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Academic OB/GYN Podcast Episode 31 – Delayed Cord Clamping
Guest Dr Judith Mercer of University of Rhode Island and I discuss her work investigating the impact of delayed cord clamping on term and preterm neonates.
Categories: Academic OB/GYN Podcast
Academic OB/GYN 
I’m curious about delayed cord clamping and gestational diabetes. I haven’t been able to find much research (other than a few studies in which women with GDM were not included). It was briefly mentioned here in relation with jaundice… but what, if any, research has been done regarding cord clamping in cases of GDM?
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Thanks for srhinag. What a pleasure to read!
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I’m not aware of any specific research on this, but have no reason to believe it would have an impact.
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Great interview. Thank you and Dr. Mercer for all the great information. I was curious, you didn’t fully answer your end of the question at the close of the interview. What are your feelings toward delayed cord clamping and cord blood donation. At my school we are very active concerning public cord blood donation. I know we sometimes struggle getting adequate volume of blood on donations even with immidiate cord clamping. I think delayed clamping would put a huge dent in the amount of blood donated. I personally feel the immidiate issue of the newborn baby that sitting there in your arms is more important and delaying clamping should be done. I wonder if you have any thoughts to how these two wonderful issues effect eachother and how to best approach them together.
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I think that delayed clamping and stem cell collection are mutually exclusive.
One is trying to save a maximum amount of blood in the baby, and the other tries to save the maximum amount of cord blood for donation. If one waits 1-2 minutes after delivery, the amount collected for storage will be very little, not enough to have a successful stem cell transplant.
I think the idea of donating cord blood, or any kind of blood for that matter, is principled on the idea that the material being donated is not of use to the donor. In this case, I think we have substantial evidence that the blood _is_ of substantial use to the donor. It clearly has an impact on fetal physiology and iron stores, potential impact on neurological development, and perhaps even on future disease progression through depletion of early stem cell populations. As such, it would be hard for me to recommend banking cord blood when that donation may actually be robbing the infant of a measurable benefit. Couched in those terms, I think most parents’ desire to bank cord blood for personal or public use would be much reduced.
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As I posted on your previous blog post, in my experience, cord blood collection and “delayed” cord clamping ARE NOT mutually exclusive.
I run a free-standing birth center and some of our clients wanted to donate cord blood. There are a few who choose to bank, mainly due to family health history.
I was happy to collect for them, but not at the price of robbing the baby of his/her cord blood. So, the first few parents that wanted to donate, we simply did things the way we always did and then collected what was left in the placenta.
I was pleasantly surprised to find we always got at least the minimum amount.
We do not clamp the cord until the cord has stopped pulsing, which generally takes 5-20 minutes. We also wait for the placenta to separate on it’s own. We don’t tug on the cord to “check” unless we are pretty sure it is separated.
So, by the time we collect from the placenta, it can be as long as 30 minutes after birth. Yet we have ALWAYS gotten at least an adequate sample for collection.
I read things about people struggling to get a sample even with immediate clamping and I think the difference is that my clients are at the extreme of healthy OB clients.
We have all seen the puny cords of smokers, asthmatics, women with crap diets, not to mention women with hypertensive disorders. Not gonna get much out of them.
However, for healthy women with good diets, cord blood collection is not necessarily incompatible with “delaying” at least a couple of minutes. I see no reason to rob the child of their own blood in order to collect.
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I really don’t think you’re right on this. The engraftment success of a transplanted cord blood unit is highly dependent on the volume of cord blood banked. You may be getting the minimum to bank, but they aren’t going to be very good units. Talk to a neonatal hematologist about it.
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Here is an answer to the diabetes question. Usually studies on delayed cord clamping exclude women with gestational and full blown diabetes because these infants are more likely to be polycythemic (too many red blood cells circulating in their blood)at birth. In spite of this, these infants often have depleted iron stores because they use up the iron that fetuses are supposed to be storing in the liver in the last few weeks of pregnancy making these extra red blood cells. I know of no studies that have looked at the issue in infants of moms with gestation diabetes. I can go on and on if you wish!
As to the comment on cord blood collection, I entirely agree with Dr. Fogelson – I think that the blood should go into the baby at birth and not into a freezer for later use. No mother would be allowed to donate her infant’s blood once he is in the nursery! Stem cell researchers need to perfect a technique to make cells multiply in the lab so that they can use smaller donations. Oncologists and others are beginning to use two babies’ donation at a time (well matched) because one donation, even a large one, is not enough for an adult. Sometimes I have seen 4 and 5 ounces donated! So the baby who should have weight 7 lbs 2 oz at birth weighted 6 lbs 13 oz instead. Meanwhile mothers are congratulated on such a “good” donation without any studies ever completed to show that this practice is not harmful!
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hi, Judith,
So should mama’s with controlled GDM not want delayed cord clamping? Is there some risk for my baby if she is polycythemic?
thanks so much,
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Nick, you know I am a big fan and supporter but I was disappointed by this episode. I thought Dr Mercer was passionate and discuss her believes regarding the importance of this topic. But this podcast is by academicobgyn.com. Normally you would dissect and analyze the scientific data regarding a topic. Unless I heard wrong three small studies and one meta analysis done in other countries showed some benefit in premise regarding IVH. No studies have shown other benefits and you mentioned increased risk of elevated bilirubin ( but not necessarily jaundice)
That is good science leading to the conclusion that more studies should be done but not good enough to say we should all change practice techniques. Hey I’m behind you on this topic. You are my friend and I love your podcasts. Since I’m out of the academic world you help keep me fresh. Prove it is better and not dangerous and I’m with you. From what I heard, so far the science has not done either….yet. I think the podcast presented the topic in a way that advocated changing practice standards now based on a belief and not on scientific evidence. Maybe that was not the intent but that the message I felt came though.
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Jeff, I think you make some fair comments. Dr Mercer is clearly passionate about her work, and does have a strong bias towards her conclusions – but I think all passionate people have that.
>> That is good science leading to the conclusion that more studies should be done but not good enough to say we should all change practice techniques.
I really don’t agree with this. Immediate cord clamping is an intervention that is clearly shown to have substantial physiologic impact on a term fetus in terms of iron stores, blood volume, and hemoglobin. Furthermore, all randomized data to date has suggested a measurable clinical benefit to delayed clamping (and restoration of a more physiological transition from placental to pulmonary circulation). No data has found a danger in delayed cord clamping.
Given that immediate cord clamping is the intervention, I think we have every bit of evidence required to suggest that right now we should be delaying cord clamping after term deliveries.
And I am not the only one –
Jaleel et al “Delayed umbilical cord clamping at birth seems to be safe and can be expected to reduce the prevalence of anaemic newborn babies in our community.”
Hutton et al “Delaying clamping of the umbilical cord in full-term neonates for a minimum of 2 minutes following birth is beneficial to the newborn, extending into infancy. Although there was an increase in polycythemia among infants in whom cord clamping was delayed, this condition appeared to be benign.”
Levy et al “Although a tailored approach is required in the case of cord clamping, the balance of available data suggests that delayed cord clamping should be the method of choice.”
Others are supportive but less definitive –
Arca et al “Although there is no conclusive evidence, delayed cord clamping seems to be beneficial in preterm and full-term neonates without compromising the initial postpartum adaptation phase or affecting the mother in the short term. However, further randomised clinical studies are needed to confirm the benefits of delayed cord clamping.”
Preterm deliveries are an area of even greater interest, given the data to suggest impact on critical endpoints of sepsis and intraventricular hemmorhage. Given concerns about delaying resucitation for cord clamping delay, this is an area worth much greater research (some of which I am involved in doing.)
Thanks for your comments Jeff!
J Pak Med Assoc. 2009 Jul;59(7):468-70.
Timing of umbilical cord clamping and neonatal
haematological status.
Jaleel R, Deeba F, Khan A.
J Matern Fetal Neonatal Med. 2010 Nov;23(11):1274-85.
Timing of umbilical cord clamping: new thoughts on an old discussion.
Arca G, Botet F, Palacio M, Carbonell-Estrany X.
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.
J Perinat Med. 2006;34(4):293-7.
Timing of cord clamping revisited.
Levy T, Blickstein I.
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Cool. Thanks for the articles. I listened to it wanting to be able to get behind it. I will listen to it again and check out these articles. Since I am not in academia in rely on this podcast to keep up.
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This was a great reply on some of my questions around premature cord clamping vs. physiological clamping to faciliate stemcells harvesting. On my quest for more information I found a study about the influence of pregnancy and birth on the yield and quality of blood retrieved from the umbilical cord.
http://www.opus.ub.uni-erlangen.de/opus/volltexte/2010/1609/
The fulltext of the study concludes with the (here translated) sentence: “IT is to be clarified if the use of an antibiotic treatment, for obtaining more stem cells from the umbilical cord during labor, can be done without increasing the risk of resistance.” This is giving me goosebumps.
Do you know how long it takes for a newborn to replace the lost stem cells? Hours, days or weeks? Thank You.
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Honestly I’m not sure if it can replace the stem cells at all. I’d have to ask a neonatal hematologist though.
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Thank you for this podcast. I was fortunate enough to attend a half-day workshop by Dr. Mercer at the 2010 ACNM Annual Meeting and it was wonderful. I look forward to the publishing of the study that she is now conducting. Any word on when this study should be concluded?
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Thanks for this very informative podcast! I am a maternity nurse at a progressive hospital where most patients ask for delayed cord clamping and the providers always comply (most do it even if the patient doesn’t mention it). I have worked other places where people think DCC is dangerous so I am glad that research is on our side. We also collect a lot of cord blood for donation for our local blood bank who harvests the stem cells for cancer patients around the world. As you mentioned in your earlier comment, we get much smaller samples than the other local hospitals that clamp and cut right away. The samples meet the minimum amount but the blood bank tells us that only the large samples are really useful for donation (the rest go for research).
A few months ago I had a patient with what turned out to be an enormous baby (10+ lbs) who labored for a long time before finally having a C/S. I didn’t always remember to collect during the C/S but this time I did and the sample was enormous. The large baby, quick cord clamping (because of the C/S) and good use of gravity to fill the bag all contributed to a sample so big that the blood bank called the patient that day and told her it was one of the biggest samples they had received and it would definitely be used for a transplant. This was a good lesson for me that a C/S is probably the best time to collect blood for donation.
Do you delay cord clamping at C/S? Is it even feasible or is it too risky for the mother? This is only done for the micro-preemies because their risk for anemia is so great. All other babies are clamped and cut immediately so they can get to the warmer.
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Dear Sara, Thanks for your question about delaying cord clamping at C/S. These babies need their own blood probably as much or more than the vaginally delivered infants. It is harder to wait (although our colleagues in England had no trouble in a study “Measuring placental transfusion for term births: weighing babies with cord intact” by D Farrar, R Airey, GR Law, D Tuffnell, B Cattle, L Duley published in the BMJ ?January 2011). My colleague, Deb Erickson-Owens, did her thesis on cord milking at C/S. She had the OBs milk the cord 5 times vigorously on 1/2 of the infants while the other half had immediate cord clamping (ICC). She got significantly more blood returned in the blood bag of those clamped immediately as you would expect. Also the 48 hr Hemoglobins were sig. higher in those babies who had cord milking. Almost half the babies in the ICC group were anemic at 48 hours. The question is where should the placental transfusion go – to the baby or to the freezer. Those stem cells are very precious (as are the red blood cells) and they were meant to be in the baby to lay down his immune foundation for the rest of his life. See “Mankind’s first natural stem cell transplant” by Jose N. Tolosa, Dong-Hyuk Park, David J. Eve, Stephen K. Klasko,Cesario V. Borlongan, Paul R. Sanberg, J. Cell. Mol. Med. Vol 14, No 3, 2010 pp. 488-495. Am not sure how to attach these two article or I would do so. I am glad to hear that you are delaying or milking for the premies. Stem cells can help heal any damage that was done in the birth process and we think that the iron in the red blood cells is essential for normal brain development. All babies need to get the majority of their placental blood. There is usually some left and harvesters need to learn to make those small amounts expand (proliferate) outside the body (in a petri dish). Hope this helps.
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To answer Holly’s question: we are in Year 4 of our 5 year grant. We have randomized 176 infants and hope to have 212 randomized by the end of this year. Of course, because it is a randomized controlled trial, we cannot look at the data until we have completed enrollment. By the early spring of 212 we should have our data.
We are also preparing a grant to study the issue of placental transfusion in term infants.
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Its not difficult at all to delay cord clamping at cesarean. We put the baby down on the mom’s draped legs and put a sterile towel over the infant to keep it warm (face uncovered of course.) We clamp at 60-90 seconds and then hand off to the pediatricians. Anecdotally, infants that are not vigorous at delivery always seem quite vigorous at 60 seconds, even without any active resucitation.
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Hi Nick,
I am a midwife from New Zealand and I practice delayed cord clamping with all of the women i care for. Since I have undertaken this practice I have noted that there has been an increse in the incidence in physiological jaudice. Is there any link between the two? I have thought that perhaps this is because of the incresead blood volume hence a higher number of uncongugated red blood cells?
Kind Regards
NZ Midwife
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There’s definitely a connection. Several studies have shown that. One studies showed an increase of infants that received phototherapy, and others just showed an increased total and direct bilirubin levels without associated clinical impact.
PS red blood cells don’t get congugated. Its the bilirubin in them that does.
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it is called Physiological Clamping of the Cord…is normal in all mammals!!!
You are just allowing something that happens naturally.
We have managed birth for so long we have forgotten that this is normal.
Delayed Cord Clamping is just a word OBs made up…like not circumcising.
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Yes, it really annoys me that we have to call delayed cord clamping the “intervention” when we are doing research! How distorted.
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I recently read “The Seven Habits of Highly Effective People”. One of the habits is “Seek to understand before being understood”. A element of this habit is the total acceptance that another person can look at exactly the same thing and see it differently than you do, or see the same thing but call it something different. We are far more effective when we focus on understanding the position of others rather that fighting about the words they use to express that position. To an obstetrician that routinely clamps cords immediately after birth, waiting 2 minutes is certainly “delayed”. Its also “physiologic”. Neither are wrong, and to fight over the language is to miss the point.
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Could you please comment on the use of managed third stage (oxytoxics) post delivery, and the timing thereof when doing delayed cord clamping? Thank you.
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The concern that delayed cord clamping may lead to overtransfusing the infant after administering a uterotonic the third stage of labor is unsupported. Yao and colleagues (Yao, Hirvensalo et al. 1968) demonstrated that the infant recieves a maximum of 90 mL/kg (normal physiologic volume) within the first few minutes after a uterotonic is administered, no matter how long the cord clamping is delayed. They used a very strong IV uterotonic no longer in use today.
The usual practice of immediate cord clamping as part of the active management of third stage has potential to cause harm by increasing the risk of anemia of infancy. it is no longer recommended by WHO, FIGO, and ICM – international OB and midwife organizations. Delayed cord clamping is endorsed by the WHO and can easily be incorported into any provider’s practice of active management resulting in benefit for both mother and infant.incorported into any provider’s practice of active management resulting in benefit for both mother and infant. One caveat is that when the infant is placed skin-to-skin immediately after birth, 2 to 3 minutes is not long enough for a full placental transfusion.
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Thanks for your response. I have been leaving cords intact with skin-to-skin for some time now, and also not rushing to give the injection immediately to mum when desired, unless truly indicated. There was an awkward moment recently where a superior was in the room as a women had a bit extra unresolved bleeding. I went to give the IM injection and this superior made a sudden fuss that the cord had to be clamped first. I know I’ve read that wasn’t necessary, and I am fairly sure she is not up on the issue. My hospital only endorses DCC for premature babies, but I see no reason to exclude full-termers from the same benefits. Is there any more recent research about this you can recommend that I might present to her?
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One caveat is that when the infant is placed skin-to-skin immediately after birth, 2 to 3 minutes is not long enough for the infant to get a full placental transfusion. We recommend that the cord not be clamped for at least 5 min (paper soon to come out).
Also, some people think that it is fine to clamp and cut the cord when pulsations cease. Pulsations cease when the infant’s blood oxygen level reaches close to 40 mmHg causing the umbilical arteries to close. It means that the blood from the heart’s efforts will no longer move through the umbilical arteries from the infant to the placenta. However, the vein is not so affected. Third stage maternal contractions cause the remaining blood in the placenta to flow through the umbilical vein to the infant after the flow has stopped in the arteries as evidenced by the cessation of pulsations in the cord. We know this because people still get a good cord blood donation after cord clamping when pulsations cease. We think that if one wants the baby to receive a full placental transfusion and all of the baby’s stem cells, one should wait at least 5 minutes.
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Dear Dr. Mercer, I´am developing a research study in order to probe start CPR with the newborn connected to the placenta, What do you think about. Thanks in advance.
Rodolfo Keller.
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Send it out to anyone you feel could help get the word out.
Substantial information about these sites can be also easily acquired.
Winning is more of a bonus, rather than an ultimate goal.
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