Delayed Cord Clamping
Background
At birth there is a transition and adaptation phase that a newborn baby goes through and this
process can take minutes to complete. Some babies need help and support during this phase,
while the majority adapt spontaneously. The mother may also need monitoring and support during
this phase at the end of the birthing process and she is vulnerable to bleeding complications during
this time. The aim is to provide support for the mother and baby directly after birth, while monitoring
for signs that intervention to improve outcome, is indicated. The best start for any baby and the
parents are that this adaptation phase is natural and cord clamping optimal to ensure
early contact between parents and baby.
Why is cord clamping important?
At term, cord clamping has an influence on your baby’s hemoglobin levels at birth. Waiting
before clamping the cord ( delayed clamping ) can improve iron stores in the first several months of
life, which may have a favourable effect on your baby’s development. Evidence shows that
immediate cord clamping can deprive a newborn baby of up to 214g of cord blood, equating to
approximately 30% of their intended blood volume. Research has shown that 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
haemorrhage.
Why has the emphasis changed over the years?
Immediate umbilical cord clamping has traditionally been carried out along with other strategies to limit the risk of bleeding after birth (post-partum haemorrhage). It is important to understand that post-partum haemorrhage is one of the most dangerous complications that can occur after birth. Research has shown that blood transfusions of the mother and even death can be prevented by an “active “management of the delivery of the placenta by the administration of oxytocic drugs that help the expulsion of the placenta. This approach has been very successful and has reduced the incidence of post-partum haemorrhage, but at the time of introduction of this policy the effect of immediate cord clamping on the baby was not considered.
Consequently, concern has arisen that delayed umbilical cord clamping may increase the risk of maternal haemorrhage. However, recent data do not support these concerns and in these studies delayed umbilical cord clamping was not associated with an increased risk of postpartum haemorrhage or increased blood loss at delivery, nor was it associated with a difference in postpartum haemoglobin levels or need for blood transfusion in the mother.
What is a balanced approach in 2017?
Delayed umbilical cord clamping is a straightforward process that allows placental transfusion of warm, oxygenated blood to flow passively into the newborn. It is part of the provision of essential neonatal care in 2017. Recommendations for the optimal timing of umbilical cord clamping apply equally to preterm and term births. The benefits of delayed cord clamping is however particularly important for preterm infants. International guidelines now recommend a delay in umbilical cord clamping in vigorous term as well as preterm infants for at least 30–60 seconds after birth.
One should be aware of the small increase in the incidence of jaundice that requires phototherapy in healthy term babies undergoing delayed cord clamping. Immediate skin-to-skin care is appropriate while awaiting umbilical cord clamping. In the case of caesarean delivery, your baby can be placed on your tummy or legs or held by the surgeon or assistant at close to the level of the placenta, until the umbilical cord is clamped.
However, when there is increased risk of haemorrhage (eg, placenta praevia or placental abruption), the benefits of delayed umbilical cord clamping need to be balanced with the need for timely haemodynamic stabilization of the mother. This will be communicated with you if the need arises.
Which areas require more research?
At this time, there is not sufficient evidence to recommend for or against delayed umbilical cord clamping in multiple gestations.
Not enough research has been done to offer guidance in situations in which placental perfusion or umbilical cord flow may be compromised (e.g. growth problems in the baby or potential distress in the baby) and obstetricians and paediatricians need to weigh the relative risks and benefits in every individual case.
Umbilical cord milking has been considered as a method of achieving increased placental transfusion to the newborn baby in a rapid time frame. Currently, there is insufficient evidence to either support or refute umbilical cord milking in term or preterm infants.
Is it ever advised not to allow delayed clamping?
If the placental circulation is not intact, such as in the case of abnormal placentation, placental abruption, or umbilical cord avulsion, immediate cord clamping is appropriate. Similarly, maternal haemodynamic instability or the need for immediate resuscitation of the newborn on the baby warmer, would be an indication for immediate umbilical cord clamping.
Does the approach change at all if I want the cord blood stem cells saved?
It is important to understand that recent research has shown that delayed umbilical cord clamping significantly decreased the volume and total nucleated cell counts of cord blood donations. In cases where a family are planning donation of umbilical cord blood, immediate cord clamping may increase the yield of cord blood obtained. Because of the delay in clamping, a smaller quantity of cord blood will be collected. The manner in which the cord blood is processed in the lab therefore becomes extremely important, as the quality of the cord blood needs to make up for the decreased quantity. Note also that umbilical cord tissue, collected at the same time as umbilical cord blood, contains a different type of stem cell and is in no way affected by delayed cord clamping. It is important that you discuss this during our consultation as well as with prospective Stem Cell Companies, before making a final decision.