Many providers who practice active management of the 3rd stage of labor will opt to include immediate clamping of the umbilical cord after the birth of the baby, and I see this a whole lot in the hospital setting -- mostly by physicians. Midwives, for the most part, will delay clamping and cutting of the cord until 1-2 minutes, or until the cord actually stops pulsating, which can take several more minutes.
Why the hurry? Why clamp and cut so quickly? It is theorized that in addition to several other actions and interventions, that it reduces the risk for postpartum hemorrhage for the woman.
What about the baby? The baby loses blood volume that rightfully belongs to him or her after the birth. Studies have shown that babies are less likely to have problems with infant anemia if delayed cord clamping occurs. While there is a slightly higher rate of jaundice that requires phototherapy in delayed cord clamping, it's actually considered to be not statistically significant when compared with immediate cord clamping and the risk of jaundice. I have read rates of phototherapy for jaundice running around 3% in immediate cord clamped infants, and 4-5% in delayed cord clamped infants.
Even OB/GYN physicians are coming around to see the benefits of delayed cord clamping. Take a look at these videos from the Academic OBGYN on Grand Rounds.
11 comments:
I think this is basically a non-issue [except possibly in premies]. Babies are born with extremely high levels of hemoglobin [around 24], which helps them cope with hypoxia at birth, and which declines normally to 17-19 [which is still higher than normal adult values] within a day or two after birth. The extra blood, therefore, from delayed clamping, is in effect, "wasted" in any event. Having seen some very severe jaundice from ABO incompatibility, and the consequent effects, such as separation of Mom and baby because the baby is under bili lights, doesn't nurse well due to lethargy, etc. I wonder if it really is that essential. But if a parent asks for delayed clamping [except in cases of Rh incompatibility], I'm willing to do it. In my experience, the cord stops pulsating long before I'm ready to cut it in any case, usually only half a minute, not up to two minutes.
Wasted?
What on earth is the hurry? That is a miniscule amount of increased jaundice when left to pulse-
It is not for the physician to decide if they get the blood or not, it is theirs.
Let's look at interventions KNOWN to increase jaundice, like the use of Pitocin, which, when administered routinely via an IV is most definitely NOT a part of the natural process.
To totally decide that a natural process is "useless" I think we need some actual proof of that, which we don't have.
The burden of proof should rest on the unnatural intervention to prove itself useful, and immediate clamping has not done this.
All my babies (9) have had their cord clamped immediately with the exception of the ninth. That OB clamped after the cord stopped pulsing. I'd say my son was a good 5-10 minutes old before the cord was cut. I had one child with polycythemia. #2. He also required phototherapy. Babies #7 and #8 also required phototherapy. All three had their cords clamped immediately.
The three that required phototherapy were also 3 of my 5 born before 40 weeks.
Anecdotes are not data but in my babies I haven't seen immediate cord clamping to be of any benefit to them *except* when it is necessary for the baby to go to the NICU team.
I agree, the burden of proof is on immediate cord clamping, not delayed. If it (delayed) was unhealthy, then it wouldn't be part of normal human (and mammalian) physiology. The normal, healthy, functioning body does not need routine artificial intervention to save it from itself.
I have been wondering about this in the case of twins. Is there any difference between the "risks" of not cutting the cord in a singleton delivery versus a twin delivery? What if there are two placentas? Or a single placenta?
good question anonymous -- anyone know the info regarding cord clamping for twins? One placenta vs two?
I would imagine that there is an increased risk, no matter which way you do the cord clamping, of placental separation starting to occur after the birth of the first twin, so it's imperative to safely get the second baby born ASAP.
Would you be able to post or email to me the citations for some of the research you read for this? Our nursing counsel is working on trying to implement delayed cord clamping for our unit, and it will be an uphill battle convincing some of the attendings. thanks so much!
Coggins and Mercer (2009) "Delayed Cord Clamping" found in AWHONN.
Mercer, et al (2007) "Evidence-Based Practices for the Fetal to Newborn Transition", Journal of Midwifery and Women's Health, Volume 52, No 3, May/June 2007. This one also examines multiple other studies on cord clamping timing and outcomes of newborns (see within the article to determine which studies you would like to read).
That should get you started Anne.
Also, in the Cochrane Review (2009): "Jaundice requiring phototherapy
(five trials - Emhamed 2004; McDonald 1996; Nelson 1980;
Oxford Midwives 1991; van Rheenen 2007: 1762 infants)
Significantly fewer infants in the early cord clamping group required phototherapy for jaundice than in the late cord clamping
group (RR 0.59, 95% CI 0.38 to 0.92). This equates to 3% of
infants in the early clamping group and 5% in the late clamping
group, a risk difference of 2% (95% CI -0.04 to 0.00)."
Love to see these issues come to light. If we are truly evidence-based practitioners, then let's discuss the evidence, and especially who pays whom for the results of studies. Clamping the cord immediately after birth without legitimate reason (e.g. mom or baby in critical distress) is not best practice.
I am by no means as experienced, but when I was on my Obs rotation in third year, we weren't really given guides as such for cord clamping.
What we were told was first to clean baby's eyes, nose and mouth and then to clamp. Maybe (most likely) I was just slow, but by that time all their cords had stopped pulsating.
The exceptions were when a mother was HIV positive (extremely high prevalence in South Africa) and Rh-incompatibility.
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