Physiologic Cord Clamping

***This is an edited and updated article about cord clamping that I originally published in 2015. Way back then, this term was brand spanking new***

For most of my career, I have been on a quest 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.) Today, I want to discuss the concept and language around delayed cord clamping. I prefer to use the 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.

Photo by Aubre Tompkins

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” (actually early obstetricians) who preferred birthing people to be laying down. This practice disrupted 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. Then, in the early 20th century, premature 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 current birth center and my previous one, we cut and clamp the cord after the birth of the placenta. Our own internal statistics (from both centers) with close to 3,000 newborns, demonstrate that this practice is 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.

cord clamping
Photo by Lindsey Eden

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 ,  here and here.

Photo by Lindsey Eden

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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