“Another thing very injurious to the child, is the tying and cutting of the navel string too soon; which should always be left till the child has not only repeatedly breathed but till all pulsation in the cord ceases. As otherwise the child is much weaker than it ought to be.”
Erasmus Darwin (Charles’s grandfather), 1801
Category Archives: Cord clamping
I just had the pleasure of discussing the advantages of delayed cord clamping with the wonderful Adriana Lozada over at birthful.com.
Here’s the link:
Check out the rest of birthful.com, too–it’s a great resource–and read Adriana’s fascinating personal history. (Great photo here of Adriana with her 10-year old “mini-me,” Anika.) Adriana has a growing list of podcasts, including interviews with such well-known figures in the childbirth world as Gene Declercq, Rebecca Dekker and Sarah Buckley. I’m honored to be in their podcast presence. Thanks, Adriana!
This question was raised recently by a young doctor at the family medicine residency program where I teach. She and her residency colleagues had been taught in their OB rotation that delayed cord clamping is the childbirth standard of care. The benefits are proven, the resident said, and early clamping doesn’t do anything for anybody.
“So why would anyone do it?”
Good question. Yet judging from the emails I received after my last post, DCC is far from the standard of care around the country:
An East Coast doula wrote that her clients can have DCC performed at birth “if they request it.” (If they request it?? That’s a bit like saying, “There’s this thing called oxygen, and if it looks like your baby’s at risk of brain damage from a lack of it, we can give him some. If you ask us to, that is.”)
A California midwife wrote that the obstetricians at her hospital are adamant that DCC is “too risky” for newborns. Despite the evidence she presented to them, they’re sticking with ECC.
A Midwestern family physician reported that the DCC/ECC debate has split the medical staff where she practices. Although there’s some overlap, the family docs are largely pro-DCC, while the OB staff is in favor of ECC.
Clinging to interventions that have been shown to be useless and even harmful is, unfortunately, nothing new in the history of medicine.
Perhaps the most infamous example in the maternity care world is that of Dr. Ignaz Semmelweis (1818-1865), a Hungarian-Austrian obstetrician who clearly demonstrated that simple handwashing could greatly reduce maternal deaths from puerperal fever—a virulent infection that plagued crowded maternity wards in the 19th century. Everybody ignored him, his career crashed, and he died in an asylum…and a few decades later everyone was washing their hands. (A brief synopsis of his story is attached below, excerpted from my book, Birth Day: A Pediatrician Explores the Science, the History, and the Wonder of Childbirth.)*
I’m encouraged that the young doctors I work with see DCC as a no-brainer (or a pro-brainer, if you’ll pardon the pun.) But too many doctors don’t see the timing of cord clamping as the important issue it is. For them, it will probably take the Invisible Hand of the Market, in the form of pressure from pregnant clients, to change minds and practices, if not hearts.
So tell me, what’s the DCC/ECC environment where you live? Email me or (better still) add a comment on the blog!
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*(Shameless self-promotion: Birth Day—a ripping good yarn—is available in paperback or Kindle from Amazon, or you can order it from me directly at www.marksloanmd.com).
Excerpt from Birth Day: A Pediatrician Explores the Science, the History, and the Wonder of Childbirth (Copyright 2009, Mark Sloan M.D.)
“In 1844, Dr. Ignaz Semmelweis, an assistant lecturer in the First Obstetric Division of the Vienna Lying-in Hospital, began to make the same connection [as Dr. Oliver Wendell Holmes]. Semmelweis noticed that women who gave birth in his First Division, which was staffed by doctors and medical students, had eight times the risk of contracting puerperal fever than those who were delivered by midwives in a distant part of the hospital. Of the many differences in patient care between the two divisions, Semmelweis saw one that stood out. Doctors did autopsies on women who had died of puerperal fever. Midwives did not.
With no access to Holmes’s still obscure paper, it took three years and a number of failed hypotheses for Semmelweis to put it all together. The final piece of the puzzle fell into place when, like Holmes, he was struck by the similarities between puerperal fever and the death of a colleague from an infection incurred during an autopsy. “Suddenly a thought crossed my mind,” he wrote. “The fingers and hands of students and doctors, soiled by recent dissections, carry those death-dealing cadavers’ poisons into the genital organs of women in childbirth.”
Semmelweis immediately ordered all doctors and students in the First Division to wash their hands in a chlorinated lime solution before attending to patients. The results were startling: mortality rates from puerperal fever fell from 18 percent in the first half of 1847 to less than 3 percent by that November. But like Holmes’s in America, Semmelweis’s breakthrough was dismissed by his colleagues, including Friedrich Scanzoni, the most prominent obstetrician in Vienna.
Semmelweis’s discovery ultimately led to the ruin of his own career and health. He was dismissed from the Vienna Lying-in Hospital in 1849, in large part because of his increasingly strident arguments with colleagues. Despondent, he spent a few unproductive years at a hospital in his native Hungary before returning to Vienna. There he wrote articles and letters blasting his former colleagues. He even accused them of murder, calling them, among other things, “medical Neros” for ignoring his advice while women died. Disabled by severe depression, Semmelweis died in a mental hospital in 1865—ironically, from an infection that started in a cut on his finger.”
Something about the cord clamping debate has troubled me for quite some time now. Long after early cord clamping (ECC) was shown to be of no benefit to either mother or baby, and in fact may harm the baby through loss of iron during a critical period of brain development, some in the obstetrics community wanted to see more evidence before endorsing delayed cord clamping (DCC) for healthy term babies. The pro-DCC evidence was theoretical, they claimed; before they agreed to wait a couple of extra minutes to clamp the cord, they wanted hard proof that DCC actually helps babies.
The logic behind this foot-dragging—“We’re not abandoning a pointless practice without a darned good reason,” more or less—escapes me. After all, this isn’t like switching from one way of transplanting hearts to another. DCC doesn’t require new equipment or extensive training, and it’s not a budget-buster, either. You simply wait 2 or 3 minutes to clamp the cord, instead of doing it right at birth. It’s not brain surgery.
Well, there’s finally some solid evidence for the hard-to-convince, pro-ECC crowd. In a recently published randomized clinical trial, a Swedish research team led by Dr. Ola Andersson discovered that a group of healthy children who had been randomized to receive DCC (3 minutes after birth) had significantly better personal-social and fine-motor functioning at 4 years of age than did those who were randomized to receive ECC (< 10 seconds after birth). The effect was more marked in boys than in girls.
Andersson and colleagues checked the children’s iron stores at several points and found that, while DCC babies had more total body iron at 4 months of age, the ECC/DCC difference disappeared by 12 months of age. Looking at neurodevelopment, they found no differences between ECC and DCC babies at 12 months, but by 4 years the DCC children showed significant developmental advantages over the ECC group. It seems like an odd finding: how could a DCC-related “bump” in iron stores in early infancy cause developmental differences at 4 years but not at 12 months?
It likely comes down to an inadequate supply of iron at a critical time in neurodevelopment—those first few months, when many of the brain’s critical neural pathways are established. The resulting delays weren’t detectable with the kind of screening that can be done on a 12-month old, but by 4 years of age more extensive testing could pick it up.
The most important thing about this study is that it was a randomized clinical trial, a study design that can show that “a” is directly connected to “b”. The researchers in this case took two evenly matched groups of infants, randomly assigned them to different treatments (DCC or ECC), and then measured the relevant outcomes (iron stores + developmental differences). While there are some shortcomings to the study—the number of kids involved isn’t huge, for example—the findings fit with what’s currently known about the effects of iron deficiency in early childhood.
This study presents a solid argument in favor of DCC. And if that’s not enough to sway ECC advocates, what is?
More on iron metabolism (and why boys are affected more than girls) in upcoming posts…
Well, things are moving mighty fast in the world of cord clamping…
A study just released in the The Lancet, Britain’s leading medical journal, found that where a baby is placed during the 2-3 minutes between birth and delayed cord clamping (DCC) doesn’t seem to matter. The researchers found that all the babies in the study (500+) received the same amount of blood from the placenta, whether they were placed at the level of the birth canal (e.g., being held by the obstetrician or midwife) or placed on the mother’s abdomen or chest. The authors’ conclusion:
Position of the newborn baby before cord clamping does not seem to affect volume of placental transfusion. Mothers could safely be allowed to hold their baby on their abdomen or chest. This change in practice might increase obstetric compliance with the procedure, enhance maternal-infant bonding, and decrease iron deficiency in infancy.
So, as long suspected by DCC advocates, there’s no problem with immediate skin-to-skin placement.
Finally… the current issue of Obstetrics & Gynecology includes an article that supports delayed cord clamping (DCC) for healthy term newborns. (Obstetrics & Gynecology is the official journal of the American Congress of Obstetricians & Gynecologists, better known as ACOG.)
Written by pediatrician Ryan McAdams of the University of Washington, the article reviews the evidence that delayed cord clamping (DCC) is beneficial for healthy term newborns compared with early cord clamping (ECC), mainly because DCC provides increased iron to the newborn.* (For a brief tutorial on the timing of cord clamping and why iron is so important to infant brain development, click here for a couple of posts I wrote for Science & Sensibility, Lamaze International’s blog.)
Despite the proven benefits of DCC, and the ease of switching from ECC to DCC (there’s no training or equipment needed–the obstetrician simply has to wait two or three minutes after delivery to clamp the cord), the American Congress of Obstetricians and Gynecologists (ACOG) has been lukewarm in recommending the practice. In a 2012 policy statement, ACOG stated that:
“…insufficient evidence exists to support or to refute the benefits from delayed umbilical cord clamping for term infants that are born in settings with rich resources.”
That phrasing was a bit of a puzzler. Given that a) it’s been known for several years that DCC increases iron stores in infancy, and b) that as many as 1 in 6 American toddlers are iron deficient, it’s not exactly clear what “insufficient evidence” and “settings with rich resources” ACOG was referring to.
McAdams dismantles that logic:
“Delayed cord clamping in term neonates promotes improved iron stores, prevents anemia beyond the neonatal period, and is more physiological than early cord clamping. Although the effect of delayed cord clamping may be more apparent in settings with a high prevalence of anemia in neonates and children, it is likely to have an important effect on all newborns, independent of birth setting.”
It’s hard to know if this will be enough to get ACOG to amend its 2012 statement on the timing of cord clamping for term babies. Regardless, now comes the hard part–convincing reluctant maternity care providers to change old practice habits and adopt DCC, with or without ACOG’s official blessing. This article should help.
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*There are even greater benefits for premature babies, but that’s the topic of a different post.
Been away from the blog too long! But I haven’t been snoozing…
Science & Sensibility just put up a post of mine about delayed cord clamping (DCC)–i.e., the practice of waiting 2 or 3 minutes after birth before clamping the umbilical cord.
It’s hard to believe that it’s so difficult to get maternity care providers to sign on to DCC (versus immediate cord clamping, or ICC) in uncomplicated vaginal births. The benefits of DCC–better iron stores for babies, improved cardiovascular transition from fetal life to babyhood, and a big dose of stem cells–are well known, and there’s no evidence that ICC is beneficial to anyone. Still, tradition is a hard habit to break, especially when it comes to medical practice.
So skip on over to S&S and have a read!