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Are we cutting umbilical cords too soon after birth?

The most common surgical procedure in the world today - one that every human alive today has undergone - is the clamping and cutting of the umbilical cord at birth. The need for clamping and cutting the…

Delaying cord clamping leads to higher levels of iron, which is important for brain development. Image from shutterstock.com

The most common surgical procedure in the world today - one that every human alive today has undergone - is the clamping and cutting of the umbilical cord at birth. The need for clamping and cutting the cord is not in dispute but how soon after birth this should occur is now being questioned.

We’ve long known that immediate umbilical cord clamping and cutting could be harmful. Charles Darwin’s grandfather Erasmus Darwin – a well-known doctor – summarised the risks back in 1801:

Very injurious to the child is the tying of the navel string too soon. It should be left till all pulsation in the cord ceases. Otherwise the child is much weaker than it ought to be, a portion of the blood being left in the placenta, which ought to have been in the child.

When the first commercial cord clamp device was released in the 1890s, instructions published in The Lancet medical journal said it should not be used until the cord stops pulsating, meaning blood flow has ceased.

However, as intervention in birth climbed in the 1950s and 60s, concerns about the amount of pain-relieving drugs and anaesthetic reaching the baby from the mother’s blood increasingly led to immediate clamping and cutting of the cord.

After 50 years of ignoring earlier advice, we are seriously examining the implications of what may have been one of humanity’s largest uncontrolled experiments.

Expelling the placenta

After birth, the mother must expel the placenta, which has carried oxygen and nutrients to the fetus during pregnancy. This process is known as the third stage of labour.

In the 1960s, midwives and obstetricians began actively managing the third stage. This involves giving women an injection of Syntocinon (synthetic oxytocin) with the birth of the baby, clamping and cutting the cord and pulling the placenta out using controlled cord traction.

Physiological third stage is prompted by the mother’s own oxytocin and pushing . Image from shutterstock.com

The alternative – known as physiological third stage – involves doing none of the steps above: no oxytocin is given, the cord is not clamped and cut until pulsation has ceased, and the mother pushes the placenta out herself.

Physiological third stage therefore means the baby remains skin-to-skin with the mother and can’t be removed; something that is easier to do once the cord is cut. As the mother and baby come into close contact and the baby starts to seek out the breast, the mother releases her own endogenous oxytocin, contracting her uterus and separating the placenta and membranes and pushes them out.

Major blood loss is one of the leading reasons women around the world die following childbirth. And there is good evidence that active management of the third stage lowers the rate of hemorrhage for the mother.

But researchers have acknowledged we still don’t know which component of this complex package of active management actually has the most significant impact.

To complicate the picture further, research shows post-birth hemorrhage rates among women who opt for a physiological third stage seem to be lower when in certain birth environments (homebirth and birth centres), and under midwife-led care. This could be because there is much less intervention in these settings that can increase the risk of haemorrhage.

Benefits for the baby

In most maternity units today, normal practice is to clamp and cut the umbilical cord immediately following the birth. This means babies miss out on between 80 to 100 millilitres of blood that they would naturally get if we waited two to three minutes.

If a baby is held below the mother’s navel during the first few minutes after birth they can receive an average increase of 32% more blood. The volume decreases with the height the baby is held at and the length of time before the cord is clamped. However, most of the blood volume passes to the baby in the first two to three minutes.

In 2011, a Swedish randomised trial published in the British Medical Journal found that, two days after birth, babies who had delayed cord clamping had lower rates of anaemia (meaning there aren’t enough red blood cells to oxygenate the blood) – 1.2% compared with 6.3%.

At four months the infants who had delayed cord clamping had lower rates of iron deficiency (0.6% vs 5.7%) which is important for brain development. Iron deficiency and anaemia in young children are considered to be a major public health issue around the world and can lead to lasting cognitive and behavioural delays.

Clinical guidelines are lagging behind the evidence on cord clamping. Image from shutterstock.com

A review of 15 studies showed late cord clamping (at least two minutes) reduced the risk of anaemia by nearly half. Bleeding in babies' brains and severe infections of the bowel also seem less common with delayed clamping and cutting of the umbilical cord.

Jaundice (a build-up of bilirubin, which gives the skin and eyes a yellowish tinge) seems to be slightly increased with delayed cord clamping. But it’s unlikely to cause long-term damage and doesn’t require further treatment.

The recently released Cochrane systematic review therefore concludes:

A more liberal approach to delaying clamping of the umbilical cord in healthy term infants appears to be warranted, particularly in light of growing evidence that delayed cord clamping increases early haemoglobin concentrations and iron stores in infants.

Time for change

Current recommendations from the World Health Organization (2006) are to delay cord clamping. And the leading midwifery (Royal College of Midwives) and obstetric (Royal College of Obstetricians and Gynaecologists) bodies in the UK changed their guidelines in 2012 recommending delaying clamping and cutting the cord for around three minutes after birth.

But the highly respected National Institute for Health and Clinical Excellence (NICE) in the United Kingdom still supports early cord clamping and cutting, as do Australia’s clinical practice guidelines.

The evidence is in, so it’s time for NICE and Australia’s National Health and Medical Research Council (NHMRC) to heed it. It may have taken us more than 50 years to begin to listen to 200-year-old advice but let’s hope we change this practice more quickly and avoid potential harm to newborn babies.

Join the conversation

23 Comments sorted by

  1. Paul Weldon

    Research Fellow

    How does this play out in the case of caesarean section? Can clamping/cutting be delayed?

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    1. ian cheong

      logged in via email @acm.org

      In reply to Paul Weldon

      Caesarean babies for presumably multiple reasons are more likely to not start breathing early. Early cord clamping permits early resuscitation if needed.

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    2. Mark Amey

      logged in via Facebook

      In reply to ian cheong

      In the APTS trial I mentioned below, infants who are born at <30 weeks gestation are randomised to late (one minute) vs immediate cord clamping. This happens in both vaginal and caesarean births. The delayed clamping is abandoned if the infant requires more than some simple stimulation, and normal resuscitative interventions are commenced.

      The outcome measures include birth haemoglobin, central blood flows (measured by echocardiography) and need for later transfusion.

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  2. Mark Amey

    logged in via Facebook

    Perhaps we should wait for the results of the Australian Placental Transfusion Study, before making recommendations?

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  3. Joy Johnston

    midwife

    Thanks Hannah for bringing this important issue into public view.
    The Three Centres labour and birth guideline (2012) recommends that cord clamping be "delayed for 2-3 minutes for fetal benefits in term and preterm infants, providing immediate resuscitation is not required." [http://3centres.com.au/guidelines/labour-and-birth/labour-and-birth#Umbilical%20cord%20clamping ]

    I would like to make a point here that the normal physiology of the third stage relies on spontaneous unmedicated progress…

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    1. Sue Ieraci

      Public hospital clinician

      In reply to Joy Johnston

      Both the article and the above commenter are in error regarding the source of umbilical cord pulsation.

      Oxygenated maternal blood flows to the foetus through the umbilical VEINS ( a reversal of the adult arterio-venous flow). The pulsation in the cord is a transmission of the baby's heart pumping, returning de-oxygenated blood to the mother through the umbilical arteries. '

      The above commenters assertion that ''pulsing of the cord is an early sign of resuscitation, ensuring an immediate surge…

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    2. Joy Johnston

      midwife

      In reply to Sue Ieraci

      Sue Ieraci, why would you hope that a baby requiring resus is not on the floor at home, still attached to the mother ...? That is indeed the setting in which I practice midwifery. The point I would like to make in this context is that when a baby is born and the midwife makes a clinical decision that some resuscitation support is needed, there is no reason to clamp and cut the cord, thereby separating mother and baby. The placental transfusion is beneficial for the baby.

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    3. Sue Ieraci

      Public hospital clinician

      In reply to Joy Johnston

      Joy Johnson - the reason I would hope so that is that there are significantly fewer resuscitation resources and skilled personnel at home, resulting in three times excess mortality for the babies of low risk mothers (compared with birth in hospital).

      An additional volume of blood may or may not be beneficial - depending on what the reason for needing resuscitation is. If the midwife conducting resuscitation does not understand newborn physiology, including placental circulation, the baby may well be in better hands in hospital.

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  4. ian cheong

    logged in via email @acm.org

    Maternal anaemia is reported here http://ajcn.nutrition.org/content/71/5/1280s.full as 35-75% (average 56%) by WHO. Maternal iron deficiency is more common than anaemia, since iron deficiency can be present without anaemia.

    The question on cord clamping should be studied in mothers with known adequate iron stores, since routine iron supplementation is recommended in that article.

    A five percent improvement in neonatal anaemia should be less if mothers have adequate iron replacement. In this case the the potential benefit may not outweigh potential harm of delayed resuscitation.

    More work required to inform routine practice.

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    1. Sue Ieraci

      Public hospital clinician

      In reply to ian cheong

      Agreed , Ian. Like many other areas of research, findings that are relevant to one setting may be inappropriate for another.

      Iron deficiency anaemia is relatively uncommon in Australian pregnant women, who tend to take pregnancy vitamin supplements. It is much more a feature of women in the impoverished world. Other causes of anaemia in the newborn include internal bleeding (such as haemorrhage around the brain, or big scalp haemorrhages), and other complications such as twin-twin transfusion.

      In the majority of cases, the additional blood transfer will make little difference to the overall health of the baby, but also will rarely do harm - so there is rarely a reason to rush to cut the cord (unless urgent resuscitation is required).

      It is important to realise that, if the cord is left intact to allow the mother and baby to remain close for ''skin to skin'' time, the baby needs to be held below the placenta for gravity to allow blood to flow to the baby.

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    2. Mark Amey

      logged in via Facebook

      In reply to Sue Ieraci

      'In the majority of cases, the additional blood transfer will make little difference to the overall health of the baby'...no, not usually, but severe polycythaemia is not benign, causes hypoglycaemia and sludging of the blood in the small vessels in the brain (and other organs), with subsequent neurological sequellae!

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  5. Peter Hindrup

    consultant

    It has long puzzled me that humans have the umbilical cord cut, where as in animals the placenta --- commonly known as the 'afterbirth', quickly follows the birth, and the cord dries up quickly and has broken by the time a lamb, for instance, is suckling. It arrives, the ewe begins licking it clean, the lamb is struggling to stand and immediately searching to suckle.
    Foals, calves the same.
    I have seen many hundreds of lambs born, We were breeding a new strain of sheep, and there was a great deal of intervention needed in the early days.
    Why? We were overfeeding the bloody ewes!

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    1. Peter Hindrup

      consultant

      In reply to Peter Hindrup

      We were breeding a new strain of sheep.

      Ought to read: We were involved in breeding a new strain of sheep.

      This was working from a Romany ram over Cheviot ewes, and progressively reducing the Cheviot factor.

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    2. Dianna Arthur
      Dianna Arthur is a Friend of The Conversation.

      Environmentalist

      In reply to Peter Hindrup

      Probably because baby humans don't have to get up and run with the herd.... just a thought.

      Perhaps a comparison with other primates would be more apt.

      Cheers

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    3. Sue Ieraci

      Public hospital clinician

      In reply to Peter Hindrup

      ''It has long puzzled me that humans have the umbilical cord cut''

      Strange isn't it, Peter? Nor do we lick the baby clean, stand and walk soon after birth, but we do post the pictures on FB and drive home in motor vehicles and discuss it all on the internet. And yet, animals all!

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  6. Peter Ormonde

    Farmer

    Cut the cord? Is that what's supposed to happen?

    Geez I wish someone had told my mum... I'm sure mine's still firmly attached after her almost 60 years of slavish devotion.

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    1. Peter Ormonde

      Farmer

      In reply to Sue Ieraci

      Not unwell at all Ms I ... in fact the opposite ... robust enough to tackle a massive lump of granite hard ironbark timber I've been lugging around for a few years. Soon to be a cello if all goes to plan.

      But I am daunted daily by my diet of pills. When will some entrepreneurial health professional come up with a simple slim volume of tasty recipes involving medications? Diamicron and tofu omelette with a drizzle of beta blockers over a bed of mashed statins and SSRIs... Chili con cardia...

      Such a tasteless gravelly way to start and end the day.

      I'd even settle for flavourings ... like we do with cough syrup but less medicinal... pills you could sprinkle on icecream. That'd help a lot. Thanks.

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    2. Dianna Arthur
      Dianna Arthur is a Friend of The Conversation.

      Environmentalist

      In reply to Peter Ormonde

      Well at least as a standby, hash brownies go down a treat.

      May well be needed after a day's chiselling of the ironbark - not afraid of a challenge are you Mr O?

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    3. Sue Ieraci

      Public hospital clinician

      In reply to Peter Ormonde

      Great to hear, Mr O (the wood, I mean, not the tablets).

      I love the chilli con cardia...

      What about Diamicron Diane or Beta Blocker Bernaise?

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  7. Amy Tuteur

    logged in via Facebook

    This piece is much ado about nothing.

    Here's what the authors of the paper looked at and actually found in terms of differences between late and early cord clamping:

    Apgar scores: NO BENEFIT
    NICU admissions: NO BENEFIT
    Respiratory distress: NO BENEFIT
    Jaundice: NO BENEFIT
    Infant hemoglobin: NO BENEFIT
    Infant anemia: NO BENEFIT
    Breastfeeding: NO BENEFIT
    Low iron levels at 3-6 mo.: slightly higher iron levels in delayed cc group*

    *According to the authors: "There was high heterogeneity for this outcome and differences in effect size may be partly explained by the way iron deficiency was defined in trials as well as when it was measured."

    So the authors looked at 6 measure of clinical benefit and found no benefit. They looked at one lab value of dubious significance and found a small benefit, but even the authors aren't sure it is real.

    This study ACTUALLY showed that there is no clinical benefit to delayed cord clamping.

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    1. Sue Ieraci

      Public hospital clinician

      In reply to Ruth Gordon

      This must be one of the most bizarre pseudo-rituals going - based on no natural processes and no tradition, but earning good money for some entrepreneurial providers.

      Can anyone explain why it is good for a newborn to remain attached to a rotting piece of meat?

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