Taking the Pulse on Delayed Cord Clamping

Farrah Sheehan Deselle, MSN, RN, CLC, CCE (BFW)

Childbirth and Parenting Preparation, Education and Support Program Coordinator

The Mom’s Place at Catholic Medical Center

I love hot topics and if you have been following my articles for the past few months, you probably noticed!  I know something is getting hotter when more and more parents start asking about it during classes and Welcome Visits at The Mom’s Place (TMP) at Catholic Medical Center (CMC).  Lately, parents have been asking about cord clamping, and there has been more written about it in social media and in scientific literature.  One dad-to-be asked recently in class, when a mom-to-be inquired about it, “what the heck is delayed cord clamping?”  Let’s explore, and take the pulse.

First, a bit of anatomy and physiology to frame our learning; babies are connected to the placenta (the nutrient dense organ that develops along the wall of uterus) via the umbilical cord.  Most of the time there is one vein (carrying oxygen rich blood to your baby) and two arteries (carrying oxygen depleted blood back to the placenta) in the tough and twisted cord.  Anyone who has ever cut a cord knows it is much tougher than it looks!  The blood flows from the placenta to your baby and back, and provides the growing fetus with all of her nutrients.  At birth, the umbilical cord remains attached to the infant at the site of the umbilicus (later the belly button), until someone clamps and then cuts the cord, leaving a bit of cord protruding from the baby’s umbilicus (making some parents squeamish).  After the birth of the baby, the placenta begins the process of becoming unattached from the wall of the uterus, in order to be birthed as well.  

Throughout the past century, the standard practice has been to clamp the cord immediately at birth, stopping the flow of blood from the placenta to the baby and back.  The baby was usually then moved away from mom and washed, dried, assessed and at some point, depending on the time and place in history, returned to mom (sometimes after many hours – but that is another topic).  Thankfully in many birth settings today, with increased awareness of the importance of keeping mom and baby together at birth, infants are placed on mom’s abdomen or chest immediately after birth.   In many settings, the cord continues to be clamped and cut almost immediately.

Delayed Cord Clamping (DCC) is the practice of keeping the cord intact for a few minutes after birth, allowing blood flow from the placenta to the baby.  The World Health Organization (WHO) and The Association for Women’s Health, Obstetric and Neonatal Nursing (AWHONN) recommend DCC because studies have demonstrated a decreased need for blood transfusions, decrease incidence of anemia and improved overall blood volume in infants who experience DCC (Sagady, 2015).  The American College of Obstetrics and Gynecology (ACOG) currently recommends the practice in infants born before 37 weeks gestation.  The umbilical cord carries oxygen rich blood and millions of specialized stem cells for development of organs and the central nervous, respiratory, cardiovascular, hematologic, immunologic and endocrine systems.  DCC has been found to decrease rates of anemia in infants as old as 6 months (McDonald et al 2013).

Immediate cord clamping has become an intervention that is so routine in some settings, it is viewed as the norm, making DCC the “intervention”.   Mounting research has demonstrated that this once seemingly benign practice is usually not necessary, and alters the normal physiological birth process that nature has created to protect infants and provide for their short and long term health and well-being.  Kerri Hoyt, Certified Nurse Midwife (CNM) at TMP at CMC reports that in her experience, “the trend in this area of the country has gone from immediate clamping and cutting (in order to pass the newborn off to the awaiting pediatric staff for immediate evaluation) to allowing skin to skin time” and waiting to clamp and cut the cord.  Perhaps the awareness of the need for skin to skin contact and not taking the baby away from mom right after birth has allowed a natural change in practice to DCC, and not rushing to clamp the cord to get the newborn to the medical staff for assessment and cleaning.  

At TMP, through committees such as Perinatal Quality and Obstetric Council nurses, nurse midwives, obstetricians and nurse leaders work together to continuously explore research and literature for evidence based practice recommendations.  Because of this, our team routinely delays cord clamping and provides infants and moms with immediate skin to skin contact at birth.  No matter where you birth your baby, as a health care consumer, your input is valuable.  Talk to your provider and your support team about the timing of clamping your baby’s umbilical cord.  Birth doesn’t ever go exactly as planned, so think about what you would like to have happen, make it known and also, as part of your preparation, consider what else might happen even if everything doesn’t go as planned.  Autumn Vergo, a CNM practicing at Dartmouth Hitchcock Keene says “sometimes, babies are born with the cord wrapped around their neck or their body in a way that inhibits descent at the moment of birth. Many midwives use hand maneuvers that loosen, unwrap, and "somersault" babies through loops of tight cord to avoid cutting it.”  Ask your provider about their experience with loosening the cord at birth, and what the circumstances are that may require clamping and cutting the cord more quickly, such as excessive bleeding for the mother, or an infant that is requiring more vigorous stimulation after birth.  Also, during cesarean birth, immediate cord clamping remains a standard practice in most settings, including at TMP.  During a cesarean birth, the opening to the uterus causes the mother to lose blood and increases her risk for infection.  Cutting the cord right after the baby is born allows for delivery of the placenta and repair of the incision as soon as possible.  More research is needed to determine if there is any risk to mother or infant in delaying cord clamping at cesarean births. If your baby does have to be separated from you, or if the cord needs to be clamped immediately, what else can you do to help your baby adjust to life outside the womb?  (skin to skin, waiting to bath your baby for at least 12 hours, and breastfeeding are a few things that help your baby adjust to his or her new life).   

Hoyt states “I think newborns are supposed to stay with their mothers as nature intended; until the cord stops pulsing when the placenta separates, both for the extra blood cells that the newborn receives, but also to promote bonding and transition to extra-uterine life for the newborn. That said, there are obviously plenty of sound reasons to clamp it before, but why do it if the baby is vigorous and healthy and mom is falling in love.”

For more specific guidelines by the World Health Organization on optimal timing of cord clamping for the prevention of iron deficiency anemia check out their guideline at:

http://www.who.int/entity/elena/titles/full_recommendations/cord_clamping/en/index.html

At The Mom’s Place, our classes encourage discussion of topics that parents want to learn more about, like DCC.  Our classes are developed using the Birthing From Within ® model (BFW) preparing parents in the body, mind, and heart for the full range of childbirth experiences. Our childbirth educators are nurses who work at The Mom’s Place and in our Special Care Nursery and have received training as BFW mentors.  If you want to learn more about our offerings or schedule a welcome visit, call (603) 626-2626 or check out our website www.catholicmedicalcenter.org/moms-place. 

Farrah Sheehan Deselle is a Certified Birthing From Within ® Mentor and coordinator of Childbirth and Parenting Preparation, Education and Support Programs at The Mom’s Place at CMC. She teaches many of the classes and works at The Mom’s Place as a lactation consultant. She has a Master’s of Science in Nursing: Health Systems Leadership. Contact Farrah at: farrah.deselle@cmc-nh.org.

References

Mayri Sagady, L.  Perspectives on Implementing Delayed Cord Clamping.  Nursing for Women's Health. 2015; 19: 2

McDonald, S.J., Middleton, P., Dowswell, T., and Morris, P.S. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews. 2013; 7: CD004074