apgar introduced her scoring system, which appears to have been based on clamping the cord within one minute to preserve the “sterile field” for surgical repairs (see Apgar et al. JAMA 1958; 168[15]:1985-9). Apgar et al. noted that many obstetricians still practiced “slow birth” waiting for pulsations of the cord to cease. Among those were Landau et al. (see Landau et al. J Pediatr Apr 1950; 36[4]:421-6), who were concerned about deaths following cesarean delivery and undertook a method of hanging the placenta above babies born by c-section to ensure full placental transfusion.
Landau et al. commented that immediate clamping and cutting of the cord after a cesarean birth was, “in marked contrast to the procedure during normal or vaginal delivery. At this time the cord is not clamped and severed until pulsations have ceased” [p423].
Landau et al. commented that in 87 sections done since instituting their technique to provide placental transfusion, there were no instances of respiratory distress, and that for this reason they did not feel justified in running a control series. To me this seems far more ethical than the current academic standard requiring random assignment of human subjects to groups to receive a treatment or to not receive the treatment. But Landau et al.’s method seems now to be forgotten because they did not want to subject any infants to immediate clamping of the cord after c-section. I hope you can comment on this. Thanks
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I think there is a difference between reality and idealism in this case. I agree that delayed cord clamping makes more sense, and that there is substantial evidence in support of it, particularly in term babies. Nonetheless, it is met with skepticism by the rank and file, and is not the standard in most countries.
There is data, but a lot of it is old, and only a few trials are randomized and large. Another problem is that the majority of the papers are published in pediatric journals which OBs don’t read. I think the YouTube video has had a substantial impact, given that many thousands of people have watched it. That’s probably has been as good or better than another publication in a journal.
The data in preterm neonates is compelling but still based on small numbers. Given the concerns we all have about not resuscitating an infant immediately after birth, we really do need randomized studies about preterm delayed cord clamping. We have one (Mercer) which is really good, but randomizes less than 100 infants, all from one small population. Its compelling enough for me, but to hit the mainstream we need more work and more publications in major journals.
Right now if I delay cord clamping and thus resuscitation in a 26 weeker most of the pediatrics folks get very nervous. It will take a lot of data before they come on board and feel that it is a good idea.
We also have to accept the possibility that when more data is published it will not show the benefit that Mercer found. I think that it likely will, but we don’t know yet. The compelling preterm data is still only based on about 70 infants. Not so many.
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The idea that it is somehow unethical to randomize patients is a classic error that has led us to great misdeeds in medicine.
Every time there is an idea, there is one particular group that feels so strongly that they think that it is unethical to randomize people away from what they believe in. Often this resistance leads to a failure for that idea to take hold, even when it was a good idea.
If people want delayed cord clamping to be standard, they must endorse and encourage the idea of further randomized trials. We have only a few trials, and any trial worth doing is worth doing more than once. The nature of statistics is that any one trial could be wrong. We needs lots. Any other position will not lead to lasting change in the academic community.
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“I think the YouTube video has had a substantial impact, given that many thousands of people have watched it. That’s probably has been as good or better than another publication in a journal.”
I could not agree more. This must be the best way to spread the word. I hope many DCC proponents will follow your example.
I think your lecture is absolutely brilliant, and am sharing the link of this blog post with as many people I can, above all obstetricians, pediatricians and midwives. And even expectant parents, on Facebook groups as well as many other websites.
And ripples are spread…
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Dr. Fogelson, thank you again for responding to everyone’s inquiries and therefore maintaining a conversation. Mercer and Skovgaard (J Perinat Neonatal Nurs. 2002 Mar;15[4]:56-75) reviewed a lot of “older” very relevant research, including concerns over thoroughbred foals (Mahaffey & Rossdale, Lancet. 1959 Jun 13; 1[7085]:1223-5) and initial lung inflation as the result of blood flow into the capillaries that supply the alveoli (Jaykka, Acta Paediatr. 1958 Sep;47[5]:484-500).
Do you know the work of Dr. George Morley? He pointed out to me the paper by Mercer and Skovgaard very shortly after it was published. He has recently examined Michigan birth records as an alternative to randomized control trials, comparing outcomes of children born in hospitals versus at home. I know there are reasons (medical emergencies etc.) why these are not directly comparable, but his findings are thought provoking and should point the way to more research of this kind. His paper is online at:
Click to access Birth%20Brain%20Injury%20PUB.pdf
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I have not read it in detail. Dr Morley’s work is interesting (and unpublished), but examining birth records is fraught with bias. There are ways to control for it, but only if you know what the element of bias is and if it is or is not present for each member of the study. That’s why birth record studies are ultimately better for creating hypotheses than actually answering questions. He should clean up the manuscript and publish it.
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Randomized Controlled Trials are considered to be the gold standard of current research, but what about evidence that has been in the medical literature for decades? The clamp was introduced as a hygiene measure. See: (1) Magennis E. A Midwifery surgical clamp. Lancet 1899 May 20; 153[3951]: 1373, and (2) Wechsler BB. Umbilical clamp. Am J Obstet Dis Women Child 1912; 60:85-6. Both Magennis and Wechsler gave instructions to apply the clamp only after all pulsations of the cord had ceased.
Banking of umbilical cord blood began in the 1930s (Starr, DP. Blood: an epic history of medicine and commerce. New York : Alfred A. Knopf, 1998). In 1940 William Windle gave a brilliant lecture on fetal blood formation and circulation (Windle WF. Round table discussion on anemias of infancy. Journal of Pediatrics 1941 Apr; 18[4]:538-547), and he stated emphatically:
“In view of the facts that the placenta contains one-fifth to one-fourth of the total fetal blood at birth and that all this blood does not pass into the infant at birth until after uterine contractions have had a chance to compress the placenta, we believe that 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…” [p546]
Windle then undertook experiments with monkeys (Ranck JB, Windle WF. Brain damage in the monkey, Macaca mulatta, by asphyxia neonatorum. Exp Neurol. 1959 Jun;1[2]:130-54). The intent was to create a primate model of cerebral palsy. What they found instead was a pattern of brainstem damage that resembled the pattern of bilirubin staining in kernicterus. Later Windle and his colleagues found that bilirubin only stains the brainstem nuclei damaged by first inflicting asphyxia (Lucey JF et al. Kernicterus in asphyxiated newborn monkeys. Exp Neurol 1964 Jan; 9[1]:43-58). This has been confirmed by at least two other groups of researchers.
Windle (Brain damage by asphyxia at birth. Sci Am. 1969 Oct;221[4]:76-84.) once more stated:
“…in any delivery it is important to keep the umbilical cord intact until the placenta has been delivered. To clamp the cord immediately is equivalent to subjecting the infant to a massive hemorrhage, because almost a fourth of the fetal blood is in the placental circuit at birth” [p78]
If the research of Windle is to be forgotten, what is to become of all the data obtained in sophisticated randomized controlled trials?
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You’re right there is a lot of basic science data out there, which in many cases as you note is in non-humans. Most of this data is basically lost to history, as it is not available in full text through online search, and the level of interest required to go searching through dusty books in a library is not reached by most. The sad truth is despite this data, right now most people clamp right away. Randomized trials can help change this.
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Thank you for your Grand Rounds Cord Clamping lecture.
My attention span is short but I was riveted for it’s duration and compelled to share it with as many people as possible.
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Just popping in to share We Can Be Much Kinder, an amazing video on delayed cord clamping
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Dr. Fogelson,
I watched your Grand Rounds with great interest, and as someone who already thought delayed cord clamping was probably a good idea based on the studies you reviewed and commonsense, I am very glad your videos have gone viral in the OB-world and will hopefully help practice begin to change soon on a nationwide scale. But I have a question (don’t think I saw asked in the above comments):
I am planning a VBAC in a few months, to be attended by a hospital-CNM practice. If all goes well, I won’t have a problem with my attendant delaying clamping. However, if I end up with an emergent c/s again (a definite possibility in my particular case), how can I get the OB who does the surgery on board with delaying clamping? When a cesarean is performed, are there additional risks to delaying cord clamping (for mother presumably)? It seems logical a surgeon wouldn’t want a patient’s abdomen opened any longer than necessary, but would a short delay really make a difference? Since I’m not scheduling a c/s, and I don’t go to the hospital’s OB practice, I assume my surgeon will be whomever is on call at the time (this is a teaching university hospital), so I won’t have the opportunity to discuss this ahead of the labor.
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We delay cord clamping at cesarean routinely in my cases, and a lot of my partners have followed suit. It isn’t difficult and doesn’t add a great deal of time to the case. The pediatricians that are routinely at cesarean need to be brought on board, though, as they will be waiting for the baby wondering why it is still on the field!
In the rare case of uterine rupture, I think it would depend a bit on the baby. If the baby is pale and flaccid, I’d strip the cord and hand it off. A baby that is bradycardic is not going to pump blood through the cord as well, and will benefit more from immediate resuscitation from pediatrics.
Most OBs are happy to delay cord clamping if you let them know. A lot aren’t aware of the data. Point them to the video and they will probably change their tune.
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Interesting to know the pedi might be more resistant than the OB! If a c/s happens this time like the first one, I won’t have time to have the OB watch the video–I only met her 20 minutes before the surgery. But if it’s really becoming that much more common, perhaps just requesting delayed clamping will be sufficient without a lot of extra convincing. Thanks for taking the time to reply. I’m glad to know there’s nothing that should preclude a c/s baby getting the benefit of all its cord blood (on a normal basis).
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If the baby is pale and flaccid, is it not possible to do resuscitation with the cord intact? And would it not be possible to “milk” the cord to get more blood from the placenta to the baby? With preparations, a table with equipment set near by, so the pediatricians can be able to do resuscitation with the cord intact?
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You are absolutely right and Patrick van Rheenen expalined how this is quite possible even with minimal preparation and facilities in the BMJ editorial just before Christmas. With luck the BASICS troley will be available from Inditherm in a few months time.
Significantly the BMJ Editor, Fiona Godlee is calling for a change in practice to delayed cord clamping.
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Dr. Fogelson,
For those obstetricians who consider the Cochrane databased to shape their practice how do you get them to look further than the current Cochrane Review that focuses on jaundice which is quite misunderstood in the general population as being normal for 50% of newborns.
{ 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}
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Sorry just to clarify that normal physiological jaundice tends to be seen as a problem rather than physiological in the general population.
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Hello I would like to see if you are interested in posting this widget of my peition on your site. Please let me know and thanks for your time. karalyn. This is the petition. http://www.thepetitionsite.com/1/stop-early-cord-clamping-now/
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I don’t really have a link out sidebar, so I don’t think I can at this point. Delayed cord clamping is clearly the way to go. People can certainly click through your comment.
In my experience I’ve never seen a cord pulsate for more than a few minutes. Several studies have shown that most cord umbilical arteries have spasmed off by 60 seconds. At this point, there’s no data to associate cord clamping with any particular neonatal or childhood disease, so some of your petition’s claims are pretty speculative at this point.
I appreciate the effort!
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The RCOG has just ammended its Greentop guideline on the p;revention of PPH on page 2 to include the following.
Four Cochrane reviews addressed prophylaxis in the third stage of labour for women delivering vaginally.The
first (Active Versus Expectant Management in the Third Stage of Labour)27 included five trials and found that
active management (which included the use of a uterotonic, early clamping* of the umbilical cord and . . . . . . . .
* Early clamping: The RCOG recommends that the time at which the cord is clamped should be recorded. Early cord clamping is defined as immediately
or within the first 30 seconds.The cord should not be clamped earlier than is necessary, based on clinical assessment of the situation. Evidence suggests
that delayed cord clamping (more than 30 seconds) may benefit the neonate in reducing anaemia, and particularly the preterm neonate by allowing time
for transfusion of placental blood to the newborn infant,which can provide an additional 30% blood volume. In the preterm infant (less than 37+0 weeks
of gestation), this may reduce the need for transfusion and reduce intraventricular haemorrhage.Delayed cord clamping does not appear to increase the
risk of postpartum haemorrhage.The timing of cord clamping needs to be made by the doctor or other attendant in the light of the clinical situation.
Early clamping may be required if there is postpartum haemorrhage, placenta praevia or vasa praevia, if there is a tight nuchal cord or if the baby is
asphyxiated and requires immediate resuscitation.A detailed consideration of the literature relating to the timing of cord clamping can be found in the
Scientific Advisory Committee’s Opinion Paper No. 14 (2009) at http://www.rcog.org.uk/clamping-umbilical-cord-and-placental-transfusion.
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I know Im late here, but I am curious-
My son had severe abnormal jaundice and hemolytic disease (I think is is what they called it) because of ABO incompatibility. I guess this is rare, but we spent weeks in the NICU and he nearly got an exchange transfusion- thankfully, the meds and lights worked, but it was a very close call.
With my next baby, assuming it’s full term, would DCC be a good idea? I don’t think they can tell ahead of time if it will have this, though we did monitor fetal arterial blood flow last time, so we had a clue it was possible. I saw a comment about this above, and wondered if DCC would be harmful to a baby with is problem.
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I think the answer is that we do not know but when jaundice is due to maternal antibodies which pass into the fetal circulation there is no reason to expect that a baby having the correct physiological amount of blood at birth will be any worse off as a result of the haemolysis which is taking place than a baby that has a smaller than normal volume. The proportion of red blood cells to antibodies would be expected to be identical. Clearly treating the baby with venesection – withdrawing blood – which is what early cord clamping effectively does would is not a treatment and would not be expected to help. Withdrawing blood and replacing (exchange transfusion) it with cells of a blood group unaffected by the antibodies will help. Indeed a baby that is anaemic as well as trying to cope with the jaundice of haemolyitic disease is likley to be in more trouble than one that has a normal Hb at birth. Anaemia is the cause of intra-uterine death in the fetus with very severe haemolytic disease and this is treated by giving a transfusion of red cells which will not be affected by the antibodies. Once the baby is born there will be no new production of antibodies. The physiological jaundice of a baby without antibodies is a completely different problem and being so common, even more common in breast fed babies, it is unlikley to have any serious consequences.
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Is there a YouTube video with the questions/comments as the end of the lecture? I find this is often the best part of a Grand Rounds.
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Yes, but I did not have release from those people to republish a video of them.
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Dr. Fogelson,
It is nice to see your interest and research on delayed cord clamping. My oldest was born at a free-standing birthing center in California run by an OB back in 1990. Cord clamping was delayed. My next 3 were homebirths attended by a midwife–in Hawai’i by the way. Of course, the clamping was delayed.
Thank you for trying to educate your peers.
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I have just found this elsewhere, and thought this might be a nice place to share it. I’m hoping that Dr Hutchon’s work will influence a shift in practice:
http://www.theadvertiserseries.co.uk/news/9068645.Trolley_saves_lives_of_newborn/
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PLEASE Dr. Fogelson, (see post #81 for reference)
I have repeated my post (#84) here because I think it got LOST up there…
I would love to hear YOUR opinion of Dr Amy’s “cord clamping and oxygenation” post.
Quoting her:
“Why don’t we ask Dr. Fogelson whether he thinks you are accurately representing what he says? Do you promise to abide by his assessment of whether or not you are “educated” on this or any other topic?
I assume not, because he would rip your self-regard to shreds.”
This comment from her was made following my (Kim L. Mosny, CPM) post:
“Listen to Dr. Nicolas Fogelson speak SPECIFICALLY about oxygenation in the first minutes after birth… [fast forward to 11:20 on this video] Certainly listen to the whole lecture, but the point is that leaving the mother/baby/cord/placenta undisturbed immediately after birth is beneficial and is biologically and naturally what would happen if others would not interfere.
His points are made that fetal-to-neonate circulation (the fetal-neonatal cardio-vascular transition) is a gradual change and the neonate DOES benefit from continuing to receive oxygenated blood from the placenta (yes, his/her heart is the pump that brings that blood into the body from the placenta) in those early seconds to minutes after birth.
[fast forward to 11:20 on this video]
Natural Birth Advocates support delayed cord clamping because to interfere is not biologically appropriate nor intellectually sound.”
Please let us hear your opinion.
Thank you.
Kim L. Mosny, CPM
Home Birth Midwifery Service
Midlothian (Richmond), VA
http://www.RichmondMidwife.com
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I commented on Dr Amy’s blog
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THANK YOU so much for your contribution to the discussion on Amy’s blog! I appreciate your professionalism and respect and…
…for NOT “ripping me to shreds” !!
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OMG!! You actually told Amy that she “fucked up” ? I am SO impressed !! WOW!! She needs that more and more from her peers!! THANKS!
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Dear Nicholas, I have just read most of the posts by you and Kim Mosny on Dr Amy’s site. Dr Amy seems to be very angry. Does she actually practice medicine or is she retired? Is she licensed? How many years of experience does she have in obstetrics? What is her publication history? Does she have an academic post, perhaps? Credentials and experience may not count for everything but perhaps are of interest when one is choosing a blog site to trust.
Thank you for taking the trouble to post in her discussion section and for your considered opinion.
Shane Marsh, Australia.
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Dr Tuteur is a retired obstetrician/gynecologist. She has no academic post that I am aware of.
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Quoting: “Dr. Amy Tuteur is an obstetrician gynecologist. She received her undergraduate degree from Harvard College in 1979 and her medical degree from Boston University School of Medicine in 1984. Dr. Tuteur is a former clinical instructor at Harvard Medical School. She left the practice of medicine to raise her four children. Her book, How Your Baby Is Born, an illustrated guide to pregnancy, labor and delivery was published by Ziff-Davis Press in 1994. She can be reached at DrAmy5 at aol dot com” http://www.blogger.com/profile/08496583576036722794
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Nicholas, with regard to O and AB incompatiblity, could a baby who had O negative blood , with a mother who had O positive, be jaundiced or have problems if the father had A or B blood, rh unknown, in the 1950s? This happened to me and I have never been able to work out why I was so unwell, according to my mother. She said I was born “yellow like a peach”. It was her second pregnancy.
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I tried to find the posts by Kim and Dr. Nicholson on the post at the link at comment 81, and could not find them. (This was the post about Rixa’s birth, from Stand and Deliver.) I didn’t find them after reading twice through all the comments. Could Dr. Amy have deleted them, or did I not look in the right place?
Susan Peterson
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Thank you so much for sharing this information ~ delayed cord cutting is something that has interested me ever since I was pregnant with my third child. I had my first two babies in the hospital, but my last two at home and did quite a bit of research before doing so. One of the things I came across was the benefits of not cutting the cord right away and was immediately intrigued. I enjoyed listening to your presentation and hearing about all of the studies done on the subject from reliable sources, and felt that you were very thorough in your explanation of why delayed cord cutting is beneficial to the infant, but I wanted to encourage you to also look into the benefits to the mother. I don’t know that there have been any studies done in this area, but I think it is something worth looking into. In the birth process uninterrupted, the placenta would be birthed before the cord is cut or clamped. I find the theory interesting that letting this process happen naturally (when possible, of course) would decrease a mother’s risk of hemorrhage after birth. Naturally, after a baby is born and is put on a mother’s chest (where an exchange of hormones occurs) and/or nursed, the body will recognize that the baby is no longer in the womb, but has now emerged from the mother. The third stage of labor now begins and the body begins the process of clamping off the blood flow to the placenta, the placenta detaches, and is then birthed. If we were to interrupt this natural process (i.e. clamping/cutting the cord) it is quite possible that this will interfere with the natural birth of the placenta (i.e. possibly delaying the body’s signals that baby has been born and in turn delaying the clamping of blood to the placenta). In a hospital setting, I do realize that death from hemorrhage is not common, as there are tools to treat this, such as pitocin, etc., but if we are not interfering with the natural process to begin with, we may avoid the possibility of this emergency all together. I did find it funny that you kept referring to delayed cord cutting as an “intervention”, because isn’t it really the opposite? Interventions, although sometimes necessary I’m sure, can often be the culprit for emergencies during labor/birth (at the hospital or otherwise).
I do hope to see you post more of your presentations in the future. You briefly mentioned at the end that delaying the cord cutting for premature or distressed infants is beneficial because they are still receiving oxygen through the cord, even if they are not yet breathing. I would love to hear you speak more about this. It would also be interesting to see a study done on whether or not this would affect brain damage occurrences in babies that have continued to receive oxygenated blood while receiving neonatal resuscitation, compared to the babies who are completely deprived of oxygen while receiving neonatal resuscitation.
I hope you realize how important the work you are doing is and how many babies and families that you have made a significant impact on through the knowledge that you are sharing. I wish you the absolute best in your career and the research that you continue to do. And keep sharing!
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Debbie –
The question of whether a baby continues to be oxygenated through the cord after birth is an important one, but at this point the answer remains theoretical. We have clear data on certain outcome measures, but no easy way to measure whether there continues to be gas transfer through the cord after birth. To me it makes sense that there is continued gas transfer for a period of time, but I don’t think we know definitively.
Infants start breathing, or try to breath, almost immediately after birth. An infant that does not try to breathe is usually depressed in some way, and needs to be resucitated. While leaving the baby on the cord makes some sense, one has to recognize that given that the infant is not doing well, up until delivery the cord was not doing a great job of delivering oxygen to the baby. One cannot assume that it is suddenly going to do a better job after birth. I think there are some situations where one could surmise that cord blood flow will improve after birth, such as a situation where the cord is severely compressed during the labor process (noted by variable decelerations in the heart rate tracing). I think there are other situations where one could surmise that the cord will not do a better job after birth, such as in a growth restricted fetus born to a mother with severe pre-elclampsia, as her placenta is damaged and isn’t going to get any better.
If a baby is born not breathing, we need to oxygenate it. I fully support the idea of trying to resucitate the baby with the cord intact in order to allow transfer of blood from the placenta to the fetus. However, I do not support the idea of significantly delaying transpulmonary oxygenation of a depressed fetus for that end, if the facilities do not exist to resucitate with the cord intact.
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Nicholas,
The Wiberg study BJOG 2 now shows quite conclusively that there is plenty of oxygen in the blood returning from the placenta for at least 90 seconds after the birth. 2.7 kPa is a lot more than the 2.5kPa which kept the mountaineers fully functional at the top of Everest as shown in the Caudwell Extreme Everest expedition. So I think we can say that normally there is pleanty of oxygen in the blood fcoming back from the placenta. By 90 seconds every baby will either be breathing or will have been whisked away to the resuscitaire OR resucitated with this oxygen supply supplemented by the placenta while ventialtion is started – as shown by Patrick van Rheenen in the recent BMJ editorial. I know which baby I would rather be !
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David Hutchon and the life-saving trolley , on ITV North East Tonight, UK
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Debbie you are spot on. Clamping the cord is clearly an intervention and the sooner it is done after birth the greater the intervention. There is evidence that early clamping does adversely affect the third satge of labour as far as the mother is concerned. I am the co-author of two Cochrane reviews which support this. The numbers of women in the trials are small so there is no overwhelming conclusion and the volume of a pst partum haemorrhage is very difficult to measure accurately. Logically if the placenta has less blood in it, it will be smaller and easier to be expelled. Peter Dunn, retired professor of paediatrics in Bristol did a little experiment looking at how easy it was to pull a placenta by its cord through a plastic ring. He found that with a marginal insertion the placenta came through the smallest ring. But he also found that the volume of residual blood in the placetna dictated the minimum sixe of ring that the placenta would come though. Pretty obvious but brilliantly simple and could easily be repeated by someone today. He used vaginal ring pessaries as the “rings.”
Nicholas is doing a great job and being in a University Hospital is in a strong position to change things quite quickly. The possibility that a baby with hypoxia, who’s circulation is rendered ischaemic because of the hypovolaemia of immediate/early cord clamping could go on to develop brain damage is something that needs to be taken very seriously, and those who continue to advocate immediate or early cord clamping when there is apparent hypoxia can only continue the parctice ethically if they are already launching a randomised controlled trial to show that their intervention of cord clamping is or is not causing any harm to the circulation and the short and long term function of the baby’s brain.
David Hutchon
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David – I’m somewhat less sure about this issue than you. A premature baby that is born hypoxic needs to be resucitated. We have data that delayed cord clamping is beneficial to premature neonates, but I’m unwilling to delay intubation and ventilation to that goal, if there are not facilities to resucitate while still on the cord. In that environment, I don’t think it would be unethical at all to cut the cord and intubate the baby.
I think the resucitation trolley that you mention is a great thing. I’d like to see that more widely used. Can it be used effectively at cesarean section?
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Nicholas,
The BASICS trolley is in development and its use will be included in planned trials of immediate/early cord clamping vs delayed cord clamping in planned RCT trieal in preterm babies. This means that unlike all previous trials of timing of cord clamping, babies who are thought to need resuscitation are not excluded and they will either get conventional mamangement with the cord clamped and the baby moved to the resuscitarie or resuscitaiton wile the cord remains intact on the BASICS trolley.
The trolley is designed to be used at all three modes of delivery including Caesarean Section. Actually it is assisted vatginal delivery that presents the biggest challenge, to get the surface for the baby in under the mother’s leg supports.
The trolley is the manifestation of a concept/procedure which has been used for many years, mainly by midwives, but also in some other research projects such as the one by Kinmond et al in the BMJ in 1995. Some resuscitation can easily be inititated by the mother when preparation is made beforehand. Sterile (at least for CS) is taken from a standard resuscitaire. This provides CPAP, blended oxygen or air or whatever the paed wants together with pressure controlled suction. For CS the paed needs to be scrubbed up and there needs to be a flat surface for the baby. Ideally a warmed surface but for a short time warmed towels are fine. This is also easy for normal deliveries but a bit tricky for forceps. However any of these difficulties can be overcome if there is the will.
Is it unethical to cut the cord and intubate the baby? Is there RCT evidence to support this management? What were the controls? Were the controls babies who were left with the cord intact, kept warm and allowed to transition naturally? Well there was no such trials according to Wyllie and Niermeyer writing in Seminars in FEtal and Neonatal Medicine in 2008. All the trials of neonatal resuscitation techniques have compared what was the standard of the time with the new proposal. There has never been any controls with no intervention at all. Of course you may say it is common sense that if a baby is not breathing at birth you should try to help it to breathe and I have no argument with that. Is it not also common sense that you do not cut off its only supply of oxygen, and render it hypovolaemic in order to get it over to a convenient machine over in the corner of the room, when there is the real possibility that it will transition/resuscitate itself and it is perfectly possible to help the baby to breathe, if necessary by intubation,by the mother’s side. It just needs a bit of forethought, preparation and lateral thinking. There does not need to be a compromise between an awkward resuscitation by the bedside and hypoxia and hypovolaemia sometimes quite severe hypovolaemia.
In 2008 at the RCOG Congress in London I presented a poster and an oral paper on resuscitation with the cord intact at caesarean section. Did anyone contact me since asking for more details or wanting to adopt/develop the approach – NO.
Nicholas, if most of your colleagues are convicned about the harm of cutting off the cord circulation too quickly at birth but some are not we need to explore why. What about your neonatal colleagues? Why are some of them not persuaded or at least willing to consider and investigate. You should contact the neonatal team at the Nationwide Childrens Hospital and research Institute in Ohio to find out what they are researching in cord calmp timing.
David Hutchon
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Dr. Ferguson, Dr. Hutchon, and others, I would be interested in your comments on the following points:
(1) Pulsations of the cord are evidence that fetal circulation is ongoing.
(2) If a baby is born at full term and with birth weight in the normal range, how can placental function be considered insufficient?
(3) Before the lungs can receive oxygen, the capillaries surrounding the alveoli must be filled with blood.
(4) The first description I have found of an umbilical cord clamp is that of Magennis (Lancet 1899 May 20; 153[3951]: 1373). It was introduced as a device to promote hygiene, and with instructions to use it only after pulsations of the cord had ceased. Another clamp was described by Wechsler (Am J Obstet Dis Women Child 1912; 60:85-6), again with instructions to wait for pulsations of the cord to cease before applying the clamp.
(5) For decades use of a clamp was highly controversial. Until the 1950s, textbooks of obstetrics taught that the cord should not be clamped until pulsations had ceased. Apgar et al. (JAMA 1958; 168[15]:1985-9) commented that they clamped the cord within the first minute to preserve the “sterile field” for surgical repair of the episiotomy etc.
(6) Landau et al. (J Pediatr Apr 1950; 36[4]:421-6) provided evidence that babies born by c-section were more likely to suffer respiratory distress because the cord was clamped immediately after birth to preserve the sterile field for repair of the uterine incision. They were able to prevent respiratory distress by removing the placenta and hanging it above the baby to promote placental transfusion. Secher et al. (Lancet 1962 Jun 9; 279[7241]:1203-1205) did the same thing.
(7) If “delayed clamping” is considered a new innovation, it is because the history of how the umbilical cord clamp came into being, and its original intended use, has been completely forgotten.
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My own answers:
(1) Pulsations of the cord are evidence that fetal circulation is ongoing.
I think so, though from a pure physics points of view I am not sure this is the case. If one has a pump leading to two circulatory systems, and one system is occluded, one would still be able to feel the cyclical pressure wave generated by the cyclical force in the pump even if there were no flow through the occluded tube.
One could certainly measure this though through doppler flow studies of the cord after birth. Perhaps somebody has published on this before. The difficult thing is knowing whether or not gas exchange continues to happen after birth. I think it does, but accept that we don’t have good evidence of this. There are skeptics that believe that once the uterus starts crunching down on the placenta gas exchange is going to be diminished or eliminated, which may or may not be true.
(2) If a baby is born at full term and with birth weight in the normal range, how can placental function be considered insufficient?
Term well grown babies generally have good placentas. There was quite a bit of discussion about preterm babies, and of babies affected by maternal pre-eclampsia and diabetes, who indeed may have very poor placentas. “poor placenta” would be a generalized term to indicate a placenta that has a significantly reduced surface area for gas and nutrient exchange between maternal and fetal circulation. We see exactly that in pre-eclampsia, which is characterized by a much less dense placenta with fewer vessels, less vessel branching, and less invasion into the uterine vascular bed.
(3) Before the lungs can receive oxygen, the capillaries surrounding the alveoli must be filled with blood.
The lungs are perfused throughout fetal life, though the percentage of fetal cardiac output that goes through pulmonary circulation is very small. The volume of blood going through those capillaries increases dramatically after birth.
(4) The first description I have found of an umbilical cord clamp is that of Magennis (Lancet 1899 May 20; 153[3951]: 1373). It was introduced as a device to promote hygiene, and with instructions to use it only after pulsations of the cord had ceased. Another clamp was described by Wechsler (Am J Obstet Dis Women Child 1912; 60:85-6), again with instructions to wait for pulsations of the cord to cease before applying the clamp.
Interesting.
(5) For decades use of a clamp was highly controversial. Until the 1950s, textbooks of obstetrics taught that the cord should not be clamped until pulsations had ceased. Apgar et al. (JAMA 1958; 168[15]:1985-9) commented that they clamped the cord within the first minute to preserve the “sterile field” for surgical repair of the episiotomy etc.
Also interesting.
(6) Landau et al. (J Pediatr Apr 1950; 36[4]:421-6) provided evidence that babies born by c-section were more likely to suffer respiratory distress because the cord was clamped immediately after birth to preserve the sterile field for repair of the uterine incision. They were able to prevent respiratory distress by removing the placenta and hanging it above the baby to promote placental transfusion. Secher et al. (Lancet 1962 Jun 9; 279[7241]:1203-1205) did the same thing.
Also interesting, though the pressure of vaginal passage on the fetal lungs may also be a key factor. Infants born by elective cesarean have a higher rate of transient tachypnea of the newborn, a condition more characteristic of physical lung disfunction than fetal anemia.
(7) If “delayed clamping” is considered a new innovation, it is because the history of how the umbilical cord clamp came into being, and its original intended use, has been completely forgotten.
Agreed. I would argue against any ‘intention’ however. Evolution is not a process of intention – it is a process of completely non-intentional random mutation followed by natural selection of those most fit to reproduce.
Thanks!
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Dr. Fogelson (not Ferguson), sorry. I am a little sleepy. Thanks so much for your efforts to promote delay in use of a clamp on the umbilical cord, and your willingness to reply and discuss issues raised by those of us following this conversation.
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Eileen,
First of all I have to say that a lot of my knowledge and understanding has been gained through you. Unfortunately when publishing etc it is not possible to credit you and sometimes, because of the “pure evidence” demanded by editors they want the original source. They would reject a refernce to your website etc. However I have always wanted to ascribe credit to you and others like George Morley. Now for your specific questions.
1. It is certainly logical ther will be flow if there are pulsations and no arterial flow if there are no pulsations. I think it is reasonable to assume that flow has stopped when pulsation has ceased, but this could be investigated. Wiberg et al were usually able to get blood for 90 seconds after birth.
2 I do not think placental function can be considered insufficient in a term baby of normal weight although it may not be delivering a good suply of oxygenated blood in some of these babies during labour if there is hypertonus of the uterus or compression of the cord.
3. Absolutely true and very important
4. Absolutely true, and unfortunately The Lancet was not willing to “celebrate” the 110years anniversary of this paper and re-emphasize the of following McGennis’s instructions.
5. Very difficult to understand what was happening. I learned most of this textbook changes from you. Jeffrey Dawes suggested that there was pressure in the 40’s and 50 for early cord clamping to get a good residual volume of placental blood for use as a transfusion, and there was a paper from China showing that there was “not much” difference in the health of babies whose cord was clamped quickly for this reason. (I can search out these refs iif someone realy needs them otherwise just believe me!)
6. I must look out this Lancet paper. Peter Dunn in Bristol was doing the same thing and lectured on it for a number of years. He told me that he was getting as good results as they were in Auckland from steroids.
7. Those of us working on this “problem intervention” know perfectly well it is not a new innovation but it just seems like it to many others and of course when it hits the media it is not much of a news item if they say it is an old argument which has been going on for years. In fact it is this “old argument” that stops many otherwise sensible people thinking about it and discussing it. The main driver for the BASICS trolley is to stop the attendant panicking and clamping the cord before the baby has had any real chance to breathe.
I am sure you really know all this but it might be helpful to others.
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I will be having a consult with an OB in a few weeks to discuss risks/benefits of VBAC (I am planning to VBAC ’round Sept). If things go badly and I end up with another c/s, I very much want to continue on with the plan of delayed cord clamping, but my CNM indicated that at the hospital I am birthing at, “they like to right in for the placenta” in a c/s and didn’t seem optimistic that I would be able to get them to DCC. Do you have any suggestions for what I could say/show at my consult to help the OB see that delaying will not be a problem even in a surgery situation? I will, of course, refer him/her to this blog post and print out the studies you’ve cited, but I know how much MDs love their patients bringing in printouts from the internet, so I’m not sure that will help. 🙂 Of course, this OB will likely not be the OB doing the c/s since it would be whoever was on call, but I figure if I can get one person to OK it, that would help persuade whoever I end up with. I would love any suggestions…
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Dr. Fogelson, thank you as always for your thoughtful responses to my questions. This is what makes your blog the most significant on the internet. I have some further responses to your responses.
First, on changes in blood-flow to the lungs. During gestation the lungs receive circulation sufficient for growth and development, but the alveoli do not expand until blood fills the capillary beds surrounding them. Respiratory function (exchange of carbon dioxide for oxygen) cannot be taken over by the lungs until blood is brought to the alveoli. Important but long-forgotten experiments by Jaykka demonstrated this (Jaykka S. Capillary erection and the structural appearance of fetal and neonatal lungs. Acta Paediatr. 1958 Sep;47[5]:484-500).
The current neonatal resuscitation program focuses on ventilation to promote expansion of the lungs, but Jaykka showed that ventilation causes uneven expansion and often leaves the deep lobes of the lungs in a fetal state. Could the increase of asthma in young children be related to this?
Second, on placental respiration following birth. Evidence for this was provided in papers by Marquis and Ackerman (Marquis L, Ackerman BD. Placental respiration in the immediate neonatal period. Am J Obstet Gynecol. 1973 Oct 1;117[3]:358-63), and Stembera et al. (Stembera ZK, Hodr J, Janda J. Umbilical blood flow in healthy newborn infants during the first minutes after birth. Am J Obstet Gynecol. 1965 Feb 15;91:568-74).
Other even older papers also provide evidence of this (Gunther M. The transfer of blood between baby and placenta in the minutes after birth. Lancet. 1957 Jun 22;272[6982]:1277-80.) and (Allmeling A. Die Gewichtszunahme von Neugeborenen infolge postnataler Transfusion [The weight gain of newborns as result of postnatal transfusion]. Zentralblatt fur Gynakologie1930; 54:850-860). Gunther and Allmeling did their research when the cord was not ligated until pulsations ceased, and many infants were active but did not begin breathing for several minutes after birth.
Thanks also to Dr. Hutchon for your thoughtful comments. I do hope use of the BASICS trolley will come into routine use quickly.
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I agree that this is proving an excellent forum for the exchange of ideas and the attention that Dr Fogelson gives to questions etc.
Thansk for your references on placetnal respiration, I will get them out but they seem very important. There are other papers that you tell us about that need wider knowledge.
About the Jaykka finding, were these lungs ventialted before or after cord clamping. If before or if the neonate was hypovolaemic for any other reason then the pressure of blood to fill the lungs may well be insufficient for the Jaykka effect to be available in some of the alveoli. Lung disease in childhood is a possible consequence but even more likely is bronchopulmonary dysplasia where there are areas of large coalesced alveoli. This is thight to be partly due to ventialtion pressures and a lot of work has gone into trying to adjust the ventialtion pressure so that the alveoli are ventialted but not over filled.
Until paediatricians accept that a physiological transition involves firstly inflation of the lungs followed by transition of the circulation which involves natrual closure of the placental circulation we will not progress with research in this area. No matter how good the reseach, carefully randomised, with sufficient numbers to reach a conclusion and outcomes evaluated etc, the research protocol is built on the assmption that immediate cord clamping is the physiological gold standard, then it is like building a nice strong brick house on sand. Now to get off and try to find Eileen references !
The thing which will bring the BASICS concept quickly into practice is consumer demand. ” I want my baby resuscitated where I can see it and without having its only oxygen supply cut off. ”
David Hutchon
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David – What’s interesting (and maybe frustrating) is that there is now enough data for preterm delayed cord clamping that it is getting hard to get an IRB approval for any new randomized studies. I recently tried to get a randomized trial through at my institution to randomize about 200 mother infant pairs, and the IRB felt that it was unethical to randomize infants to immediate cord clamping given the data currently available.
I was a little stunned by this, as it is pretty standard practice in my hospital (when I am not attending) and in the vast majority of hospitals to clamp immediately and hand off to the neonatalogists. While I think delayed clamping is better, it seems odd that it would be unethical to do something that we are already doing all the time. I think my mistake was wording the introduction in my IRB application too positively towards delayed clamping, and not emphasizing enough the barriers to acceptance by pediatricians and obstetricians. The IRB felt that even if those were considered, an educational campaign was more appropriate than additional randomized trials.
Kind of a catch-22.
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What’s interesting to me is that this very line of thinking was espoused by commenters earlier in the threads.
I think more randomized data is needed in preterm infants to get across the board acceptance, but to get there we will need IRB approval for more studies. It seems that one must present the idea to the IRB as a possibly helpful thing in need of more data, not something that we already believe in. Lesson learned on that one.
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Since so many trials already have been performed over the years, proving that DCC is beneficial, for both babies and mothers, while ICC/ECC is harmful, wouldn´t it be more efficient to spend the time and energy on reaching out with this information to as many people as possible – both physicians and the public – instead of performing yet more trials ? For example the implementation of brilliant Grand Round lectures, and then posting them on Youtube 🙂
I also think it is important that we who advocate DCC stick together , since this combat can be pretty tough without the support from like-minded.
The main problem here actually seems to be that the vast majority of physicians within maternity- and neonatal care are either dumb or very obstinate , since they refuse to give up a non evidence based intervention that so many studies already have proved is harmful.
Or maybe there is some other underlying reason to why they refuse to stop clamping umbilical cords prematurely ? What could that possibly be?
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Linda – I can assure you that there are few if any physicians that could be classified as dumb. On the average physicians are far more intelligent than the average bear, a characteristic required to successfully enter and complete the requisite educational process.
Obstinate on the other hand, well that’s a common characteristic of physicians, myself included.
I think the data for term delayed cord clamping is very strong, and it is difficult if not impossible to defend a policy of immediate clamping at term.
The data for delayed clamping in premature infants is compelling, but I don’t think one can make as strong a case as one can at term. There are legitimate concerns about delaying traditional resucitation of a premature neonate in order to delay cord clamping. It is possible to resucitate an premature infant with the cord intact, but I can say with confidence that the vast majority of hospitals are not equipped to do this.
Entire physical structures have been built around the idea that the infant will be passed off to the pediatricians at birth. A commitment to delayed clamping of premature neonates that require resuscitation would require a major industrial change for hospitals. It will take more education and more data before that happens.
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Thank you for responding my comment.
Well Nicholas, I´m not sure your colleagues at the hospital you are working could be so very clever, since they still clamp cords prematurely despite your brilliant and compelling lecture, which I assume none of them could have missed
When it comes to cord clamping, I actually think the average bear is far more intelligent than the average physician. 😉
Since the vast majority of hospitals are not yet equipped to resuscitate babies without cutting them off from their blood- and oxygen supply, well… then it is high time to equip them – and to hurry before any more child is injured, or die! . What are we waiting for?
And until all hospitals are fully equipped, an ambubag could easily be available at every delivery. Oxygen is not needed since air is now recommended for initiating resuscitation .
Additionally: The essential resuscitation equipment is the placenta.
Hand on heart, which information would you give the women you need for your trial ? Would you tell them the following ? :
” 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.” (excerpted from your absolutely brilliant blog post Delayed Cord Clamping Should Be Standard Practice in Obstetrics)
In the RCT on cord clamping which was recently conducted here in Sweden, parents were withheld this vital information, and those who happened to be well informed, and therefore opted DCC, were denied (!!!) , although the majority of Swedish hospitals already had adopted DCC (except for those hospitals where cord blood is collected , for research or donation. Even there the information of course was withheld, and still is)
I don’t believe any woman would sacrifice either her baby or her self for science’s sake, if they only were told the truth . Nor do I believe that any researcher would want their own children or grandchildren to participate in a RCT on cord clamping.
Is it even legal to withhold parents information on interventions concerning their children´s health ? I don´t just mean cord clamping trials, but information concerning all births where non evidence based interventions are performed ?
This quote, by Rich Vinkel, is worth considering:
“These practices are now thoroughly entrenched and seem to be immune from appeals to science, human rights or common sense. It appears that medicine views the bodies of women and children as some kind of empty wilderness waiting to be conquered and colonized”
Honestly, wouldn’t it be better to go for disseminating information to the public?
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The current evidence would certainly be part of any informed consent document, as would information about current standards of care. As I said, its hard to justify any more randomized trials at term, but at preterm the evidence is not so strong. Dr Mercer continues to enroll patients into her randomized preterm study today. Is she doing something wrong?
I think you are demonstrating very well why this practice has a hard time catching on – too much religion, not enough science. There is a lot of data, but you are making claims that are completely without evidence. I can assure you that the placenta alone is inadequate to keep a severely preterm infant alive. If you take a 26 week infant and leave it on its cord without intubating it, it will eventually die. Even a 30 weeker could potentially die.
Neonatalogists have legitimate concerns about the delay in resucitation that delayed cord clamping would cause. We either need to address those concerns by building equipment that allows both parties to be happy, or by finding data to suggest that the 1-2 minute delay in resucitation is not a concern. I think the latter would be better, since it would take a lot of acceptance before hospitals are going to spend a great deal of money on a completely new idea.
When you say things like “before another child is injured or dies!” its very inflammatory and does nothing to help the process. Despite immediate cord clamping, we are able to keep alive children who would have no chance of survival in nature. Our technology and knowledge base in this are has been an area of huge advancement in the last twenty years. When you suggest that the people who have made these advances are “killing and injuring babies” through immediate cord clamping, you are insulting those who are doing an incredible amount of good, and ultimately working against your underlying goal. Its like saying “I hate you you murderer, now change!”
There is a lot of good in the NCB movement, but radicalism and non-scientific naturalism destroys any chance of mainstream acceptance.
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Someone told me this week that menstrual blood could be considered for stem cells, so maybe our babies can keep their own blood after all. ‘Bout time.
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Considered, maybe. Proven to be useful, no. Its hard to see why menstrual blood would be any different than normal peripheral blood.
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>> And until all hospitals are fully equipped, an ambubag could easily be available at every delivery. Oxygen is not needed since air is now recommended for initiating resuscitation
Maybe for term infants, but that’s not what the concern is. Term infants generally don’t need resuscitation, and there’s a hell of a lot more involved in resuscitating a premature infant than an ambu bag.
You need (at minimum):
2-3 people
intubation equipment
a ventilator that can deliver PEEP (or more recently BIPAP)
ability to place an IV or umbilical line
an area that can be made sterile to place an umbilical line
a way to keep baby warm (its difficult to do all this on mom)
Doing this at bedside would require a much different setup than most hospitals have right now.
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Nichlas is right, although we may think “cord calmping is killing babies” we should tone it down when speaking publicly. There is no doubt that the vast majority of physicians are acting in good faith.
As my quote in the Australian Placental Transfusion Study says, research is needed to show HOW “effective care and resuscitiation can be combined with deferred cord clamping and allow a physiological transition to pulmonary respiration”. This is a particular challenge with the very preterm baby.
A few years back babies at around 26 to 28 weeks would never have survivedand susrvival today of these babies is down to the care of modern neonatology. However can I say this view is based on a randomised controlled trial showing that babies of 27 weeks left with their cord intact did not survive as well. No ! Such a trial did not exist. All the babies surviving at 27 weeks (apart form those involved in trials) have had the cord clamped quickly after birth so we really
do not know how they would have done wbeing left with the cord intact alone. But common sense tells us that they would have needed all the normal things like warmth, fluids, etc that all babies need. I’m just trying to get over the fact taht a lot of neonatal care is not based on ideal RCT evidence and the vast majority of care came AFTER the intervention of cord clamping.
Although we ae launching the BASICS trolley resuscitaire, I agree that the best solution would be if we were able to establish that babies do not need resuscitation if the cord is left intact for a few minutes. I think this is likely in the vast majority of babies but there will be a few where active resiscitation is necessary, and it probably does not apply to preterm babies. However they can all be ventilated by PEEP by long tubing connected to the resuscitiare. For term babies ILCOR states that an ambubag is appropriate. Keeping babies warm is not difficult for a few minutes, wrapped in a warmed towel. There may be better “more technological” solutions, but it hardly rocket science! Being pragmatic we do not need to do EVERYTHING by the mother. Getting an endotracheal tube in place is quite possible. Getting an IV line is likely to be just as “sterile” as it is on a resuscitaire, but I do not think this is normally done in a pretem baby within the first 3 minutes. In theory they are going to be less in need of IV fluids after DCC as they will be normovlaemic rather than hypovolaemic afer ICC.
The more neonatologists that start to think about and realise that cord clamping is a serious intervetnion in transition, the more we will get them involved in the “debate”. Until the cord is clamped the responsibility for the baby remaisn with the obstetrician or midwife. However we need to co-operate so that the neonataologist is ready to take over the care of a baby that is transferred in optimal condition. At present all the evidence, common sense, and our knowledge of physiology tells us that we are not ding this for either the term nor the preterm baby, nor for the vigorous or compromised baby.
David Hutchon
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Nicholas, I apologize for using inappropriate vocabulary, and agree with David that we have to tone it down when speaking publicly.
I even believe that physicians who clamp immediately when resuscitating preterm or compromised term babies, are acting in good faith.
Just getting a bit frustrated sometimes, since I have advocated DCC since the 80s, and realizing it´s still so very hard to convince physicians that the best thing to do is to leave the cord intact..
I am of course happy that the technology and knowledge base in this area has been an area of huge advancement in the last twenty years and that it has saved many babies´ lives, even though I´m sure the outcome would be even better if the cord was left intact.
I didn´t say, in my last comment, that we should choose between delaying cord clamping OR resuscitate the baby, since I believe we can do both, simultaneously .
I agree with most of what you are saying and admire your way to advocate for DCC and disseminating the information in an exemplary manner. .
Some of my favorite quotes from your lecture (video no 4) :
“You have to prove to me that phlebotomize the baby of 40% of its blood volume is right……. I think , that the burden of evidence is not on anybody to show it is dangerous. The burden of evidence is to show clamping immediately is safe.. ….Delayed cord clamping is what we evolved to do. We evolved to get the blood that´s in the placenta I don´t have to prove that´s right. .”
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Deccan Cronicle, June 22 : “The uterine lining has cells that can regenerate themselves and their growth potential is much higher compared to cord stem cells.
Though embryonic stem cells are also therapeutic, it has been mired in a lot of ethical controversies, paving the way for the use of MenSCs”
http://www.deccanchronicle.com/channels/lifestyle/health/menstrual-blood-panacea-many-ills-905
Hopefully , in the foreseeable future, newborns can keep their own blood.
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Just found something very interesting, from 1999 :
Intubation of newborn during delivery with intact umbilical cord–a case report.
Abstract
A 24-year-old gravida 2, para 1 woman at 38th week gestation was scheduled for elective Cesarean section (C/S) because of a previous C/S and prenatal diagnosis of congenital diaphragmatic hernia. We decided to intubate the newborn during delivery before the umbilical cord was cut. After delivery of the fetal head and part of the shoulders, the mouth of the fetus was cleared and the trachea was intubated orally with a 2.5 mm internal diameter (I.D.) endotracheal tube under sterile conditions while the uteroplacental circulation was still intact. The patient had to be repeatedly resuscitated due to bradycardia in intensive care unit. No surgical correction of the hernia was attempted because of the poor condition of the baby, which died 3.5 hours after birth. Although our case ended up in mortality despite successful perinatal intubation, we recommend that in case where airway or ventilatory problems are anticipated, tracheal intubation is done during delivery before the umbilical cord is clamped. When the fetus is sharing the maternal circulation, it will allow physicians to have more time and safety to perform corrective measures.
http://www.ncbi.nlm.nih.gov/pubmed/10410411
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That’s called an EXIT procedure (Ex Utero Intrapartum Treatment). We’ve done several at our hospital. Its becoming more common in more places for babies with upper respiratory obstructions. Sometimes they even do surgery on the defect before the baby is entirely off placental circulation.
Its important thought to realize that a true EXIT is with the baby still halfway in the uterus, with only the surgical site pulled up out. Its not clear that the persistent umbilical circulation we see in EXIT is still there when the baby is completely out and the uterus is allowed to contract down on the placenta.
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Is the cord clamped and cut right away when EXIT is finished , without lowering the baby or milking the cord?
Is it easier to intubate a baby while performing EXIT, than to do it on a bedside trolley?
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The primary use of EXIT is in infants who have congenital defects that obstruct the airway, which without exit would likely be fatal. These infants cannot be intubated at all. These anomalies may require complex surgery in order to be able to establish a patent airway, which can only be done because the infant is left on placental circulation while this procedure is performed. The above reference is EXIT for a congenital diaphragmatic hernia, which clearly was not successful.
I heard of EXIT done the first time only a few years ago, and is not really mainstream. Its limited to tertiary teaching centers for the most part.
I’m not an expert in this, but I am not aware of what people do with the cord after EXIT. They transect it eventually, of course. I suspect delayed cord clamping is not the first thing on most pediatric surgeons’ minds after doing a life saving surgery for an infant that otherwise would have died.
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>>> I suspect delayed cord clamping is not the first thing on most pediatric surgeons’ minds after doing a life saving surgery for an infant that otherwise would have died.<<<
I actually took it for granted that DCC is performed at EXIT.
So maybe the baby, described in # 169, could have been in sufficiently good condition for a surgical correction of the hernia , if he / she only had received the placental blood before clamping? Either by lowering the baby and milking the cord , or by autologous transfusion of placenta blood after the birth. Or, if the previous fail; rapid transfusion of O negative blood after birth.
Of course we do not know, but I cannot help but wonder
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Linda – delayed cord clamping is an important thing that we should support, but you can’t go overboard with it. The paper you quote describes an infant with a lethal congenital anomaly that causes varying levels of lung non-development. A baby in the report died because it had a lethal anomaly. That was its natural fate, and the care team involved was not able to avert that despite their attempts. Immediate vs delayed cord clamping doesn’t reasonably enter into it.
Ascribing every ill that may befall an infant to immediate cord clamping is neither evidence based nor helpful to the underlying goal.
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Surely the EXIT procedure is delayed cord clamping at its optimum and demonstrates the sound principle of getting the baby breathing before cutting off the placental circulation. The paediatric surgeons clearly know that oxygenated blood is retruning from the placenta. Once the know the lungs are working no doubt they may not be particularly concderned about the “placental transfusion” but this will have oocurred in any case as soon as the baby is partially delivered from the uterus.
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David – I wonder if this is true. It would seem to me that complete placental perfusion would be almost mutually exclusive with continued oxygenation. After all, if all the blood were in the baby, what would be carrying the oxygen and CO2 to the placenta? I suspect these processes are mutually exclusive, and as one process grows the other recedes. I suspect that as EXIT is done under a total paralysis of the uterus with paralytics or nitrous oxide, that transfusion of blood to the infant has not yet happened. I don’t know for sure though.
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Nicholas,
It is certainly all hypothesis regarding the “placental transfusion”. Perhaps I was being a little too presumtive. However EXIT certainly demonstrates the logic of trying to get the lungs working before abandoning the placenta. If the lungs need a significant amount of the “placental transfusion” then this part will have happened because the pressures will all be relatively equal.
I think we really just need to keep focues on the sequence of events whish occur in nature, which are also very logical. Breathing and getting the lungs working before shutting down the placenta.
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Yep.
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Nicholas, of course we can not expect that DCC can save a baby who suffers from an incurable fatal disease or lethal congenital anomaly .
However, concluding an advanced surgery by phlebotomizing the patient of a huge amount of blood, I wouldn´t call wise.
I believe calling a spade a spade would be helpful to the underlying goal.
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We’ll have to agree to disagree here then.
Delayed cord clamping can be supported by rigorous data, particularly at term. When you start agitating about whether delayed or immediate cord clamping affected the outcome of an infant that has a completely lethal anomaly, in my opinion you are missing the point of the situation, and now come across as less thoughtful and credible.
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.I actually agree with you on most things. Including follows:
“You have to prove to me that phlebotomize the baby of 40% of its blood volume is right”.
“ Delayed cord clamping is what we evolved to do. We evolved to get the blood that´s in the placenta. I don´t have to prove that´s right.”
“Obstinate on the other hand, well that’s a common characteristic of physicians, myself included.”
Thanks for a very interesting discussion. I’ve learned a lot.
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Are you one of those folks that always has to have the last word? If so, take it.
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Thanks for the sensible critique. Me and my neighbor were just preparing to do a little research about this. We got a book from our area library but I think I learned more from this post. I am very glad to see such wonderful info being shared freely out there…
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Dear Dr. Fogelson, I would like to ask one specific question.
Do you have any thoughts on delayed cord clamping in a Velamentous insterstion of placental cord situation? ( distant from the cervix)
I was diagnosed with that, but really want to wait 5 minutes before they clamp the cord.
Is this possible? I am disheartened because my local birthing center wont accept me due to the velamentous insertion and my OB-GYN, just plainly won’t wait.
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I am sure Dr Fogelson will give a similar opinion. A velamentous insertin of the cord is a specific indication for delayed cord clamping. Witha velamentous insertion there is les support for the cord as it leaves/enters the placenta and this can result is easy kniking of the cord and the vessels getting obstructed. Since the vein with itsn low pressure tends to get blocked very easily this results in blood backing up in the placenta and hypovolaemia in the baby. It takes time for this to be corrected after birth otherwise the baby remains very short of blood.
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I generally I agree I suppose. A velamentous insertion means the cord inserts into the membranes away from the placental disc, and the vessels of the cord run unprotected in the fetal membranes for a distance before the reach the protection of the placenta. Most labor with velamentous insertion are uncomplicated, a few more than average will be complicated by fetal distress in labor. Vasa previa is a specific and severe problem that is a small subset of velamentous insertions, but if the fetus is already delivered this danger will have passed.
I don’t see velamentous insertion as being a indication or contraindication. I don’t think there’s any evidence to support Dr Hutchon’s idea that infants with velamentous insertions would have different volume issues. I do think however that delayed clamping would have the same benefits as it would typically, and that the velamentous insertion would not be a reason to not do it.
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Dr Fogelson, almost in agreement ! However you are incorrect that there is no evidence that velamentous insertion are prone to cord compression. Correct that the re is no evidence of “different volume issues”. However how do you classify the different volume issues of the newborn. The blood volume of a newborn can never be measured,even the biotin studies of Aladangady were hours after birth and did not include sick babies (who may have had volme issues). We can only guess that any individual baby may have volume issues if it is very pale with a low BP but you’ll still find some neonatologists who feel this appearance is more due hypoxia than a (low) volume issue.
http://www.bmj.com/content/337/bmj.a1940.full?sid=9c0fb1f0-7011-4699-8e0a-ce753d901a45
“Compression of the abnormal vessels, which compromises the placental circulation, may also result in fetal compromise or death”.
Certainly it is not well recognised but it is logical and there is no evidence or logic to say that delayed cord clamping should not be carried out when there is a velamentous insertion. One situation where DCC is probably contraindicated is where there is a suspected rupture of the vasa praevia associated with a velamentous insertion.
If you look at the BMJ case report the baby was in good condiion at birth, did not need a transfusion and indeed the neonates Hb was not reported so the antenatal bleeding was not fetal. Almost certanly the fetal distress was due to cord compression which may well have been due to compression of the unsupported cord as it enters the membrane. This cord compression was stated in the BMJ article and is also in other textbooks. No large series has been reported as far as I know but there is certainly no way, with current techniques, that you could link velmentous cord compression with neonatal volume issues.
Get your careres to quote you some evidence for their advice>
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I think maybe you are misreading what I wrote. There’s no doubt that fetuses with velamentous cord insertions are more likely to have cord compression events in labor.
I agree that delayed cord clamping is indicated in these cases, as in any other case.
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What is the best way to try to influence my OB/GYN in the direction of delayed cord clamping? He was adamantly opposed to it with my last birth and I’m due in a few weeks for another one. I love my OB/GYN and this is honestly the only area where we disagree. He thinks it increases the risk of jaundice. I’ve tried to find an article about it that would be from a resource he trusted because I want to make sure I approach this adequately prepared.
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Rebekah,
I am not a medical professional so I am just sharing my personal opinion and an article that I found on the internet. Personally, I would think that anything that is closer to the natural process of birth is better for the baby, assuming there are no complications during birth. And it seems that delayed cord clamping is more similar to the way other mammals give birth.
I found the following article, it is 10 years old though, which analyzes the “current” research data: “CURRENT BEST EVIDENCE: A REVIEW OF THE LITERATURE
ON UMBILICAL CORD CLAMPING” “http://cordclamping.info/publications/LIT%20REVIEW%20ARTICLE-MERCER.pdf”
I would suggest do the “search/find” on the page for “jaundice” and also see p. 407 for
Hyperbilirubinemia, p. 413,-414 comments.
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Also the website http://cordclamping.info/publications/publications.htm has many research articles on delayed cord clamping, perhaps you can find something interesting and useful.
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I would go with the meta analysis from JAMA.
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.
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Maisels M J, Whats in a name? Physiologic and Pathologic jaundice: The conundrum of defining normal bilirubin levels in the newborn. Pediatrics 2006, 118 805 – 807
Gives a good review of the most recent evidence about physiological jaundice. Ask your loved OB how they can be sure that the the jaundice (1% more “needing” phototherapy according to the Cochrane Review) that they are concerned about is worse than the sudden stress on the cardiovascular system as 40% of the circulation is clamped off, together with the loss of blood volume up to 205mls, plus the loss of all these stem cells
IThere is no evidence one way or the other because nobody has looked at the long term consequences of early clamping. The concern about jaundice coes from haemolytic jaundice. T
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Dear Dr
Thank you for this really interesting lecture. I read about this subject a lot when pregnant with my first child and it was very important to me to delay the clamping of the cord. Unfortunately I was in labour in total for 56 hours and it ended in a ventouse delivery. My notes stated that the cord was clamped before the birth of the shoulders because it was too tight to loop around the neck. I was very upset by this as I understand the Drs were doing what they felt needed to be done at the time, however I am concerned what effects may be long term. My son is now 3 and I still worry that he did not get all his vital stem cells and other cells that he needed. Am I being completely irrrational to still worry about this? My son needed initial rescusitation but apart from that he is very healthy, no anaemia, and his cord gases were fine . He had no heart decelerations in labour although there was a question mark over this when syntocinon was administered. He has met all his milestones early or on time. I was very alarmed when I read on one site that vital cancer fighting t cells are present in the cord blood. Does the body produce these itself and therefore delaying cord clamping gives it a good start, or has he missed out on many of these factors? I guess what I am asking is, does early cord clamping have long term effects that I should be concerened about? Many thanks!
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I appreciate the comment. I wouldn’t lose any sleep over it. I think that delayed cord clamping is a better way to go, but immediate cord clamping has been practiced for decades without any clear negative impact. I think it has a more measurable impact in preemies than term infants. When we aggregate large groups of infants, we find improvements in iron stores in term infants that have cord clamping delayed, but at an individual level its hard to see any impact. The idea of stem cell reserves is an interesting concept, but at this point is theoretical. There have been no studies that have clearly proven this idea to be true, or to impact neonatal or longer term pediatric outcomes.
I’m pretty sure my cord was clamped at birth. I turned out ok.
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I totally get the feeling… I’m still annoyed 18 years later that my perinatologist clamped the cord so fast after my daughter’s birth. She has allergy issues and mild asthma, and was anemic at 4 months, but beyond that is brilliant and a fantastic human being. Would she have been better off with her full blood supply? Probably. But we’ll never know. (And the allergies probably have more to do with having a tube rammed unnecessarily down her throat than with the early cord cutting, if you look at research about such things).
And my second child has a chromosome disorder, and while her outcome was probably improved by delayed cord clamping, it wasn’t curative, and thus my child who had DCC is academically and developmentally at the far other end of the bell curve from my child who was clamped immediately.
The plural of anecdotes is not data, and it is VERY hard to know what about our kids has to do with their births.
Ultimately, look at your kid. Does he have health issues that worry you? Is he developmentally behind? No? Then thank your lucky stars and move on. Yes? Deal with them, and move on. It’s not something you can fix or correct. But it is something you may be able to do something about for future kids if you have them… unless the cord ends up so tight around the neck that it needs cutting for delivery. Which happens occasionally. Most interventions exist because sometimes they are necessary.
Breastmilk contains a lot of the “good stuff” that is in the umbilical cord, and more besides. Stem cells. Cancer fighting cells. Immune system components. That and diet can correct the vast majority of things one might see from early clamping. Yes, my kid was anemic at 4 months. But it took very little iron supplementation to get her back to normal… less than a month. She certainly had enough blood, as she grew from 7 pounds 11 ounces to 24 pounds in her first 6 months.
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Many thanks for your reply. I was just wondering- this is probaby a very ignornat and naieve question but if the cord is cut from a babies neck and therefore, say half of it still remains attached to the baby, and the baby has a heartbeat, can any of the remainder of blood in the rest of the cord flow into the baby – or does the whole cord need to be attached to the placenta for the baby to get any benefit at all? Thank you!
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There is certainly a bit of blood in the cord, but the vast majority of the blood is on the other side of the clamp. Most of the blood is in the placenta, after all.
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Thank you, I have really appreciated your respones.
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Silly example, but if you got upset at the idea of someone suggesting that it might be more physiologically sound for some reason to wash your pits before your hair, or vice verse, and were unwilling to listen to or consider sources that provided evidence for a different shower routine being more optimal, then it might well shift into the realm of “ritual”. And many doctors get quite defensive about practices such as immediate cord clamping and dismiss evidence to the contrary… I’d say that does count as ritual.
That said, I don’t really like the idea of lotus birth myself. Placentophagy makes far more biological sense… 😉
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Dr. Fogelson, thank you for sharing this presentation. I have shared it with my friends and colleagues who are L&D nurses, midwives & residents. It is great to have the data laid out so well.
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I feel the term “delayed cord clamping” is misleading. Premature cord clamping versus physiologic cord clamping gives a better idea of what is really taking place. What do you think?
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I have heard others make the same comment. I don’t really care what people call it. Both are correct. Waiting several minutes after delivery is indeed delaying the clamp from the typical immediate clamping. Its also more physiologic.
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Great blog. I truly love how it’s easy on my small eyes and also the details are well written. I’m wondering how I might be notified each time a new post has been manufactured. I have enrolled in your rss feed which should do the secret .Possess a nice day.
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All of this is so, so true..birth is meddled with way too much. Hopefully change can come about slowly. Thank you so much for shining this light, the medical profession certainly needs to change this ‘routine’ procedure and let nature take its course..
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Thanks you so much for a great lecture. I’m a trained RN and Childbirth Educator/doula in Australia and have supported many births over 20-odd years. I’ve been immensely frustrated at the attitude of most medical personnel I’ve come in contact with regarding delayed cord clamping – not to mention other archaic & potentially harmful practices that are still being used! The only time I’ve seen DCC used has been at home births (including my own 24 yrs ago). The arguments I’ve heard against DCC have at times been ludicrous including 1 midwife who told me ‘we don’t want the bad blood getting to the baby now do we?’!!
I recently found the FB page ‘Leaving A Baby’s Umbilical Cord To Stop Pulsating (Delayed Cord Clamping)’ and am excited that delayed cord clamping is finally starting to be recognised here in Australia. Aside from medical professionals, I’ll be sharing a link to this page & ur lecture with every pregnant mum I know – maybe if they can pass on what they learn to their own doctors/midwives there’ll be a few more eyes opened to the benefits of DCC and more babies benefiting from the practice.
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There is another FB page, Cord-Clamping.com that you might also enjoy.
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Dr. Folgeson, Imagine my great intereset when I ran across both this site and your grand rounds while writing a case study in relation to delaying cord clamping! (I am an RN and student nurse midwife) Have you run across any research specifically addressing infant positioning on the maternal abdomen while leaving the cord intact in relation to blood volume transferred? I have found very little. I know that the higher the infant is in relation to the placenta, the less volume will be transferred, but I am wondering if anything specifically states one of its interventions was placing the infant on the maternal abdomen. Also, one institution I rotate through has a policy of early clamping, supposedly because of a risk of “reverse” transfusion from infant to mother. Do you know of any research supporting or refuting this claim? In my experience as a student and labor nurse, I have yet to see this. Your response is greatly appreciated!
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Laura C, positioning has been discussed in the comments above and there are many references there too. Read them all; they are well-informed and worth the effort.
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Hello, I’m a midwife from Spain. Thank you for your conference and the very intresting comments too! In my hospital (1000 births per year) we are actually reviewing this topic cause since 2010 we are collecting blood for donation (only public bank allowed!), and we are proud that they were able to transfuse 7 cases of infant leukemia with good results last year.
On the other hand we are concerned about the issue treated here, cause we know that DCC is the best practice for the newborns.
So, what we are doing now (temporarily) is telling the mothers that if they want and if there is enough blood after DCC , they will be able to be donors. At birth we don’t open the pack of the Bank until we see (after DCC) if there is enough blood. (We’ve noticed that there are other items that have influence in the amount of blood you get like length of the cord, size of the baby, etc.).
I think that with this practice we are selecting appropriate samples, without interfering with the newborn transition. (for the bank to process an insufficient sample has a high cost!).
We haven’t got quantitative results of this practice yet. As I said we are actually reviewing the topic.
So, thank you again for your information!
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Isn’t all the blood the baby’s? How can you tell whether the baby is able to (in effect) donate 100 mls or more, or less? I wouldn’t want a newborn to donate any blood to anyone else. The baby’s body needs every drop available for iron stores and who knows what else. In addition, these cells have been found in breastmilk, I think I read somewhere, so that might be a better place to find it.
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Sigh. My son’s girlfriend recently had a baby at Women’s Hospital in Houston. She managed to have a completely unmedicated birth, and baby is nursing well, so I am overall happy about the way the birth went. But when my son asked the doctor not to clamp the cord right away, he said that delayed cord clamping leads to jaundice. My son (very new to this whole baby thing) said he didn’t have the answer to that on the spot, and they went ahead and did immediate clamping. And then although baby was neither very large nor very small,( 7-14) and mother had no GD, blood sugar was low, requiring formula, they said. Then baby got a bit jaundiced anyway, also requiring formula, they said. Sigh again.
Please continue to spread the word among doctors about delayed cord clamping. Someone in peds will have to address the other issues.
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Thanks for your comment. The delivering physician was correct, in that babies where one delays cord clamping will on average have higher bilirubins than those who were clamped immediately. The question to me is which state is actually the state that we were evolved to be birthed under. As I mention in the video, we are the only species that clamps immediately, and thus has lower bilirubin levels at birth than we otherwise would have.
There are no studies to suggest that the mildly increased levels of bili has any negative impact on neonatal health (ie kernicterus, severe jaundice). That said, if the pediatricians are putting babies under the lights based on numbers alone, a policy of delayed cord clamping will inevitably lead to an increased number of babies who are treated for jaundice.
Not to worry either way. Term babies will do great no matter when you clamp the cord.
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You are absolutely correct Nicholas until your last sentence when you said the vast majority of babies will do great no matter when you clamp the cord, BUT there are a few who have cord compression causing CTG abnormalities, mild intrapartum hypoxia but marked redistribution of blood volume from the baby to the placenta which is increasing the placental venous pressure and ensuring a return of oxygenated blood in the cord. Although the baby is hypovolaemic the pressure of the birth canal keeps the pressure in the veins and maintains the cardiac return. As soon as that baby is born, sometimes by forceps .the pressure around the body is relieved and cardiac output will fall but provided the cord is left intact blood will rush back from the placenta as the cord pressure is relieved. It only takes a minute especially if the baby is not elevated. But if the cord is clamped the blood is permanently trapped in the placenta and the baby will fail to respond well to any resuscitation until its blood volume is restored by which time who knows what brain damage has been caused. The recent study from Norway showed no increased risk of jaundice needing phototherapy after delayed cord clamping, in fact there were fewer needing phototherapy in the delayed group.
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Bilirubin is only a problem if the blood-brain-barrier has been breached. In experiments with newborn monkeys, Lucey et al. (1964) found that bilirubin only entered the brain in monkeys subjected to asphyxia at birth [1]. Asphyxia was caused by clamping the umbilical cord and delivering the infant head into a saline-filled sac. This finding was confirmed by other researchers decades ago [2-4].
Bilirubin staining is not uniform throughout the brain, but found only in subcortical centers, nuclei in the auditory system and basal ganglia, which are sites of highest blood flow in the brain. See the seminal paper by Seymour Kety (1962), which is free online [5].
Thank you, Dr. Hutchon, for your explanation. Clamping the umbilical cord is probably not healthy for any baby. The umbilical cord clamp was introduced a little more than a century ago, as a hygiene measure. Instruction for its use was to wait for pulsations of the cord to cease before applying the clamp [6, 7]. Textbooks before the 1980s all advised waiting for pulsations of the cord to cease, which happens when the anatomy of the heart has changed to redirect blood flow to and from the lungs.
References:
[1] Lucey JF et al. Kernicterus in asphyxiated newborn monkeys. Exp Neurol 1964 Jan; 9(1):43-58.
[2] Lou HC et al. Breakdown of blood/brain barrier in kernicterus. Lancet. 1977 May 14;1(8020):1062-3.
[3] Lou HC et al. Pressure passive cerebral blood flow and breakdown of the blood-brain barrier in experimental fetal asphyxia. Acta Paediatr Scand. 1979 Jan;68(1):57-63.
[4] Levine RL et al. Entry of bilirubin into the brain due to opening of the blood-brain barrier. Pediatrics. 1982 Mar;69(3):255-9.
[5] 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
[6] Magennis E. A Midwifery surgical clamp. Lancet 1899 May 20; 153(3951): 1373.
[7] Wechsler BB. Umbilical clamp. Am J Obstet Dis Women Child 1912; 60:85-6.
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Dear dr. Fogelson,
Thank you for this lecture. I’m currently writing my master’s thesis about early vs. delayed cord clamping with low birth weight infants. Your lecture was very informative and it was a nice break from searching in pubmed and reading articles all day.
Thank you again!
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Midwife thinking: regarding the water temp and length of time pulsing…my 3rd child was born in the water which was not ideally warm but not super cold either and it continued to pulse for a very, very long time…is 20 mins. She needed that as she was quite purple but she ended up great. She is 5 yrs old today and super bright. My 4th child was born at 35 weeks and I requested that the cord be left in tact. We let it mostly collapse before he saw the nicu nurse for help clearing his lungs. He only needed chest percussions for 30 mins in our room and was fine holding his O2 after that.
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Dear Dr. Fogelson,
Do you know a text or literature which details the best procedure for delaying cord clamping in caesarians? My wife’s OB is worried about blood loss during the delay, and says that clamping is essential before injecting the oxytocin. Really?
Charles, Oxford, England.
(I’m a scientist, not a medic, and a patient to be in a couple of months, so I really need the data to talk sensibly to the OBs and anesthetists who do this stuff.)
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Dear Charles,
Although you are in Oxford you may be disappointed to learn that even in this centre of excellence there is some ignorance especially amongst the obstetricians. This is the sort of nonsense that I have also heard from the RCOG say that the dealy may cause the mother to lose a few hundred mls of blood. Even if was true, and I have done many hundreds of caesarean sections (as a jobbing obestetricians rather than a desk academic) and know that the blood loss risk occurs well after the first 3 to 5 minutes after birth for delayed cord clamping. Even if were true what mother in her right mind would put her own risk of losing a few extra 100mls ( 4%) against her baby guaranteed loss of at least 20% ?
There is no need to delay the oxytocin before clamping the cord as the only effect of oxytcin is to speed up the redistribution of blood from the placetnal part of its circulation into the babies body.
There are numerous publications and you will note that there is virtually no challenge from the “establishment”.
This is my latest and you can get all the other references from it. As a scientist you can probably come to this without preconceived ideas. Have a look on my website for the presentations at the Birmingham Conference on 19th April.
Hutchon DJR. Immediate or early cord clamping vs delayed clamping. J Obstet Gynaecol 2012 32:
260 724–9.
David J R Hutchon djrhutchon@hotmail.co.uk
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I agree with Dr Hutchon that there is no data to support your obstetrician’s concerns. I have delayed cord clamping at hundreds of cesareans as well, and there is really no more blood loss than any other case. The blood loss starts after the placenta is removed, not before, assuming that there is no laceration of a uterine vessel.
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Evaluating Cord Pulsation- Dr Luca Daini
“I was familiar with Lotus Birth and one month before the birth our third child my wife, who is an oncologist, and I decided to explore it as a possibility. Elisa’s birth was a planned caesarian for 12/12011 at the La Spezia Hospital. We had already gone through two caesarean births and it all being so far removed from nature our resolve for a Lotus Birth was strengthened.
My duty in the operating room was to manage the placenta due to the absence of staff dedicated to such duties. After the delivery of the placenta what struck me the most was the evaluation of the cord pulsation by the neonatologist. About three minutes after the placenta was removed from the uterus, she pinched the cord between her fingers and said: ‘There is no more pulsation….’
Her words reflect a modern medical culture that does not see the necessity of leaving the cord attached to the newborn once it ceases its pulsation………..
Once my wife, daughter and i reached our room and found ourselves in a more private environment…… I wanted to evaluate the placenta for myself. I wanted to check if the pulsation had completely stopped, although I did not want to limit myself to checking the arterial pulsation. My aim was to investigate what we osteopaths call Cranial Rhythmic Impulse (CRI)
CRI is a ‘pulse’ that you learn to measure manually at osteopathic training. it has a slower rhythm that the arterial respiratory rhythm, and its frequency is around 8-12 oscillations per minute. It is possible to discern it in all tissues of the living body. All body frequencies must be harmonized to maintain life – heart rate, CRI and probably others less easy to perceive.
After checking my daughter’s CRI, I tried checking its presence in the placenta, which by now was showing no arterial pulsation signs. To my great bewilderment, The CRI was present, and was identical in both its frequency, amplitude and strength to the child’s CRI. It was as if the infant’s body and the placenta were one unit, partaking of the same ‘breathing exercise’
I evaluated the CRI over the following days. On the second day the rhythm in the placenta had diminished, showing less amplitude and strength compared to that of the infant. Such decrease gradually continued, and by day four I was not able to detect the CRI in the placenta. It was as if the vitality was slowly leaving the placenta-infant unit, a unit which for nine months had kept her dependent on her mother, had nourished her, and then in those four days had transferred itself slowly and completely into the infant’s body.
Because there was a little difficulty caring for the infant with the mummified cord I considered removing it. The neonatoligist had been ready to cut the cord at three minutes. An osteopath would have been ready to do so after four days. Then it occurred to me that there might be a parameter we were not yet able to evaluate, to which the future will show that exchanges between the newborn and its placenta continue happening until their complete and natural break. With this in mind, my wife and i decided to wait until Mother Nature would complete its task undisturbed, and until the cord would detach without human intervention.
Having had this experience I can only say that Lotus Birth is a great choice for childbirth. For situations such as ours and I include natural pre-term births, as it allows the infant a more gradual detachment from the source of nutrition, the placenta. This may make the ‘handover’ that may be associated with achieving self-sufficiency, such as cardio-pulmonary and gastro-enteric efficiency, less traumatic.”
“As we move from a Newtonian to the Einsteinian paradigm of existence with the understanding that everything is energy and that there are subtle energy fields that exist and which we are part of, we can identify sensitivities that previously have been beyond our comprehension, although well documented and acknowledged in Indigenous and Eastern health systems. It is these subtle energies that Lotus Birth addresses and so accommodates the metaphysical needs of the mother and baby.”
The above is from the 2nd edition of ‘Lotus Birth’. where there are more accounts of C/section lotus births and of the recording of the CRI. The findings support DR Dani. We continue to gather information to help people understand the advantages of lotus birth. Parents, MD’s midwives, doulas, osteopaths and other practioneers who know about the subtle bodies are invited to join this pioneering work.
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