The clamping and cutting of the cord is “one of the oldest interventions in the birth process” according to the American College of Nurse-Midwives Position Statement on Delayed Umbilical Cord Clamping. Early cord clamping was thought to prevent maternal postpartum hemorrhage and it was this idea that helped the practice gain acceptance as a standard of care in the 1960s. While research has since shown that early cord clamping does not reduce postpartum hemorrhage, there is still debate within the maternity care community about the optimal time to clamp the umbilical cord. While delayed cord clamping is discussed in most childbirth classes and often appears on the birth plans of families interested in a low intervention birth, it may be that families, doulas and care providers are not using the term to mean the same thing or all have the same understanding of what the evidence does and does not say about the practice.
First, let’s define “delayed cord clamping.” Just as we found with postpartum depression, this is a phrase that is commonly used in the maternity community but is not as clearly defined as one might think. The World Health Organization (WHO) considers cord clamping to be delayed when the cord is clamped “more than one minute after birth or when cord pulsation has ceased.” The American College of Obstetricians and Gynecologists (ACOG) has not issued a specific definition of delayed cord clamping. Their most recent document on the subject, an Opinion from the Committee on Obstetric Practice issued in December 2012 references 30 – 60 seconds after birth. The American College of Nurse-Midwives (ACNM) recommends delaying cord clamping for two to five minutes after birth depending on certain circumstances in their May 2014 Position Statement. If you are confused at this point, you are not alone. This lack of consistency across maternity care organizations about how to define delayed cord clamping is likely part of why there is still little consistency in how this practice is carried out despite growing evidence that waiting to clamp the cord has benefits for babies that last for months or even years.
Benefits of Delayed Cord Clamping
We know that the umbilical cord is a baby’s lifeline before birth. Once the baby takes her or his first breath does the umbilical cord still have a function? The short answer is yes, but only for a brief period of time. The cord, as we know, connects baby to placenta. The baby’s blood circulates through its body and through the umbilical cord to the placenta and back again receiving oxygen and nutrients from the mother. A full term baby may have as much as one third of its blood in the placenta when labor begins. During labor and birth, the placenta transfuses most of the blood back to the baby, but not all. The cord continues to pulse after birth to continue this process and, if left undisturbed, can transfuse enough blood to supply the baby with iron for around three months. A 2013 Cochrane Database Review of research on delayed cord clamping found that infants whose cords were clamped one minute or later after birth had higher iron levels when measured at two to six months of age. ACOG’s Committee Opinion on the subject states that the extra iron received after birth from the placenta “may help prevent iron deficiency during the first year of life.” Iron is very important for normal cognitive and social development in infants and deficiencies can lead to long-term consequences.
There are particular benefits of delayed cord clamping for preterm babies. ACOG recommends waiting 30 – 60 seconds after birth in these cases due to a nearly 50% reduction in the incidence of intraventricular hemorrhage or bleeding within the brain, a life threatening condition. Preterm infants also benefit from reduced need for blood transfusions and improved circulation when cord clamping is delayed by at least 30 seconds.
In a study published earlier this year in JAMA Pediatrics, researchers found that benefits to delayed cord clamping extend into early childhood. A Swedish study found that four-year-olds whose cords were clamped three minutes after birth had higher fine motor and social skills than those whose cords were clamped less than 10 seconds after birth. This is one of the few studies of full-term infants on the impacts of delayed cord clamping.
Risks to Delayed Cord Clamping
Research indicates no difference in immediate birth outcomes between babies whose cords are clamped early versus delayed including APGAR scores and respiratory distress. In their 2012 Committee Opinion (i.e. prior to the 2013 Cochrane Review), ACOG mentions several concerns (their term) regarding the universal adoption of delayed cord clamping including: risk of polycythemia in the baby, or too many red blood cells, particularly when other risk factors for the condition such as maternal diabetes, severe intrauterine growth restriction and high altitude are also present, the impact on timely resuscitation efforts for infants in respiratory distress, and that the practice may be technically difficult. ACOG notes that maternal hemorrhage due to delayed cord clamping remains a “theoretical concern” because of the volume of blood that continues to flow through the uterus at birth.
Recommendations for Delayed Cord Clamping
WHO (2014) – Not earlier than one minute after birth.
ACOG (2012) – No recommendation. Evidence supports waiting 30 – 60 seconds in preterm infants. Evidence is insufficient to support delayed cord clamping in term infants.
ACNM (2014) – Delayed cord clamping as the standard of care for term and preterm infants in all birth settings. Their Position Statement specifies time length in certain circumstances:
• Five minutes for term infants placed skin-to-skin
• Two minutes for term infants placed at or below the birth canal
• 30 – 60 seconds in preterm newborns
With a range between 30 seconds and five minutes it’s easy to see how there can be confusion about what is meant by “delayed” clamping of the cord. As doulas, our role is to share information with our clients and encourage them to discuss issues that matter to them with their care providers. Sharing up-to-date evidence on the risks and benefits of a care practice so that families can make informed decisions is an essential role of doulas.
Resources
ACNM Position Statement: Delayed Umbilical Cord Clamping http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000290/Delayed-Umbilical-Cord-Clamping-May-2014.pdf
World Health Organization, “Optimal timing of cord clamping for the prevention of iron deficiency anaemia in infants” http://www.who.int/elena/titles/cord_clamping/en/
ACOG Committee Opinion, “Timing of Umbilical Cord Clamping After Birth”: http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Timing-of-Umbilical-Cord-Clamping-After-Birth
Cochrane Database Review: “Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes” http://www.ncbi.nlm.nih.gov/pubmed/23843134
Science & Sensibility post on the 2013 Cochrane Review: http://www.scienceandsensibility.org/new-cochrane-review-further-substantiates-early-cord-clamping-is-not-beneficial/
JAMA Pediatrics, “Effect of Delayed Cord Clamping on Neurodevelopment at 4 Year of Age”: http://archpedi.jamanetwork.com/article.aspx?articleid=2296145