Physiologic Cord Clamping 29


I have been on a quest recently to take back much of the language that we utilize around birth in our culture. (You can read another piece on the idea of my language revolution in regards to Community Birthing here.) For this piece, I plan to discuss the concept and language around delayed cord clamping. I would like to suggest an alternative phrase; physiologic cord clamping. When we use the word delayed, this makes it sound as though we are doing something abnormal and delaying what is normal or appropriate. Instead, let’s turn the tables and refer to immediate clamping as “premature” cord clamping and place the emphasis on this practice as an interruption in the normal process.

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  • What is the history of cord clamping? When and why did premature clamping become the norm? Early historical accounts by midwives and traditional birth attendants often do not clearly address the timing of the severing of the umbilical cord but some evidence points to physiological clamping that occurred well after the birth of the placenta. It is theorized that the practice of immediate clamping began sometime in the 17th century with the appearance of “male midwives” who preferred women to birth laying down, thus interfering with the physiologic process of third stage which required more frequent manual removal of the placenta. So, premature clamping likely originated as a procedure for the needs of the provider; if you are going to do a manual removal of the placenta (a life saving but rarely needed intervention in physiological birth) having the cord clamped and cut makes it much easier. In the early 20th century, early clamping of the cord was thought to help prevent “excessive” transfusion of maternal blood that could cause hemolytic disease of the newborn. This theory was not based in research or evidence but rather an “idea” and the supposed benefits never materialized. Never the less it became wide spread practice. Then, in the 1950’s, the famous Virginia Apgar, the developer of the now universal ‘Apgar’ test for the assessment of newborns based her work on babies whose cords had been immediately clamped and even referred to the unclamped cord as a “contamination” of the required sterile field.  All of these factors and many more have led us to where we are now with the practice of immediate, or what I prefer to call premature cord clamping. You can read more about this history here.

 

  • Whose blood is the cord blood anyway? Isn’t it extra blood? This is a critical concept in my opinion. Naming the blood “cord blood” makes it sound as though it belongs to the cord and not the baby. In reality, this blood belongs to the baby. It is important to point out that in the womb; the placenta, umbilical cord and baby are all one entity, they do not function apart from each other.  They are inseparable and the blood that is found in any one of these locations is part of the total blood volume that baby utilizes. At the moment of birth, the amount of blood that is in the umbilical cord and the fetal side of the placenta is between 80-100 ml. This may not seem like very much, however, in relation to the baby’s size this is up to 1/3 of their total blood volume; the blood volume that they are accustomed to having. If I as an adult was suddenly deprived of 1/3 of my blood volume, I would absolutely feel the effects, not just at the moment but for a long period of recovery afterwards.  In essence, this is what happens to our newborns when we practice premature cord clamping.  At my birth center, we cut and clamp the cord after the birth of the placenta. Our own internal statistics with well over 2,000 newborns, demonstrate that this safe and healthy; excellent Apgar scores, high rates of breastfeeding and low rates of pathologic jaundice.  Newborns are immediately placed in the arms of the birthing person, and are kept skin to skin–uninterrupted–until they latch themselves to the breast and then nurse until they are done. In the event that a baby requires some level of resuscitation, these measures are easily done with the cord kept intact. In fact, as a provider, in those cases I am happy to have the additional support of the umbilical/placental oxygen system. I would also note that our babies are very alert and active and typically require little stimulation. Here I will venture into the realm of my personal theory and “wild speculation” so please take it as such; I posit that the “normal” newborn observed in a setting that practices premature clamping is one who is in mild shock from the deprivation caused by that clamping and often requires more stimulation and takes longer to become alert. Additionally, the “normal” laboratory values for newborn blood counts (hematocrit, hemoglobin, red blood cells, etc) used today were derived from babies who experienced premature clamping and therefor are actually abnormal and represent low levels.

 

  • Are there any proven benefits to physiologic clamping?  To me, the real question should be, “What are the benefits of premature cord clamping?” This practice should be justified as it is the interruption in the physiologic process. But alas, today’s maternity culture requires that in order to affect change we are expected to produce the evidence that demands a return to traditional practice. Luckily, as per usual, the evidence is indeed in our favor. At this point the health benefits of physiologic cord clamping have been well documented, both for premature and term infants. The World Health Organization recommends that the cord be clamped not any sooner than 1 minute after birth and that 1-3 minutes is considered optimal, you can read the full report here. There is also new emerging research that adds even more strength the practice of physiologic clamping; in July of 2015 a new study reported finding that there are potential benefits to children, especially in boys, years down the road in increased neurological and fine motor development, you can read more about this here. It has also been well documented that physiologic cord clamping has important benefits in relation to long term iron stores. Adequate iron levels are crucial for neonatal brain and neurological development. Additionally, there has been some concern about physiologic cord clamping and an increase in pathological jaundice that requires intervention, in some studies there a very small risk for this and in others there is no increased risk. You can read more about these issues here and here.

So, it seems logical to ask ourselves why our system still practices the non-evidence based practice of premature cord clamping? The available evidence is growing to support a return to physiologic cord clamping and it is starting to make a come back in certain areas. Let’s start by taking back the language; call out early clamping for what is as premature. And give the proper reference to delayed as physiologic cord clamping. If you are a birth attendant when do you clamp the cord and why? If you are a parent when was your baby’s cord clamped and where did you give birth?

 

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Top Image Credit Monet Nicole

Bottom Image Credit Briony Hope


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29 thoughts on “Physiologic Cord Clamping

  • Lucy

    Very interesting — thank you! Do you know if one would one be able to donate umbilical cord stem cells to a public bank if one delayed clamping? In other words, if one left the cord for 3 minutes after birth, would one still be able to donate stem cells, while giving one’s child the benefits of physiological clamping? Or are the two practices incompatible?

    • aubrekate Post author

      Lucy, this is a good question and one that I have been asked before. I have spoken with the “reps” of all the major US cord blood banking companies and they have across the board replied to me that it is possible to do both. However, in practice, it can be more tricky. I have found that the sample size requested by the blood banks is usually 60-100ml. What is typically found in the cord at birth is 80-100ml so this can make it very tricky to try and do both. I have done it though, kind of a half and half approach, for families who really wanted both.

  • Jenny

    My son had a physiological third srage and only cut cord when the placenta was out due to an unplanned homebirth. He then got polycythaemia which, as a midwife myself made me feel cheated, like I’d done something wrong. The paediatricians couldn’t believe I had ‘left’ it that long and it’s left me feeling a bit ambiguous about it now whereas before I was such an advocate for delayed clamping.

      • aubrekate Post author

        Thanks for sharing this presentation, I have watched about half of it so far and it very thorough. I must admit that I am chuckling at his complete omission of midwives and midwifery so far. Does he ever circle back around to us and our history around cord clamping?

    • aubrekate Post author

      Jenny, this always intrigues me. At my birth center, we have over 2,000 babies and never have had a baby with polycythemia. We routinely cut and clamp the cord after the birth of the placenta. Did your son have objective signs or symptoms of polycythemia? Or was he diagnosed based on a routine blood count check? This goes back to a point I made in the article about what the normal newborn blood count values are based on as I posit they are based on data from newborns who experienced premature cord clamping. Having polycythemia based simply on lab data is very different than if there were signs or symptoms. Does that make sense?

    • aubrekate Post author

      Denise, I mostly agree with you. I think “we” usually do way to much interference in the birth process, but I also feel that we do need to have some standardized way of communicating. I attend many births where there is no VE and I also attend births where I have had to do one. And yes, most placentas will birth on their own, but I have had rare cases where they have not and I needed to intervene. I am averse to saying that anything; an intervention or lack thereof should ‘always’ or ‘never’ happen or be needed. Each birth is its own unique process and I will respond or not accordingly. But, for sure less is usually more in my opinion.

  • April Ross

    Great info. Can you give any info on the best way to get a blood sample from the cord without clamping prematurely? I am Rhesus neg and expecting my 4th child. Last birthwe delayed until after placenta was delivered but couldn’t get a sufficient sample from placenta resulting in babe needing to give blood next day in hospital, we had a home birth.! Not wanting a repeat this time but cannot find any info. Thanks

    • aubrekate Post author

      April, thanks for reading my article. Your question is one that I have gotten before. At my center, we routinely cut and clamp the cord after the birth of the placenta and are usually easily able to draw a small sample of cord blood from the cord insertion site on the placenta. Our lab only requires a sample of 1cc, which is very small. So, that would be my “tip”; draw the sample from the vessels that can be found at the insertion site on the placenta. There is usually enough residual blood there for the sample. I hope this helps and good luck to you this time with getting this done.

  • Karen Strange

    Well written and addresses the main points of what happens with immediate cord clamping. Terminology is the beginning.
    I recently heard Dr. Frank Louwen a German OB give a lecture (with fabulous videos and photos) on breech birth to a large audience of OB’s, Pediatricians, Neonatologists, midwives, and the general public. It was fascinating, clear, descriptive and very easy to understand. It was an hour long and about every 8 minutes he stopped lecturing and went to the front of the stage and said, KNOW NORMAL. If you know normal, its hands off. If you know normal you also know when it is not normal and then you do the least amount to get it back to normal, then it’s hands off again. He did this repeatedly during his lecture. That really sunk in in a new way.
    As a midwife, I feel I have always known normal but over time I have learned that so many things I learned to do actually interfere with normal physiology.
    The cord is one major area which most of us leave alone but as Aubre wrote so clearly the question is what are the benefits of immediate cord clamping…and as a midwife I have to ask myself, is what I am doing interfering with normal physiology of labor and birth the period after birth? What the benefits of everything I “do” at birth. The cord is a great place to start.
    Thank you Aubre, I love your article!

    • aubrekate Post author

      Karen,
      Thank you for your thoughtful comments. Yes, I feel as a midwife, my expertise is to know normal and to know it inside and out; that way when something is not normal I know when to intervene. I actually learned this working with newborns in the nursery at the hospital. Being exposed to so many babies over the years gave me excellent “radar” for when something is off, often times these signs are very subtle and easily missed. So knowing normal is critical. That talk and the speaker sound amazing, I love that approach of stopping at certain intervals to help cement a point! Powerful stuff.
      We must always question and examine everything that we do and don’t do. And yes, let’s turn the tables and make “medicine” justify the interference as opposed to us having to justify the physiologic process.
      I also just have to say, that as the expert in the neonatal transitional period that you are, your opinion on this matter means a great deal to me. I am honored that you find my article insightful and good.

  • Erin

    I am a NICU nurse who tends to be a little more in tune with how perfect women’s bodies are … And that less intervention is almost always more… I wanted to say this was a great article and I find it so interesting about the terminology used!! Thanks for this great article!!

    • aubrekate Post author

      Kerri,
      Congratulations on your babies! Monoamniotic/Monochorionic twins are ones who share a placenta and the amniotic sac but have separate umbilical cords. These births can be tricky and should be attended by a provider with experience in these cases. I do not attend these births and so do have this experience. Also, I am not in a position to give you specific medical advice. I would recommend that you discuss this issue with your care provider. I do however, wish you a healthy pregnancy and birth! Blessings.

  • Denise Hynd

    I am a homebirth midwife in New Zealand where I take blood from the placenta to do the testing of baby’s blood after a physiological birth of the placenta that is leaving the placenta to stop pulsating before the (RHesus negitive or not) woman births her placenta!

  • Ola Andersson

    Dear Aubre,
    you bring some interesting thoughts on what language to use when to refer to the different timings of cord clamping, and I must admit; I haven’t thought of how misleading the term ‘cord blood’ might be.
    Also thank you for linking to our research results, although it might be better to link directly to the paper (http://dx.doi.org/10.1001/jamapediatrics.2015.0358) than to the (excellent) article by NPR? You can also watch me explaining our findings in a short Youtube clip: https://youtu.be/eg1a4BBrl84

  • Patricia

    Thanks for writing something on this important issue. Instead of “timing it” how about waiting for the cord to stop pulsating and blanche white? Even better, how about waiting till the placenta has delivered, like all other placental land animals do? Mother Nature has had millions of years to perfect how third stage happens and we would do well to understand that there must be some very good reasons for the fact that things happen the way they do if we don’t interfere.

    • aubrekate Post author

      Hi Patricia, thanks for checking out my post! At my birth center we absolutely wait to clamp and cut the cord until after the placenta has birthed and usually until after the babe has nursed even.

  • Denise Hynd

    So appropriate to talk about the placenta being birthed rather than delivered there is no safe pulling out or delivering of any placenta unless the uterus is held back. This latter is not physiological also when we leave the cord to stop pulsating the emptying of the blood volume in the placenta aids it’s seperation from the wall of the uterus and itsbirth!!