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Common Objections to Delayed Cord Clamping – What’s The Evidence Say?

November 13th, 2012 by avatar

by Mark Sloan M.D.

Today’s guest post is written by Dr. Mark Sloan, pediatrician and author of Birth Day: A Pediatrician Explores the Science, the History and the Wonder of Childbirth.  Dr. Sloan shares information and current research on delayed cord clamping after birth, in a helpful Q&A style format that consumers and professionals can use to discuss this important topic.

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photo credit pattiramos.com

Many maternity care providers continue to clamp the umbilical cord immediately after an uncomplicated vaginal birth, even though the significant neonatal benefits of delayed cord clamping (usually defined as 2 to 3 minutes after birth) are now well known.

In some cases this continued practice is due to a misunderstanding of placental physiology in the first few minutes after birth. In others, human nature plays a role: We are often reluctant to change the way we were taught to do things, even in the face of clear evidence that contradicts that teaching.

Though there is no strong scientific support for immediate cord clamping (ICC), entrenched medical habits can be glacially slow in changing. Here are some often-heard objections to delayed cord clamping (DCC), and how an advocate for delayed clamping might respond to them:

1) I have a very busy practice. DCC takes too much time!

Not really, especially when you consider the benefits. Nearly one-third of a baby’s total blood volume resides in the placenta at birth. Half of that blood is transfused into the baby by 1 minute of age. By 3 minutes, more than 90% of the transfusion is complete. (1)

 2) Immediate clamping helps prevent severe postpartum hemorrhage.

There is no convincing evidence to support this view. Several large studies, including a 2009 Cochrane review of 5 trials involving more than 2,200 women, have found no significant difference between ICC and DCC in terms of postpartum hemorrhage or severe postpartum hemorrhage. (2-6, 10)

 3) A healthy, term baby doesn’t get much benefit from delayed clamping.

Though this is a commonly held belief, it’s definitely untrue.

Whether a fetus is premature or full term, approximately one-third of its total blood volume resides in the placenta. This is equal to the volume of blood that will be needed to fully perfuse the fetal lungs, liver, and kidneys at birth.

In addition to the benefits that come with adequate iron stores (see below), babies whose cords are clamped at 2 to 3 minutes—and thus, who have an increased total blood volume compared with their immediately-clamped peers—have a smoother cardiopulmonary transition at birth.

A third benefit: stem cells, which play an essential role in the development of the immune, respiratory, cardiovascular, and central nervous systems, among many other functions. The concentration of stem cells in fetal blood is higher than at any other time of life. ICC leaves nearly one-third of these critical cells in the placenta. (1,3,4,6-10)

Unclamped cord over the course of 15 minutes.
photo nurturingheartsbirthservices.com

 4) Okay, so delayed clamping means a baby gets more blood and more iron. But iron deficiency isn’t really a problem in first-world countries, right?

Wrong. At least 10% of the general U.S. toddler population (1-3 years of age) is iron deficient, with the prevalence rising well above 20% in selected ethnic and socioeconomic populations.

Immediate cord clamping is only one of many factors that contribute to iron deficiency in early childhood. But babies who start out life low on iron have a very difficult time catching up. Delayed cord clamping provides a baby with as much as a 4- to 6-month supply of iron. (1,3,6-10)

 5) Doesn’t iron deficiency just make kids tired?

Iron deficiency does much more damage than that. Early infancy is a time of rapid brain growth and development, and iron is essential to that process. Studies of infants with iron deficiency have found specific deficits in cognitive processing (including attention and memory) which may lead to permanently decreased intellectual functioning. Making matters even worse, children with severe iron deficiency often exhibit “emotional dulling”—difficulty engaging with caretakers and their environment—which can lead to long-lasting social-emotional deficits. For many reasons, early infancy is a particularly bad time to be low on iron. (1,11)

 6) Don’t babies get plenty of iron from breast milk? 

Unfortunately, no. While breast milk contains a remarkable array of healthful components, a high concentration of iron isn’t one of them. This most likely has to do with maternal recovery from childbirth. A recuperating mother has her own urgent iron needs; replacing the blood typically lost in childbirth takes a lot of it. Nature intends babies to get most of the iron they’ll need for their early development from the placental blood reservoir, rather than from mother, and so comparatively little iron goes into breast milk.  (3,7)

 7) But the baby can lose significant blood volume back into the placenta (aka “backflow bleeding”) if clamping is delayed.

This is extremely unlikely in an uncomplicated birth. With some brief exceptions (e.g., between uterine contractions, or when a baby bears down during crying), blood flow immediately after birth is primarily one-way, from placenta to baby. Here’s a brief explanation of why this is true:

In a process that begins during labor and accelerates as the newborn begins to cry, the pulmonary blood vessels, which receive very little blood flow during pregnancy, open and fill. This relatively sudden change causes the newborn’s blood pressure to fall below the pressure in the placenta. Placental blood, driven by strong uterine contractions, follows the pressure gradient and flows through the umbilical vein into the baby.

As the newborn’s oxygen saturation increases, the umbilical arteries close, which stops nearly all blood flow from baby to placenta. The umbilical vein, which isn’t sensitive to oxygen, remains open somewhat longer, allowing a final bit of blood to flow from placenta to baby before it, too, closes.

The lack of significant “backflow bleeding” is confirmed by the fact that DCC results in ~ 30% greater neonatal blood volume than does ICC.  (1,12)

8) DCC can lead to dangerously high levels of neonatal jaundice.

Since bilirubin, the source of neonatal jaundice, originates in red blood cells, it seems logical that the increased blood volume associated with delayed clamping could lead to severe hyperbilirubinemia.

Yet while some studies have demonstrated mildly increased bilirubin levels in DCC babies in the first few days postpartum, most have found no significant difference between DCC and ICC.

This seeming paradox—relatively stable bilirubin levels in the face of substantially increased blood volume—may have to do with increased blood flow to the neonatal liver that comes with the higher total blood volume associated with DCC. Yes, more blood means more bilirubin, which in turn could mean more jaundice, but better blood flow allows the liver to process bilirubin more efficiently.  (3,4,6,7,9,10)

 9) Delayed clamping can lead to neonatal hyperviscocity—“thick blood” that can cause kidney damage and strokes.

DCC can lead to a somewhat higher neonatal hematocrit than ICC, which isn’t surprising given the additional blood volume. Yet, despite fears of thicker blood “sludging” in organs like the brain and kidneys, no studies have demonstrated this to be the case from DCC alone. (4,6,9,10)

 10) You can’t have both the benefits of DCC and immediate skin-to-skin contact. If you place a newborn on his mother’s abdomen (i.e., above the level of the placenta), gravity will reduce the flow of blood from placenta to baby.

Gravity does matter, but mainly in terms of the speed of the placental transfusion. A baby held below the level of the placenta will receive a full transfusion in about 3 minutes; one held above the placenta (e.g., a baby in immediate skin-to-skin contact) will also receive a full transfusion—it just takes a little longer (about 5 minutes). (1,13)

 11) But what if the baby needs resuscitation? Isn’t it best to hand her over to the pediatrician immediately?

One of the first things a truly sick baby in the NICU is going to receive is fluid support—often as a 20 to 40 ml/kg bolus of normal saline or blood. Yet that is exactly what’s left behind in the placenta with ICC—about 30 ml/kg of whole blood. There is considerable evidence that sick babies, both term and preterm, have better outcomes with DCC. It’s better to let nature do its own transfusing. (14-16)

Summary: 

Delayed cord clamping promotes a healthy neonatal cardiopulmonary transition, prevents iron deficiency at a critical time in brain development, provides the newborn with a rich supply of stem cells, and helps sick neonates achieve better outcomes—all with little apparent risk to mother or baby. The evidence of benefit from DCC is so compelling that the burden of proof must now lie with those who wish to continue the practice of immediate clamping, rather than with those who prefer—as nature intended—to wait.

What do you tell your patients, students and clients about delayed cord clamping?  Do you have a favorite resource or two that you like to share?  What are the community standards around delayed cord clamping in your community?  Are health care providers discussing this with their patients?  Do they have recommendations one way or another that you are hearing?  Please join in the discussion.- SM

References

1) Mercer JS, Erickson-Owens DA. Rethinking placental transfusion and cord clamping issues. Journal of Perinatal & Neonatal Nursing. July/September 2012 26:3; 202–217 doi: 10.1097/JPN.0b013e31825d2d9a

2) Andersson O, Hellstrom-Westas L, Andersson D, et al. Effects of delayed compared with early umbilical cord clamping on maternal postpartum hemorrhage and cord blood gas sampling: a randomized trial. Acta Obstetricia et Gynecologica Scandinavica. Article first published online: 17 Oct, 2012. DOI: 10.1111/j.1600-0412.2012.01530.x

3) Chaparro, CM. Timing of umbilical cord clamping: effect on iron endowment of the newborn and later iron status. Nutrition Reviews. Volume 69, Issue Supplement s1, pages S30–S36, November 2011.

4) Ceriani Cernadas JM, Carroli G, Pellegrini L, et.al. The Effect of Timing of Cord Clamping on Neonatal Venous Hematocrit Values and Clinical Outcome at Term: A Randomized, Controlled Trial. Pediatrics. Vol. 117 No. 4 April 1, 2006 pp. e779 -e786 (2,3 8,9(doi: 10.1542/peds.2005-1156). Published online March 27, 2006.

5) WHO. Department of Making Pregnancy Safer. WHO recommendations for the prevention of postpartum haemorrhage. Geneva: World Health Organization, 2007.

6) McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD004074. DOI:10.1002/14651858.CD004074.pub2.

7) Andersson O, Hellstrom-Westas L, Andersson D, Domellof M. Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. British Medical Journal. 2011; 343: d7157. Published online 2011 November 15. doi:  10.1136/bmj.d7157

8) Ceriani Cernadas JM, Carroli G, Pellegrini L, et.al. The effect of early and delayed umbilical cord clamping on ferritin levels in term infants at six months of life: a randomized, control trial. Arch Argent Pediatr. 2010; 108:201-208.

9) Hutton EK, Hassan ES. Late vs early clamping of the umbilical cord in full-term neonates: systematic review and meta-analysis of controlled trials. JAMA. 2007 Mar 21;297(11):1241-52.

10) McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD004074. DOI:10.1002/14651858.CD004074.pub2.

11) Carter RC, Jacobson JL, Burden MJ, et al. Iron deficiency anemia and cognitive function in infancy. Pediatrics. 2010; 126:2 pp e427-e434 (doi: 10.1542/peds.2009-2097).

12) Mercer JS, Skovgaard R. Neonatal Transitional Physiology: A New Paradigm. J Perinat Neonat Nursing 2002; 15(4) 56-75

13) Yao AC, Lind J. Effect of gravity on placental transfusion. Lancet. 1969; 2:505-508.

14) Mercer JS, Vohr BR, Erickson-Owens DA, et al. Seven-month developmental outcomes of very low-birth-weight infants enrolled in a randomized controlled trial of delayed versus immediate cord clamping. J Perinatol. 2010; 30:11-16.

15) Kinmond S, Aitchison TC, Holland BM, et al. Umbilical cord clamping and preterm infants: a randomized trial. British Medical Journal. 1993; 306:172-175.

16) Rabe H, Wacker, A, Hulskamp G, et al. A randomized controlled trial of delayed cord-clamping in very low-birth-weight preterm infants Eur J Pediatr. 2000; 159:775-777.

About Mark Sloan, M.D.

Mark Sloan has been a pediatrician and a Fellow of the American Academy of Pediatrics for more than 25 years. Since 1982, he has practiced with the Permanente Medical Group in Sacramento and Santa Rosa, California, where he was Chief of Pediatrics from 1997 to 2002. He is an Assistant Clinical Professor in the Department of Community and Family Medicine at the University of California, San Francisco. Dr. Sloan’s first book, Birth Day: A Pediatrician Explores the Science, the History and the Wonder of Childbirth was published in 2009 by Ballantine BooksHis writing has appeared in the Chicago Tribune, the San Francisco Chronicle, the San Francisco Examiner, and Notre Dame Magazine, among other publications.  Dr. Sloan can be reached through his blog.

 

American Academy of Pediatrics, Delayed Cord Clamping, Do No Harm, Evidence Based Medicine, Healthy Birth Practices, Healthy Care Practices, informed Consent, Medical Interventions, Newborns, Research, Third Stage, Uncategorized , , , , , , , , , ,

  1. avatar
    Tess
    November 13th, 2012 at 08:22 | #1

    Thanks so much for this post, I am a post grad student of evolutionary medicine and am trying to convince my lecturer that this is a valid topic to study from an evolutionary perspective. It certainly appears to me that there is enough disadvantage in immediate cord clamping to argue that delaying is the evolutionary norm and has fitness implications.

  2. November 13th, 2012 at 12:08 | #2

    I am infinitely pleased that more and more physicians are vocalizing support of DCC. As a doula and educator, I do my best to help parents understand the benefit, but it does absolutely no good if their doctor doesn’t practice that way. I’ve seen parents ask AS the baby is being delivered, “Please make sure you delay clamping” and the second the baby’s feet are delivered, the provider clamps so fast nobody can stop them. It’s incredibly frustrating.

  3. November 13th, 2012 at 12:21 | #3

    Thank you for writing this concise piece. It will be good to have one source to which I can refer my students.

    I was wondering if you can clear up some confusion regarding DCC and donating or banking cord blood. Everything I’ve heard / read says that it’s an either / or scenario. Either you DCC or you donate, but not both due to an insufficient amount of blood. However, Gina @TheFeministBr mentioned yesterday that you can do both DCC and donate.

    So, I’m looking for some clarification. Thanks!

  4. November 13th, 2012 at 14:21 | #4

    I’m happy to see that ICC is losing popularity in large hospitals where I’ve worked– even just a couple of years ago, immediate cord clamping was used regularly. The last several births I attended at a teaching hospital were all DCC, one of which was with a compromised baby who needed resuscitation (they did it bedside with cord intact). Patient demand is the #1 driving force of this, more than research, and I’m glad new physicians are learning more gentle ways to welcome babies.
    Thanks for such a great post Dr. Sloan–I always look forward to what you have to say!

  5. avatar
    Chan McDermott
    November 13th, 2012 at 16:49 | #5

    Thanks so much for the great article — very helpful! I’m looking forward to checking out your book. I echo Deena’s request that you address DCC and cord-blood banking — I’d love to hear your perspective. thanks!

  6. avatar
    Denise Hynd
    November 13th, 2012 at 16:54 | #6

    Though it is time t talk about the benefits of physiological birth of the placenta and baby I thank you for this reat summary article -t the link for which I have put on my blog “Hands off the Cord!” at http://birthmatters.co.nz/issues-of-birth-rights/hands-off-the-cord/

  7. avatar
    Jackie Levine
    November 13th, 2012 at 18:17 | #7

    @Deena Blumenfeld RYT, RPYT, LCCE
    Deena, I’ve had this information about how to handle DCC and cord blood collection for a while, and give it to all classes and clients. I am careful to say that the baby needs its proper amount of blood to make a healthy beginning in the first minutes of life, and that cord blood collections should take 2nd place. This info came from one collection company in particular, but I think it’s safe to say that the info can be extrapolated to all of them. I’m not sure exactly where or how I found it, but it’s pretty definitive. The cord blood people have only recently taken steps to instruct that parent’s wishes to have the baby get its full complement of blood is an important part of customer service. Here it is:

    Ex-Utero Umbilical Cord Blood Collection Instructions (included in all PacifiCord collection kits):

    In the event of a precipitous delivery, emergency surgery, or a parents desire to allow the cord to stop pulsating, it is possible to collect the umbilical cord blood after the delivery of the placenta.

    1. After the placenta delivers, transfer the placenta into a sterile basin.

    2. Elevate the placenta to increase gravity and facilitate blood flow.

    3. Uncoil and straighten the umbilical cord and wipe cord clean with the sterile gauze provided.

    4. Starting at the most distal end of the cord, disinfect at least five inches of the cord with the alcohol wipes provided.

    5. Disinfect the same area with the PVP swab sticks provided.

    6. Using another alcohol wipe, remove the iodine prior to collection.

    7. Beginning at the most distal end of the cord, insert collection bag needle bevel down into the umbilical vein and hold in place.

    8. Lower collection bag and allow the blood to drain to gravity, rotating the collection bag to mix the anticoagulant. It should take approximately 2-5 minutes to collect the remaining blood.

    9. If blood flow stops or slows during the collection process, or if the umbilical vein collapses, select another site closer to the placenta. Repeat the cleansing process and reinsert the needle.

    10. If blood flow or collection volume is poor, the placenta can be gently massaged to promote increased blood collection.

    Wendy Spry, LVN, CPSS
    Healthcare Educator, PacifiCord
    wspry@pacificord.com
    http://www.pacificord.com
    P: (949) 379-5241
    Ex-Utero Umbilical Cord Blood Collection Instructions (included in all PacifiCord collection kits):

  8. avatar
    Tessa K.
    November 13th, 2012 at 20:03 | #8

    Another reason is: 12) But, delayed cord clamping during a Caesarean is not normal procedure.

    Great article – love the info here. :)

  9. November 13th, 2012 at 20:49 | #9

    Since attending the first Lotus Born baby here in Australia 26yrs ago I have been very aware of the significance of the placenta. I encourage you to explore this amazing birth option that is now being practiced world wide. That babies are still subjected to massive blood loss at birth is scandalous and with the information that it is damaging readily available must be seen as malpractice. We are yet to ascertain how many long term health conditions are set in motion by this horrific procedure. There were never any controlled trials to establish that cutting the cord immediately was advantageous. It’s plain common sense that it is wrong to do so.. Leaving prem babies with their placentas will improve outcomes dramatically.

  10. November 13th, 2012 at 21:05 | #10

    @Shivam Rachana Thank you for commenting on your experiences in Australia. I understand the procedure of Lotus Birth, which is that the baby remains connected to the placenta via the cord until it spontaneously falls off. (please correct me if I am wrong.) Can you provide any research that supports your statement that leaving preterm babies with their placentas improves outcomes. I am not sure I even understand what could is happening between the baby and the placenta after the placenta has been expelled. I would love to read more information and review studies on the benefits. Thank you.

  11. November 14th, 2012 at 10:26 | #11

    Cord clamping would be a great topic for discussion in evolutionary medicine. There’s a quote I love by Aristotle: “Nature does nothing without reason or in vain.” That’s certainly true of the timing of cord clamping and the benefits of placental transfusion. The rush to cut the cord is a 20th-21st century phenomenon–not even a blink of an eye on the evolutionary time scale. @Tess

  12. November 14th, 2012 at 10:33 | #12

    Thanks for the details on DCC and cord blood banking, Deena. The pros and cons of cord blood banking itself is a whole different discussion, but it’s good to know a parent can have both if desired. Collecting cord blood for banking shouldn’t be allowed to interfere with the timing of cord clamping. @Jackie Levine

  13. November 14th, 2012 at 10:47 | #13

    In terms of the benefits of DCC, I haven’t seen any studies that found much benefit to waiting longer than a few minutes before clamping. Certainly in terms of the clear benefits of DCC to the newborn–increased iron stores, smoother cardiopulmonary transition, and an increase in circulating stem cells–it’s hard to see how leaving the baby attached to the placenta until it spontaneously separates (ie, long past the time that blood flows from placenta to baby) would improve on that. And preterm babies present their own issues; access to the cord vessels when newborns are sick (e.g. for fluid administration or blood sampling) is often critical.@Sharon Muza

    @Mark Sloan M.D.

  14. November 14th, 2012 at 15:39 | #14

    A nurse asked this question after I posted your article to our web site. I’d appreciate very much a response from Dr. Sloan. Thank you.

    “Last week I worked with a newborn after DCC who was having significant tachypnea in 80′s. The pediatrician said it was likely polycythemia related to DCC. Sludgy blood trying to oxygenate the body. Was expected to resolve without intervention but it did seem like an unnecessary stressor on the new parents and lots of work for baby who appeared a bit hesitant at the breast because he was huffing and puffing so much. Feedback? Thoughts?”

  15. avatar
    Jackie Levine
    November 14th, 2012 at 16:30 | #15

    @Mark Sloan M.D.
    Just to say, Dr. Sloan, it was me, Jackie Levine, who posted the protocol from the Pacificord company. And Dr. Sloan, as you said, banking cord blood is a whole other discussion.

    The most galling aspect of all is the fact that, as item #1 of your article explains, there are caregivers who are so “busy” that they don’t have the time to wait respectfully for this new baby, this new life, to be treated as best-evidence care demands. OBs are quick to admonish mothers that the caregiver is responsible for her health and the health of her baby, but when a doc behaves in a way that is so obviously contrary to that very health and safety, how can that possibly build respect and trust in the caregiver-patient relationship?

    It’s not only that caregivers don’t have “time” for DCC…In 1998, a questionnaire mailed to family physicians and obstetricians found that only 40% felt that evidence-based medicine was “very applicable to obstetric practice”. Comments from this survey included “obstetrics requires manual dexterity more than science”, “evidence-based medicine ignores clinical experience”, and that following evidence-based guidelines could result in “erosion of physician autonomy”. These views were described as obstacles to the adoption of evidence-based practice. (Olatunbosun OA, Eduoard L, Pierson RA. Physicians’ attitudes toward evidence based obstetric practice: a questionnaire survey. Br. Med. J. 316, 365–366[1998]). No kidding! It’s kind of horrifying to read that those attitudes exist where maternity care is concerned…But after all, it’s not THEIR baby, is it?

    If you’re about to give birth, you should also know that ”since obstetrics generally has lagged behind other disciplines in its efforts to have standardized, outcomes-based practices, there may be greater cultural barriers among obstetricians to changing practices based on new data”(Northwestern University Feinberg School of Medicine, Department of Obstetrics and Gynecology, 680 North Lake Shore Drive, Suite 1015, Chicago, IL 60611, USA..From Gynecology: Changes in Episiotomy Practice: Evidence-based Medicine in Action Justin R Lappen; Dana R Gossett, Posted: 05/12/2010; Expert Rev of Obstet Gynecol. 2010;5(3):301-309. © 2010

    Judith Mercer did a great article on DCC in a Science and Sensibility post from Nov., 2009, and OB Nick Fogelson has a youtube grand rounds video to watch. Of course,there’s Penny Simkin’s great and charming video demonstrating the reasons for DCC on youtube as well. I suggest everyone google it and send the link to every mother-to-be in your address book. Show it to your classes. I use all these aids to alert parents-to-be, as well as articles like:
    Delayed Clamping of the Umbilical Cord: A Review with Implications for Practice – Gina Eichenbaum-Pikser, CNM, MSN; Joanna S. Zasloff, CNM, MSNPublished: 09/24/2009
    and:
    Delayed Umbilical Cord Clamping Advantageous in Preemies, Study Confirms SOURCE: http://bit.ly/MFvyYs Obstet Gynecol. 2012:120;325-330. Reuters Health Information © 2012

    How can any ethical caregiver, responsible for the health and safety of a new life, ignore this most important, evidence-based protocol? Grrrr!

  16. avatar
    Anne Ferguson
    November 14th, 2012 at 19:28 | #16

    So now how do we get hospitals to put procedures into place where bedside resuscitation can be the norm? That’s the next big thing I hope to see changing where I work as a doula. I have seen doctors mention the idea that skin to skin and DCC can’t go together (WHAT???) but I’ve also seen more traditional OBs being open to DCC. There’s hope for the future!

  17. November 15th, 2012 at 10:11 | #17

    My apologies, Jackie! @Jackie Levine

  18. November 15th, 2012 at 10:53 | #18

    Jody – though I can’t comment on a particular case, studies I cited in the bibliography (particularly numbers 4 and 6) have found no difference in the rate of symptomatic polycythemia between DCC and ICC. “Sludgy blood,” as you so well describe it, is associated with a number of common pregnancy conditions, including maternal diabetes, hypertension, smoking, and post-dates (1). DCC by itself does not increase that risk.

    And a correction: I realize in reviewing the bibliography just now that I inadvertently duplicated one reference (6 and 10 are the same reference). It doesn’t change the strength of the argument for DCC, but I apologize for the error. @Jody Branham CNM, MSN

  19. November 16th, 2012 at 17:35 | #19

    Hi Dr. Sloan, I just wanted to say thank you for this article! It is so well-written and I really appreciate your thoughtful responses to everyone’s questions. I agree with one of the other commenters– it will probably take consumer demand to shift this evidence-based practice into the mainstream.

    On my Facebook page, (http://www.facebook.com/#!/EvidenceBasedBirth) I linked to your article along with this question from a reader,”Is it ok to do skin to skin after birth before the cord is clamped? One of my OBs stated that HE would hold the baby, lower than the placenta until the cord stops pulsing.”

    I was amazed by the number of responses from people who said they hear this misconception all the time from care providers! Thank you for helping set the record straight!

  20. November 17th, 2012 at 02:24 | #20

    Dr. Sloan, a big thank you for taking the time to publish this article! I wholeheartedly agree, it is high time majority of parents are educated about delayed cord clamping. As a childbirth educator I am passionate about teaching pregnant couples about the advantages of DDC, so that they can become the spokesperson for their newborn child to receive it’s rightful quota of enriched blood flow and stem cells. In class I quote something along the lines of; “even as far back as in the year 1801, Eremus Darwin had written in his scientific papers: “the cord should not be tampered with, least the babies health be compromised”. Hopefully your article and this discussion will go a long way towards removing the myths about DDC. I will be sharing your article on my website (http://www.sydneywellbeing.com). Thanks again for being a valuable source of information!!!

  21. November 17th, 2012 at 15:14 | #21

    @Jackie Levine Thank you! This is the information I was looking for.

  22. avatar
    Mark Sloan
    November 17th, 2012 at 18:16 | #22

    @Katherine Ferris
    Thanks for your kind words about the post, Katherine. Erasmus Darwin (Charles’s grandfather) isn’t the only prominent physician who has taken issue with early cord clamping over the centuries. One of my favorite quotes is from Charles White M.D. (1728-1813), a renowned British obstetrician and founder of the Manchester Royal Infirmary.

    In his textbook, “A Treatise on the Management of Pregnant and Lying-In Women” (1773), White described the early cutting of the “navel string”—the umbilical cord—as an “error” that was still practiced simply because physicians (as opposed to midwives) were used to doing it that way:

    “Can it possibly be supposed that this important event, this great change which takes place in the lungs, the heart, and the liver, from the state of a foetus, kept alive by the umbilical cord, to that state when life cannot be carried on without respiration, whereby the lungs must be fully expanded with air, and the whole mass of blood be circulated through them…Is it possible that this wonderful alteration in the human machine should be properly brought about in one instant of time, and at the will of a bystander?”

  23. November 20th, 2012 at 22:18 | #23

    Hi Sharon, to appreciate the benefits of Lotus Birth, which is as you describe, one needs to extend their understanding of reality to the meta physical zone. This accounts for the energies that both surround and permeate our bodies. These systems are well documented in eastern health systems and are explained as chakras, meridians and the aura. They are engaged in acupuncture and shiatsu treatments. Quantum physics is now providing a frame work towards this understanding with studies of the body’s bio electrical fields. The aura is an energy field that surrounds each living thing. It is a vibrational force field that provides protection and information to the organism about its environment.

    Lotus Birth provides a time of energetic integration. The giving and receiving process that occurs between the baby and its placenta in utero continues energetically after birth. The placenta feeds vital energies to the child and draws away toxic vibrations.

    The person who began Lotus Birth was Clare Day. She was clairvoyant and could see auras (this is a much more common capacity than is generally recognized in our culture mainly because of the aggressive opposition to such notions) She recognized holes in people’s auras as cord trauma. The navel is a major chakra. The disturbance to this chakra with current obstetrical practices is brutal.

    During the days following the birth the baby’s placenta conducts a process of transmitting energy to and drawing energy from the baby. When the baby’s aura is complete the process stops and the cord comes away at the navel. As an intuitive visionary I consider that at this point the immune system has the support of an fully formed aura from which the baby benefits.

    There are additional benefits from Lotus Birth in that it creates a particular environment for the new born and the mother that enhances the post birth time and the establishment of the new relationship.

    My book Lotus Birth is available at http://www.lotusbirth.net and I think that you will find it fascinating.
    I also recommend the work of Dr Bruce Lipton http://www.brucelipton.com

  24. avatar
    Ann Grauer
  25. November 22nd, 2012 at 16:33 | #25

    Thank you Dr Sloan for such an excellent article. There has been some interest from paediatricians in the timing of cord clamping in preterm babies but very little in term babies and now that obstetritians are finding less reason to early clamp for the safety of the mother, paediatricans are voicing more concerns/objections regarding delayed cord clamping. I have always considered that DCC is close to physiology while ICC is the intervention. I suspect that the “normal range” of Hb , Hct and bilirubin are all obtained from a population of healthy babies AFTER EARLY CORD CLAMPING !

    The normal range really should come from babies who have a completely physiological birth and transition.

    One group of babies where early clamping seems to be indicated is when there is suspected fetal distress sufficient to result in respiratory depression. WE are developing a resuscitation trolley which is small and maneuverable and can right up to the mother so that the baby can be resuscitated without disconecting the cord and allowing the continued volume of blood together with any available oxygen within the blood to reach the baby. Very often I suspect given 20 seconds on the trolley with an intact placental circulation the baby will turn out to be rather less compromised than was thought. The LifeStart trolley is available in Europe from Inditherm plc. (I have no financial interest and all royalties are going to charity.)

  26. avatar
    Mark Sloan
    November 25th, 2012 at 16:20 | #26

    @David Hutchon
    Dr. Hutchon – I agree with you completely. Immediate cord clamping is an intervention, delayed cord clamping is not. Like all medical interventions, ICC should be judged on its merits. As the benefits of DCC become more apparent (and the benefits of ICC less so), it seems to me that the burden of proof should shift to those who want to continue to intervene via ICC, not on those who choose DCC.

    I agree, too, that the norms for neonatal Hct, bili, etc., were likely obtained from ICC babies, which could exaggerate the risks of DCC. It would be interesting to see comparable “norms” for a large group of DCC babies. We’ve seen this sort of norm-creation before – e.g., when growth curves from a subset of formula-fed, ethnically homogenous babies became the standard for tracking infant growth patterns.

  27. avatar
    Mark Sloan
    November 25th, 2012 at 16:25 | #27

    @Ann Grauer
    Ann – The ACOG Committee Opinion isn’t the last word on cord clamping. They didn’t oppose delayed clamping outright, just said they don’t feel there’s enough evidence to support it for term babies born in “resource rich” areas (a term they didn’t define). Their refusal to support DCC is odd, given the long list of DCC benefits they included in the Opinion, versus the only negative – an increased risk of hyperbilirubinemia.

    They did support DCC for preterm babies, so that’s good news.

  28. November 27th, 2012 at 11:28 | #28

    So well written and with great resources too! I wish I could share this with the whole world!

  29. avatar
    Kathy
    November 28th, 2012 at 08:54 | #29

    Great Information! I am excited to share more Evidence-based info with everyone! I so appreciated Jackie’s comments. As I work with many different providers I do find that the “medical management” model to be the least effective & satisfying for all involved. I am glad to have several more resources from this one article to refer to people seeking the best info we now have rather than a personal reason for someone other than the newborn. Thanks for all your hard work in research to help us provide the Best Care we can! As a nurse of many years in the birth field & a doula-in-training I appreciate up-to-date factual info to give to my future parents & to share with any of my birth colleagues.

  30. December 5th, 2012 at 05:07 | #30

    Jaundice is caused by the chemicals in the Vitamin K jab. The immature liver is not ready to cope with a huge dose of toxic chemicals on the first day of life.

  31. avatar
    Jennifer
    December 26th, 2012 at 14:29 | #31

    Dr. Sloan: I recently had a family where the baby had thick mec, vacuum delivery, and poor tracing, beg for DCC on the grounds that ICC would cause the baby to be autistic. While I’m a fan of DCC, this assertion made me laugh out loud. The rate of ICC over the past 4 or 5 decades has been pretty much the same or decreasing, while the autism rate has gone through the roof. While increased iron stores associated with DCC are obviously good for the brain, the autism argument seems beyond ridiculous. I went to the website they were looking at, and all of the studies seemed correlative: DCC improves iron stores, anemia is associated with decreased brain function, therefore ICC causes MR, CP, and autism. They note ICC is associated with Csections and low Apgars. Clearly, they have failed to see that the Csections and low Apgars are often due to other, more obviously brain damaging things, like placental insufficiency, abruptions, tight nuchal cords, and other causes of poor tracings, and that these are more likely the cause of brain damage than the ICC per se. I know that people want easy answers for autism, but this isn’t it.

  32. December 27th, 2012 at 14:29 | #32

    The belief that ICC can lead to autism is very similar to the disproved belief that vaccines cause autism. Both ICC and vaccine administration are experienced by the vast majority of American newborns, including many who will ultimately be diagnosed with autism. But association doesn’t prove causation, and any ICC-autism link is speculative at best.

    Having said that, I think a baby with meconium aspiration syndrome could benefit greatly from DCC in the near-term, as well as receiving the long-term benefits of improved iron stores. A final bolus of well-oxygenated blood — one that will help properly perfuse the lungs – may be just what that baby needs to keep from slipping into persistent pulmonary hypertension. As DCC-compatible resuscitation tables continue to be refined, hopefully we’ll see that become the standard of care.

  33. avatar
    Leah
    December 29th, 2012 at 17:13 | #33

    Thank you so very much for this article! I am expecting my first baby soon and in all my research about giving birth, I only once read any mention of the timing of cord clamping and cutting. It seems to be one of those things new parents don’t think about. My mom has had seven children – all with very limited to no intervention – and this subject stumped her too. I can’t tell you how happy I am to find this clear, concise, and (above all) well-documented information on DCC. Can you tell me how best to broach the subject with my rather old-school OB?

  34. December 29th, 2012 at 17:25 | #34

    I am glad that you found this article useful. You asked about how to best broach the subject with your OB. I suppose, the first thing to do is ask your OB what are his or her thoughts on the subject. You might be surprised to find out that your desire for DCC is exactly the way they already practice. It might be a pleasant surprise. If they do not reply in a way that lines up with the way you would like to have your baby and birth treated, I would print out the Dr. Sloan’s article and share it with your OB, explaining that this is one of the pieces of info you used to make your decision. Give them time to process it and inquire if they have current research that provides information that contradicts the sources used by Dr. Sloan. Ask if the OB might share the info they used to guide their practice. I think that with discussion, you and your doctor can find a way to make sure that your baby’s needs are met and your provider feels comfortable. Come back and let us know how that discussion goes!

  35. January 15th, 2013 at 07:19 | #35

    What a terrific and concise article. I will definitely use this article as a resource in my classes. Equally intriguing is the discussion that has followed. Thank you!

  36. avatar
    Katie Garrett
    January 23rd, 2013 at 19:04 | #36

    had a frustrating event occur today during a delivery at a local hospital. I was attending a birth when the doctor I work for decided to come in the room for the delivery. The mother had asked that the cord clamping be delayed until it no longer pulsed. The OB/GYN told me to cut the cord as soon as the baby was out even though the mother requested again that we delay cutting(baby was pink and crying). As a Nurse-Midwife I am obligated to do what the doctor tells me to do, I had no choice but to go on and cut the cord. The doctor patted the pt’s arm and told her that “we don’t want the baby to loose all her blood” Needless to say I was upset and the pt was heart broken. The pt had expressed regrets about not requesting DCC with her previous 2 births. I am hoping that this article will help me convince the doctor that DCC is beneficial not detrimental to term newborns. Thanks for this article-and wish me luck!

  37. avatar
    Ellie Bradway
    January 25th, 2013 at 19:27 | #37

    @Jody Branham CNM, MSN
    When I hear of “Sludge” blood I think of the Vitiman K shots that makes the blood thick. It is very hard to offer suggestions because so many factors can play into it ranging from genetic issues to possiable drug effects if mother had pain medicaions.

  38. avatar
    Rebecca
    March 7th, 2013 at 04:11 | #38

    Great article

  39. March 15th, 2013 at 07:54 | #39

    Fantastically useful article that articulates the facts and overcomes potential objections in language that birth professionals would take seriously. Birthing parents facing objections can refer their practitioners to this article. Particularly pleased to see the argument for babes needing resuscitation though there is no mention of the fact that oxygen is supplied to the baby through the umbilical cord whilst there is blood flow, thus providing a back up oxygen supply while breathing from the lungs is established. It makes no sense to me to cut this safety net immediately which can – to my logic – actually cause the need for resuscitation. The only discrepancy I have is that I understood, from the likes of Dr Sarah Buckley and others, that the placental blood flow is a to-ing & fro-ing pulsatile motion that actually endorses the ideal of waiting until the cord stops pulsing (for the quantity to equilibrate). Video series on EDD for those interested: http://bitly.com/10X4ryE

  40. avatar
    Chris
    April 4th, 2013 at 20:23 | #40

    The AAP endorses ACOGs committee opinion number 543, dated December 2012 “the evidence is insufficient to confirm or refute potential benefits of delayed cord clamping in term infants”
    I have struggled with this question of delayed cord clamping for the last 14 years. I have changed my opinion a few times. I have spoken to approximately 9 neonatologist, men and women who are specialist in neonatal physiology, and they were all of the opinion that the cord should be clamped right away. They explained neonatal physiology in detail. Each giving a similar story. Thus I am conflicted on what is best practice. What I do when a labor patient desires delayed cord clamping is explain all the different sides to the story and they can decide for themselves. If you have overwhelming evidence, could you please direct me to the study?

  41. April 9th, 2013 at 18:17 | #41

    Hi Chris,
    I think the articles in the bibliography do a pretty good job of making the case for delayed clamping. The data on iron stores is there, as is the physiology of natural clamping. That’s where I start in discussing it with other physicians and parents.
    Take care,
    Mark Sloan

  42. avatar
    Imari
    May 16th, 2013 at 06:45 | #42

    This is so helpful. I work in a place where babies are born daily to immediate clamping, and delay is seen as rather radical and hippie like. . do it if you dare. . I do dare and have so far seen only good results. The NICE guidelines which still don’t include any delay for active third stage are hampering good midwives and doctors from being told about this wonderful, simple way to boost the health of our patients, babies whether term, normal, premature or compromised and women who will have settled, healthier and happier kids, and less blood loss often at delivery.

  43. May 16th, 2013 at 09:01 | #43

    I have been looking for a concise resource to post on my website and FB. This is excellent. I put my hands on many placentas and am always bummed to see a cord thick with blood. I am so hopeful that the culture of ICC will continue to decline. I no longer attend births but am still hearing crazy tales about hospital based care providers in my community who refuse to wait. Thank you for this!

  44. September 9th, 2013 at 13:40 | #44

    I’m a Physiotherapist & I specialize in prenatal & postpartum care.
    I certainly advice my clients to demand DCC for its benefits, infact I have been promoting Lotus Birth too. What would you like to say about that

  45. avatar
    PETA Melanie
    February 3rd, 2014 at 04:33 | #45

    Having just given birth 4th time and experiencing the wonder of having a home birth where I was supported in my choice to do a cord burning ceremony instead of clamping & cutting. This was a truely amazing experience, happening approximately 2-3 hours after our baby was born. The whole family surrounded the baby while we held two bees wax candles made locally to the cord until it separated cortarising the ends taking around 10 minutes & leaving our baby very content & peaceful. He then slept for 3 hours and did not have any jaundice & The cord fell off on day 4. With my other 3 children I left the cord unclamped and attached for 6-12 hours after birth until we felt ready to ceremonially cut the cord an honour given to a chosen member of the family.
    It makes no sence to me to clamp & cut so quickly after birth as the baby has been reliant on the placenta for the 9 months of gestation and it seems to be a significant part & aspect of the life of the baby & it’s connection to the mother.
    I also feel it is important to connect with the placenta & have grown a plant/ tree where the placents have been buried. When my daughter who was almost 3 years old when her first brother was born in a hospital birthing suite and looked at the placenta she was truely amazed & called it Da Centre.

  46. avatar
    blondemomma
    May 6th, 2014 at 09:36 | #46

    #6 True, breastmilk doesn’t contain high levels of iron…BUT babies do have iron stores, which are usually ample for the first 6 months AND the iron breastmilk contains is bioavailable! Formula has huge amounts of iron because it’s an iron which is a difficult form to be uses by the body, whereas the iron found in breastmilk is used more completely than that found in artificial milk.

  47. avatar
    Mirian
    June 6th, 2014 at 05:19 | #47

    I requested to my Doctor ,that I wanted DCC , I was told no! with a list of problems that I might have if I do it, im looking for another Doctor and definitely im not having my baby in that hospital, im due December 5th, I live in Long island.NY anyone in LI that knows where I can have DCC with no excuses…please!

  48. avatar
    Irma
    July 1st, 2014 at 19:44 | #48

    To Chris
    Higher blood volume will result in better lung and alveoli expansion,
    Higher hemoglobin levels will result in higher oxygen carrying capability.
    Getting both maternal oxygen through the placenta and through the environment (21% room air)provides a gentle and safe transition from a wet environment to the dry environment for the baby.One thing is not mentioned in this article that DCC also result in very low resuscitation rate as the auto-resuscitation is done by the placenta.In 14 years I am doing DCC,the babies are doing great.That is the only way,that is the best way.A system is already in place,it is all written in the DNA.The placenta and and the circulatory system is pulsating to return that 30 plus percent of blood into the baby as we need to look at not just the baby,but the UNIT which includes the placenta,the cord and the baby.
    AAP need to understand this new research and the benefits for both preterm and term born babies.Babies can’t wait and this harmful practice of ICC must stop at once.

  49. avatar
    Kelly
    September 2nd, 2014 at 09:38 | #49

    Hi,

    Can the author recommend which studies listed in the references are best to present to your Ob that will provide evidence of the benefits of DCC?

    Thanks!

  50. September 3rd, 2014 at 09:26 | #50

    Hi Kelly,
    The Cochrane review (#6 in the references) does a good job of showing that early cord clamping offers no advantages to mother or baby. The Andersson article (#7) shows that delayed clamping improves iron stores in babies, which is the main benefit of delayed clamping.

    And this article (not in the refs), by Dr. Betsy Lozoff at the University of Michigan, is an excellent review of the connection between iron deficiency anemia and developmental delays:

    Iron deficiency and child development. [Review] [140 refs]
    Lozoff B.
    Food & Nutrition Bulletin. 28(4 Suppl):S560-71, 2007 Dec.

    Here’s a quote from the abstract:

    “In the human, there is compelling evidence that 6- to 24-month-old infants with iron-deficiency anemia are at risk for poorer cognitive, motor, social-emotional, and neurophysiologic development in the short- and long-term outcome.”

    Those three articles provide evidence that early clamping provides no benefit to mother or child, leads to iron deficiency in infancy, and describe what iron deficiency does to a growing brain. Hope that convinces your OB to change. Please let me know if you have any other questions.

    Best,
    Mark Sloan
    @Kelly

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