ACOG Revises Recommendations on Delayed Cord Clamping - A Step in The Right Direction or Not Enough?

cord karen 1.jpgLate last week, The American College of Obstetricians and Gynecologists (ACOG) released an updated Committee Opinion "Delayed Umbilical Cord Clamping After Birth" which provides a revised recommendation to the previous statement that was released in 2012.  The current recommendation is to wait at least 30-60 seconds before clamping the umbilical cord for healthy, full term infants.  ACOG has recognized the benefits of and recommended delayed clamping for preterm infants for several years.  Based on research published in the last few years that indicates both premature and term newborns will benefit, they have now updated their recommendations to delay cord clamping for healthy full term infants as well. It should be noted that the Society of Obstetricians and Gynaecologists of Canada has been recommending delayed cord clamping since 2012. Other organizations in the field of maternal infant health have also had these recommendations on the books for several years.  The World Health Organization recommends that the umbilical cord not be clamped earlier than one minute after birth in term or preterm infants who do not require positive pressure ventilation. Recent Neonatal Resuscitation Program guidelines from the American Academy of Pediatrics recommend delayed umbilical cord clamping for at least 30–60 seconds for most vigorous term and preterm infants. The Royal College of Obstetricians and Gynaecologists also recommends deferring umbilical cord clamping for healthy term and preterm infants for at least two minutes after birth. Additionally, the American College of Nurse–Midwives recommends delayed umbilical cord clamping for term and preterm infants for 2–5 minutes after birth.

The American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice makes the following recommendations regarding the timing of umbilical cord clamping after birth:

  • In term infants, delayed umbilical cord clamping increases hemoglobin levels at birth and improves iron stores in the first several months of life, which may have a favorable effect on developmental outcomes.
  • Delayed umbilical cord clamping is associated with significant neonatal benefits in preterm infants, including improved transitional circulation, better establishment of red blood cell volume, decreased need for blood transfusion, and lower incidence of necrotizing enterocolitis and intraventricular hemorrhage.
  • Given the benefits to most newborns and concordant with other professional organizations, the American College of Obstetricians and Gynecologists now recommends a delay in umbilical cord clamping in vigorous term and preterm infants for at least 30–60 seconds after birth.
  • There is a small increase in the incidence of jaundice that requires phototherapy in term infants undergoing delayed umbilical cord clamping. Consequently, obstetrician–gynecologists and other obstetric care providers adopting delayed umbilical cord clamping in term infants should ensure that mechanisms are in place to monitor and treat neonatal jaundice.
  • Delayed umbilical cord clamping does not increase the risk of postpartum hemorrhage.

It is interesting to note the terminology used when referring to separating the newborn from the umbilical cord and placenta.  While the physiological norm (no interference) is for the cord to stop pulsating, and the intervention has been to clamp immediately, many professionals and consumers - midwives, doulas and parents in particular, have urged for decades that the cord be "allowed" to stop pulsing naturally before clamping occurs.  Somehow this "delayed" clamping was seen as the "radical" practice that caused all sorts of consequences for both the birthing person and the newborn.  Parents who requested this practice were provided all sorts of information stating why this was detrimental to the newborn, and the intervention was recognized as the safe and appropriate practice.  This revised ACOG recommendation has been a long time coming and attempts to restore the practice to the physiological norm that existed previously.

The benefits of delayed clamping for the premature baby have been recognized and recommended by ACOG for several years now. There are still questions about best practice for those newborns who require resuscitation at the time of birth.  How can a baby be resuscitated and treated while continuing to support the delivery of oxygenated placental blood via the umbilical cord?

trollye 2.pngResearchers in the United Kingdom have been exploring the use of a "trolley" that can be brought alongside the bed, and will support the baby during resuscitation efforts while allowing the baby to continue to receive blood via the unclamped umbilical cord.  ACOG states: "...infants requiring resuscitation may benefit considerably from placental transfusion, but their need for immediate attention raises questions about whether they should undergo immediate or delayed umbilical cord clamping and whether umbilical cord milking may offer a unique benefit. The feasibility of resuscitation at the bedside with intact placental circulation also is an important question." The study demonstrated that "initial care after birth can be provided on this trolley at the mother’s bedside for vaginal births and alongside the theatre table at caesarean section."

Another question that still needs further investigation is the benefit of "milking" the umbilical cord.  Milking the cord refers to compressing and squeezing the cord in the direction of the neonate several times, allowing the newborn to get several surges of placental blood before clamping and cutting the cord.  This milking consumes less time than delaying cord clamping and may provide some benefits when time is limited to begin treatment or in the case of a cesarean, complete the surgical procedure. There are some thoughts that milking the cord four times provides the same benefits as delaying the clamping 30 seconds in preterms that may need immediate treatment.  You can read more in the paper "Milking Compared With Delayed Cord Clamping to Increase Placental Transfusion in Preterm Neonates."

For families that would like to donate or private bank cord blood, the benefits of delayed umbilical cord clamping to the infant should take precedent over donation and additionally genetic counselling should be provided to those families that have made the decision to private bank cord blood.  I previously wrote a post about what families should know about private cord blood banking, which you can find here.

Delayed cord clamping does not interfere with active third stage management or increase the risk of postpartum hemorrhage for the birthing person.

Science & Sensibility has previously covered the topic of delayed cord clamping thoroughly and you might want to check out some of our previous posts to review the topic:

The reality is that Lamaze International has long seen immediate cord clamping as an intervention that conflicts with two Healthy Birth Practices - Avoid Interventions that are Not Medically Necessary and Keep Mother and Baby Together - It's Best for Mother, Baby and Breastfeeding.  ACOG's recent revised Committee Opinion is a great step in the right direction.  The recommendation to delayed clamping until 30-60 seconds has passed  will increase the number of newborns who receive that precious bolus of red blood cell rich cord blood at birth.  Is there any reason that clamping cannot be delayed until the placenta stops pushing blood through the cord and it shuts down on its own, allowing for the physiological norm?  What are you sharing in your childbirth classes with families about the benefits of delayed cord clamping? What are you seeing and hearing from your clients and students about the care they are receiving in birthing locations in your community?  Will you change how you cover this topic in light of this revised statement?  Let us know in the comments section.

Cord Photo credit: One Tree Photography

 

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