Question of the Month

Mandy Gatling asks:
What are the benefits of early versus delayed cord clamping?


Mandy Gatling holding little Lydia, a friend's baby.
Mandy and her husband Ben are looking forward to welcoming their own baby in July!

The Benefits of Delayed Umbilical Cord Clamping and Cutting
submitted by Rachel Thompson, RN and Charis Midwifery Student

     The moment of birth approaches as the mother's body bears down, pressing her infant into the world. At first, only a glimpse of the infant's presenting body part is seen through the opening of the birth canal. Then, contraction by contraction, the infant emerges from within the protective environment of the mother's uterus where it has spent its life thus far and is expelled to become an individual human being, separate and independent from the continuous life flow of oxygen and nutrients to which it has been attached. Having slipped into an environment unlike anything it has known, the infant's tiny body must adapt within moments after its birth. The complete severance from the infant's mother will occur with the clamping and cutting of the umbilical cord, the lifeline it has had to its mother all along. The timing of this event, however, is a matter of vastly differing opinion with alternatives including the cutting of this lifeline immediately, leaving it completely uncut until it separates naturally, or clamping and cutting it sometime between these two extremes. While opinions vary among health care providers, delaying umbilical cord detachment significantly increases the wellbeing of the newborn.

     Currently, there are various methods of umbilical cord cutting within the practices of obstetrics and midwifery. In the hospital setting, where the medical model of practice is adhered to and labor and birth are managed within that scope, the promoted habit is to clamp and cut the cord within 30 seconds after the birth of the newborn (Buckley, “Leaving Well Alone”). Hutton and Eman document a study in their research showing that immediate clamping and cutting of the umbilical cord is the method most common to western world practitioners. As of 2001, “The American College of Obstetrics and Gynecology (ACOG Educational Bulletin 216, Nov 1995) and the Society of Obstetrics and Gynecologists of Canada (SOGC Policy Statement No 89, May 2000) advise immediate clamping of the cord at birth” (Morley, “To Whom it May Concern”). The common application of immediate cord cutting is the immediate clamping and cutting of the cord as the baby is placed on the mother's abdomen, and if the newborn is not showing signs of respiratory effort right away, whisking it away to a warming table where its airway is suctioned in order to clear away any fluid or mucous. If respiration does follow within 30 seconds, the caregivers use a bag mask to perform ventilation on the newborn. If this does not stimulate breathing, then “endotracheal intubation is performed with positive pressure ventilation” (Morley, “Neonatal Resuscitation”). Morley goes on to explain that over 30% of neonates are assisted with some form of pulmonary resuscitation because the newborn lungs have not yet begun to function, however, he adds that the reason for this is that the physiological support of the umbilical cord has been severed (“Neonatal Resuscitation”). This method of immediate umbilical cord cutting is fostered within the medical model of care as normative for all births, both vaginal and cesarean section.

     Conversely, delayed umbilical cord clamping and cutting is the normal practice among most midwife attended births whether in the hospital or at home births. This delay spans the spectrum of a two minute wait to clamp the cord to the extreme of refraining from cutting the cord at all. Lotus birth is the term applied to the practice of not cutting the umbilical cord so that the placenta may remain attached, allowing for the natural separation of the cord from the newborn at the umbilicus somewhere between 3-10 days after birth has occurred (Buckley, “Lotus Birth”). Although this practice is one more common to other countries, it was first introduced in the United States in 1974 by a woman named Clair Lotus Day who convinced her doctor to allow her to take her newborn baby and the placenta home with the umbilical cord uncut (Buckley, “Lotus Birth”). Lotus birth promotes a close and strong mother-baby bond, as leaving the placenta attached creates circumstances which make transporting the infant much more challenging. The mother is encouraged to remain with her baby and placenta, keeping quiet during the immediate post partum period which both benefits in her healing and limits visitors who are wary of the site of the placenta (Buckley, “Lotus Birth”). On the other hand, if the mother has a large family, it is much more inconvenient to carry both the baby and the placenta as she cares for her other children, as pointed out by Susan Oshel, a midwife who has practiced for over 30 years. Mrs. Oshel also mentioned another drawback to lotus birth being that the placenta begins to become “fragrant” as it deteriorates in the days before the separation of the umbilical cord from the newborn occurs. Oshel added that, “Once that placenta is out [of the mother's body], it has done its job.” and went on to explain that the Wharton's jelly swells so soon after birth that by the time the cord has ceased from pulsing, there is no longer fluid moving through the blood vessels in the umbilical cord, thus there is no physiological benefit to the placenta being attached to the baby any longer.

     In order to provide a foundation in support of the benefits of delayed umbilical cord cutting, one must understand the dramatic physiological changes which occur within the neonate at the time of birth. During the fetal period, the function of the umbilical cord is to provide oxygen and nutrients in the flow of blood from the mother to the fetus and to carry fetal waste products away to the placenta where the blood is filtered by the mother's circulatory system. The fetal circulatory system has several major differences from the adult circulatory system. An initial shunt carries blood directly from the umbilical cord entering from the umbilicus through the ductus venosus which bypasses the highly oxygenated blood past the liver to the inferior vena cava where it mixes with deoxygenated fetal blood that is returning from the lower extremities (Morley, “Why Do Babies Cry?”). It then flows into the right atrium of the heart and through a second shunt called the foramen ovale which connects the right atrium to the left atrium. This allows the well-oxygenated placental blood, although it has been mixed with deoxygenated blood, to flow directly into the left atrium (Morley, “Neonatal Resuscitation”). From there it is pumped out of the heart by the left ventricle and is delivered directly to the brain, heart and upper body of the fetus to ensure that their oxygen supply is plentiful. Upon returning to the heart through the right atrium to the right ventricle, the blood is then pumped through the third shunt, the ductus arteriosus which bypasses the pulmonary circulation since the lungs are not functioning in the oxygenation of the fetus at this time and hence only need to receive approximately 5% of the cardiac output (Morley, “Why Do?”). The ductus arteriosus delivers the blood to the descending aorta which supplies the lower body with blood and finally, a portion of this blood returns to the placenta via the two umbilical arteries to be filtered and circulated once again (Page, 341-350).

     At the time of delivery, there is a marked shift in circulation as the umbilical vessels are constricted by the Wharton's jelly, the ductus venosus closes, the vessels to the liver open, the foramen ovale shuts causing the atrial chambers to be separated. The ductus arteriosus also closes, circulating blood to the lungs, opening the pulmonary arterioles and supplying blood to the pulmonary supporting organs (Morley, “Why Do?”). These alterations in the circulatory system of the newborn establish it as independent from its mother. All these changes occur within minutes of birth and happen most efficiently with the support of uninterrupted flow from the placenta through the uncut umbilical cord.

     At the moment of birth, even though the newborn is no longer protected by the safe haven of its mother's uterus and the amniotic fluid, the function of the umbilical cord is still crucial in the transition that the baby must make to become totally independent of its mother. Efficient activation of the fetal organs at birth requires a tremendous influx of placental blood through the umbilical cord, as Morley explains. By leaving the umbilical cord uncut until it closes physiologically on its own, the newborn actually receives somewhere between 50 to 100 ml of additional blood (Buckley, “Leaving Well Alone”) and this provides a 30-50% increase in the newborn's blood volume which activates and establishes the functioning of vital organs (Morley, “Neonatal Resuscitation”). The liver requires sufficient perfusion of blood in order to begin its task of maintaining blood glucose levels and filtering blood of toxins. If this blood supply is cut off by early cord clamping, hypoglycemia may occur, putting the newborn at risk of convulsions and decreasing its ability to excrete bilirubin, thus compounding its chances of physiologic jaundice (Morley, “Neonatal Resuscitation”). Increased blood flow to the kidneys is necessary in order for adequate regulation of fluid volume and electrolyte and acid-base function. Also, warm blood from the placenta assists in the baby's temperature regulation. Hence, the newborn suffers if the umbilical cord is cut immediately because it must suddenly rely on its own means of temperature control which requires additional energy expenditure. In utero, the circulation to the baby's pulmonary system has been minimal because its oxygen supply has been from its mother. However, beginning at birth all of the neonate's blood must circulate through its lungs. Blood must perfuse the alveoli and erect the pulmonary capillaries in order to initiate aeration.  Thus, additional blood is needed to fill the lung tissue and respiratory muscles before respiratory efforts happen (Morley, “Neonatal Resuscitation”). Immediate cord cutting decreases the perfusion of the lung tissue by placental blood, which results in reduced pulmonary function (Morley, “Lost Causes”).

     An interesting study documented in Morley's article “Neonatal Resuscitation” was performed by Peltonen who filmed the fetal thorax flouroscopically during birth and determined that immediate cord clamping actually reduced the neonatal cardiac size “due to incomplete filling of the ventricles” with placental blood. Morley adds, in the same article, that without the final powerful surge of blood flowing in from the umbilical cord, the foramen ovale and the ductus arteriosus do not close completely, resulting in heart murmurs and the possible necessity of heart surgery to correct the problem. These valves and shunts which are meant to close at birth to reroute the blood flow may not close properly if the blood volume and oxygen supply to the baby is suddenly cut off (Falcao).

     The most crucial organ affected by the sudden severing of the flow of oxygenated blood immediately at birth and the one most vulnerable to permanent damage is the brain. The umbilical cord acts to carry oxygenated blood to the fetus in utero. During a normal physiological birth, the integrity of the brain is protected by this flow. However, when the cord is cut, the fetal brain is exposed to pure hypoxia until resuscitation is established, thus causing irreversible injury to the brain tissue (Morley, “Neonatal Resuscitation”). Damage to the neurons can happen in as little as six minutes, caused by neonatal asphyxia or hypoxia (Morley, “Lost
Causes”). If the newborn does not begin to breath on its own as soon as it is born, the oxygenated blood flowing from the placenta will support the infant's need for oxygen for several minutes, thus preventing injury to the brain and possible death (Falcao). It actually takes about 20 seconds after the newborn's first breath for the normal shift in blood flow to occur but if the umbilical cord is cut before that shift happens, the baby's body goes into a “shock” condition because of the lapse in time that the baby is receiving oxygen (Oshel). The crying response of a newborn actually slows the intake of placental blood by the increased thoracic pressure that happens as a result of crying, and the constriction of the vessels in the umbilical cord. This seems to be indicative that the amount of additional blood a baby receives at birth is actually regulated by the baby's own unique need for the specific blood volume (Buckley, “Leaving Well Alone”). The crying, of course, is confirmation that breathing has been established and that the vital organ systems are receiving oxygen and have begun to operate.

     A collaborative article by Hutton and Hasson lists some of the risks of early cord clamping as: hypovolemic damage, iron loss, several blood disorders, type 2 diabetes, and anemia. Preterm infants are especially at risk for anemia, intraventricular hemorrhage (brain bleed) and the increased need for blood transfusion (Science Daily, 17 August 2007). Peltonen also noted a strong connection between immediate cord clamping and anemia. He went further to state that recent studies show association between anemia and “learning and behavioral disorders and mental disabilities” (Morley, “Neonatal Resuscitation”). Morley adds that anemia is simply a manifestation of the loss of the additional blood volume which would have been delivered to the newborn had the umbilical cord cut not been immediately. However, each of these risks can be greatly reduced simply by added blood volume through the unclamped umbilical cord at delivery (Science Daily, 17 Aug 2007).

     Anemia and its relationship to the timing of umbilical cord cutting is a topic of fairly recent research but one which has fully supported delayed cord cutting. The research has shown that even a two minute delay in cord cutting benefited both the short and long-term iron status and increased hematocrit levels as well. These benefits actually extend beyond the early newborn period, as documented in a study showing that there is a 47% decrease in the risk of anemia and a 33% decrease in the risk of deficient iron stores in infants of delayed cord cutting tested both at two and three months (Hutton, “Late vs. Early Clamping”). Science Daily presented first time documentation based on a study done by Dewy and Chaparro, nutritionists at University of California, Davis, showing evidence of significantly enhanced iron levels up to six months of age, and states that delayed umbilical cord cutting increases iron levels by 27-47mg of iron which is equal to one to two months of the infant's iron requirements (Science Daily, 18 June 2006). The reason that delayed umbilical cord cutting has such a positive influence on infant iron levels is because the placental blood is rich in iron. Even at the time of birth, 6% of the normal fetal red blood cells are found in the placental circulation (Hutton, “Late vs Early Clamping”) so by waiting to cut the cord, not only is the neonate's rightful 6% of red blood cells (RBCs) being returned to its own circulation, but it is being gifted with supplemental iron from its mother through the placenta for its first months of life. Long term effects of iron deficient anemia resulting from early cord cutting are being connected with manifestations such as physical and cognitive delays, which usually are not discovered until school age (Grajeda, et al).

     There are several arguments which the medical community presents in support of immediate cord cutting. The first is polycythemia, which is the “increased number of erythrocytes per volume of blood, which may be caused by large placental transfusion” (Lowdermilk and Perry, p G-24). The concern of physicians is that the blood may become too thick and also, that more red blood cells produce physiologic jaundice as the baby's body breaks down the RBCs. However, Buckley debates that this is an unreasonable argument because there have been no proven adverse effects to polycythemia (“Leaving Well Alone”). Hutton supports her statement that the increased RBCs from delayed cord cutting has no significant impact on either the blood viscosity (thickness) or the infant's bilirubin levels. In her documentation, there was no additional need for phototherapy in infants who were jaundiced as a result of polycythemia produced by delayed cord cutting. Even those infants that were considered “polycythemic” were asymptomatic (“Late vs. Early Clamping”).

     A second concern of the obstetrical practitioners is retained placenta and postpartum hemorrhage. Studies prove that an upright position for birth encourages the delivery of the placenta. While this issue may not have so much to do with the timing of cord cutting as it does the position of the woman at birth and the other interventions which are introduced during a medically managed birth, there is also “some evidence that early cord clamping increases postpartum hemorrhage and retained placenta by trapping blood in the placenta, thus increasing placental bulk which is more difficult to expel” (Buckley, “Leaving Well Alone”). Medical intervention practices implemented in the hospital setting also do not encourage the mother to produce her own oxytocin which greatly decreases the risk of postpartum hemorrhage (Buckley, “Leaving Well Alone”).

     A final argument of the medical community at large is the harvesting of stem cells. It is a very common and popular practice at this time. In order to withdraw stem cells from the blood in the umbilical cord at the time of birth, the procedure dictates that immediate clamping is necessary. At that point, 100ml or more of blood is drawn from the umbilical cord, stored in a bag and sent within an hour or two to a lab for processing. While the stem cells may be very beneficial in treating diseases, the newborn is able to benefit from the richness of the additional placental blood, not only in oxygen, iron, blood volume, and warmth but from the uniqueness of
the stem cells to this stage of development. It may even protect the infant from those diseases for which stem cells are harvested to treat (Buckley, “Leaving Well Alone”).

     After describing the vast physiological benefits of delayed cord clamping, I would be negligent to leave out the emotional and psychological effects that early cord clamping has on the newborn. Author Joseph Chilton Pearce hypothesized that because a baby's adrenalin levels peak at birth, when the cord is clamped and cut immediately, the baby is more likely than not to be separated from its mother. He explains that separation from its mother means that the adrenalin hormone which is pulsing through the baby's tiny body is not comforted and soothed by contact with its mother, smelling her unique smell, hearing her calming voice and the reassuring sound of her heartbeat, and feeling the warmth of her skin. When the infants adrenalin level is not soothed, this activates the brain function of psychological shock and hence the baby is programmed for stress (Buckley, “Leaving Well Alone”). At the moment of birth, both the mother and the baby need this initial introduction to be uninterrupted in order to establish a healthy lifelong bond. Delayed umbilical cord cutting protects this crucial time by not allowing the mother and her baby to be separated physically.

     The benefits of delayed cord cutting were witnessed and documented as early as 1801, when Erasmus Darwin recorded the following: “Another thing very injurious to the child, is tying and cutting the naval 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, a portion of the blood being left in the placenta, which ought to have been in the child” (Buckley, “Leaving Well Alone”). What was apparent to Erasmus Darwin in 1801 has been corroborated by scientific research in our own day, namely: that newborn wellbeing is increased by a delay in umbilical cord removal. Such a delay supports a more natural and physiologic transition toward independence for the infant, and conveys both immediate and long-term physiological, psychological, and relational benefits.

Works Cited
Bergel, Gary. “When You were Formed in Secret.” Intercessors for America, 1998. I-10 and I-15.

Buckley, Sarah J. “Leaving Well Alone: A Natural Approach to the Third Stage of Labour.” 2003. http://sarahbuckley.com/articles/leaving-well-alone.htm

Buckley, Sarah J. “Lotus Birth-A Ritual for Our Times.” Birthsong Childbirth Education and Support Services. 16 December 2007. <http://onyx-ii.com/birthsong/page.cfm?lotus>.

Falcao, Ronnie, LM MS. “Risks of Premature Cutting of the Umbilical Cord.” <http://www.gentlebirth.org/archives/cordRisks.html>.

Grajeda R, Perez-Escamilla R, Dewey KG. “Delayed Clamping of the Umbilical Cord Improves Hematalogical Status of Guatemalan Infants at 2 months of Age.” American Journal of Clinical Nutrition. 1997 February. 65 (2):425-31.19January2008.<http://web.archive.org/web/19960101000000- 20061015225030/http://cordclamping.com/Grajeda.htm>.

Hutton, Eileen K. and Eman S. Hassan. “Late vs Early Clamping of the Umbilical Cord in Full- term Neonates.” JAMA.2007;297:1241-1252.26January2008.<http://jama.ama-assn.org/cgi/content/abstract/279/11/1241>.

Morley, George Malcolm. “Lost Causes and Side Effects.” BMJ. 2001; 323: 1389 (Abstract).
17 December 2001. <http://www.bmj.com/cgi/letters/323/7326/1399#18099>.

Morley, George Malcolm. “Neonatal Resuscitation: Life that Failed.” OBGYN.net. 9 February2003. 19 January 2008. <http://www.obgyn.net/pb/pb.asp?page=/pb/articles/neonatal- resuscitation>.

Morley, George Malcolm. “To Whom it May Concern.” 29 August 2001. 16 December 2007.
<http://www.whale.to/a/morley17.html>.

Morley, George Malcolm.”Why do Babies Cry? The Anatomical and Physiological Changes During the Moments After Birth”. 11 April 2002. 2 February 2008.
<http://www.whale.to/a/morley4.html>.

Oshel, Susan, CPM. Personal Interview. 14 January 2008.

Page, Lesley Ann. Chapter 16: The Newborn. The New Midwifery. Patricia Percival, associate editor. Edinburgh: Churchill Livingstone, 2000. 341-50.

ScienceDaily.18June2006.29November2007. <http://www.sciencedaily.com/releases/2006/06/060618224104.htm>.

 © Rachel Thompson ~ used with permission

Derek and Rachel Thompson
 

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