Delayed Cord Clamping

In the back of my mind, I had the idea to write  post about cord clamping, the research for and against early/late cord clamping, and all that jazz. Well, I didn’t write it soon enough, so now I don’t have to write it at all (or do the extensive research required for such a post), because Nursing Birth has written it. Since it’s very long, I won’t write any more about it, except to say GO READ IT and save it for future reference!

19 Responses

  1. Thanks so much for the link!!! I wish more women and birth attendants were educated on this subject!

    ~Melissa
    http://www.nursingbirth.com

  2. Sorry, full of bull shit. No extensive research there. Popular misconception is more acurrate. Notice every woomeister on the plant is jumping on her band wagon?

    Read the BMJ for what might be a good research article on delayed cord clamping. Ask a few Nicu Docs what can happen if the baby gets too much blood. It is more troublesome than just jaundice. In short listen to the experts and as a nurse we are not experts in Neonatal physiology. We are consumers of research. I worry when nurses are consuming research that is total crap!

  3. Pinky, but I have done just what you said — read the BMJ, plus some Medline & Cochrane articles, and while I unfortunately could not read much beyond the abstracts, it seemed that the uniform opinion of the studies was that delayed cord clamping was associated with benefits for the preterm or term neonate, with little if any negatives. If you have other studies that contradict that, feel free to post them (here or on your blog).

    I understand that it is possible for babies to get too much blood. This is one reason I support waiting until the cord stops pulsing before clamping and cutting it. It is possible for too much blood to be in the baby when the clamp is placed — blood that would have been returned to the placenta with the next pulse — blood that is trapped inside the baby that should not be. Also, if the baby is held below the level of the placenta, too much blood may drain into the baby; but if the baby is held on the mother’s abdomen or chest, then this “transfusion” is unlikely to happen.

    But it is more probable for babies to have anemia (which can be problematic and even deadly, particularly in underdeveloped countries) if immediate cord clamping is used — the percentage I remember being quoted most frequently was 40% of babies (75% in sub-Saharan Africa) may have anemia due to not getting enough blood at birth due to ICC, whereas polycthemia (in the studies I read, this was the only negative outcome mentioned that was higher in the DCC group vs. the ICC group) affects from about 1-4% of all neonates, with most of the babies having certain risk factors: LGA, SGA, mothers with DM or GD, etc. It may be that these particular at-risk babies should have ICC performed, but babies not in these risk profiles should be allowed the full complement of their own blood.

    Still, going back to polycthemia — one study (published in 2007) noted a higher rate of polycthemia in babies who had DCC, but said that it was benign — it caused no problems to these babies. From other reading, polycthemia was diagnosed if the hematocrit was >65%; but not all polycthemia caused problems — many times, it is benign. In reading these things, I was made to think about how that back in the 50s-60s, infant growth charts were drawn up, using formula-fed babies as the norm. This meant that when breast-fed babies were brought in and charted, they appeared to be smaller and weaker and “needed” to be on formula because they were underweight. Similarly, I wonder if what is considered “normal” in blood volume depends on whether the baby was clamped immediately or not. The fact that the polycthemia noted in the DCC group was benign indicates to me that perhaps it may actually be normal, and not a problem, in infants that have DCC. Also harking back to the near-100% formula-feeding days, jaundice was noted to be higher in breastfed babies than in formula-fed babies, which led to many mothers being told to either discontinue b/f entirely, or to supplement; now it is believed that this type of jaundice is not just normal but may even be beneficial. Of course, jaundice can be a problem in neonates, so they need to be observed to make sure it’s not a problem — and it may be just the same thing with polycthemia — sometimes it is a problem, sometimes it is not. If polycthemia develops with ICC, it is more likely to be the problematic kind; but it ought to be studied more fully to see if polycthemia that develops with DCC is more or less likely to be benign or problematic.

  4. I have no problem with delayed cord clamping, which I mentioned on the Nursing Birth site. However, there were some frankly uninformed and dangerous assumptions from commentors on delaying cord clamping in babies that need resuscitation. This happens to be my area of expertise and I commented on these misguided assumptions, backed up by evidenced based practice. It was purely scientific and not personal. Yet my comment was deleted. This discredits the blog author if she cannot answer evidence based practice with further evidence. You can do whatever you want to on your own blog, but giving dangerous assumptions presented as fact to vulnerable nursing students and new moms, is well, dangerous.

  5. I never delete any comments on my blog. I hate that too.

    I think the jury is still out on Delayed cord clamping. Also you have to read the study. And see how they came to their conclusion. Just looking at the abstract, you will not get the total information that you need to decide if it is adequate.

  6. Also the baby, once born becomes a high pressure system. The placenta is a low pressure system. So if the baby is placed on the Mom’s abdomen, the baby is more likely to lose blood than gain blood. This was explained to be my 6 different Nicu Doctors. Nicu Doc’s are the professionals on neonates so they are the folks I talk to when I have a question about the neonate.

  7. RR — feel free to post your comment here — I won’t delete it.🙂

    I agree with you about deleting comments — it discredits the blog owner (and reminds me of Dr. Amy).

  8. RR — I just happened to think, it may be that your comment was automatically filtered to her spam folder. My comment moderation settings are to require me to approve the comment the first time somebody comments, but once they’re approved, all other comments are automatically approved (but I know it must reset if a person doesn’t comment after some period of time, since I’ve had to re-approve some people). Some blogs are set up so that all comments require moderation (approval), and other don’t have any moderation at all.

    My blog is also set up so that comments over a certain length or with two or more links are automatically sent to the spam folder, if the person is not already approved for commenting — so this may be what happened with your comment, if it was your first time commenting on that blog.

    When you post a comment (in WordPress), it should show up on the post right then, or say it’s being held in moderation. If it just disappears into the ether, you can be pretty sure it’s been filtered to spam. If it shows up and then disappears, then it was “filtered” with the delete key. Perhaps you can post a shorter comment to her blog and see if it goes through, or post a comment with either no links or only one, or (what I have done a few times, if I was not allowed to post my comment, for one reason or another) write your rebuttal as a new blog post on your own blog and link and/or comment on that post. That’s what I had to do with the “breast is best myth is busted” post that I wrote a couple of weeks ago — it was either too long or had too many links, so the comment was discarded automatically. Fortunately, I was able to recover it so I could post it on my own blog.

  9. Hi Kathy,
    One of the reasons I like your site so much is that you do not delete comments! You can take the heat, and I appreciate it. I also like the Nursing Birth site, so I was disappointed I was deleted. Oh well. My comment was up for a couple of hours (as was Pinkies BTW), and both disappeared hours later. I may address the comment about cord clamping and compromised babies later on my site.
    Thanks

  10. RR & Pinky — please do, both of you, write your opinion plus any research (or anecdotal accounts) that support your opinion. I hope you do understand that by looking at the research (perhaps just summaries or abstracts, which is not as good as full articles, I understand; yet as I would snarkily say to Dr. Amy, “Lots of Very Smart People in White Coats” were involved in the original research, plus peer reviewing prior to publishing, as well as comments [particularly the BMJ’s “Rapid Response”] made afterwards), that all seem to give the uniform position that the research is valid, and shows that delayed cord clamping has greater benefits than risks to the average neonate.

    Not only can I “take it” if someone disagrees with me, but I want to know and learn more, and if I am wrong, then I want to be right.

    I understand — believe me — that a particular practice may benefit one person while harming another. Looking at C-sections, the research and literature is clear that on balance, vaginal birth (even VBAC) is better for mother and child unless there is a medical indication for a C-section. This does not eliminate the fact that there will be one mother or one baby out of 100, 1000, or a million that will suffer greater harm from a lack of intervention than they would have suffered from the intervention. So, it may be that you are seeing some babies who have problems due to delayed cord clamping (although I have some questions and theories about that), but because problems like anemia and other problems associated with not enough blood do not become apparent until after the neonatal period has passed, you may not be seeing the many more children who are suffering from immediate cord clamping.

    Pinky — your comment about high/low pressure systems is intriguing. It makes me curious in a couple of ways. First, you stated that the problem with DCC is too much blood; but now you seem to say that DCC could be associated with too little blood. I understand what you’re saying about the “low pressure system” of the placenta, but is it possible that a physiologic 3rd stage could help stabilize the pressure of the placenta, so that there is not quite the imbalance seen? Also, since there are certain babies that seem to be at higher risk for polycthemia, is it possible that these babies would be helped by being placed for some time above the level of the placenta, thus allowing some of the excess blood to drain out of their bodies back into the placenta? and that immediate cord clamping may trap too much blood in their bodies, with the cord being clamped seconds after birth, with the baby being lower than the placenta that whole time?

    I understand that having the baby well below or well above the placenta may cause some weirdness; but the typical out-of-hospital birth (including my two), has the baby being placed in the mother’s arms, which would be approximately the level of the placenta, or perhaps a little higher. And if the mother is lying down, the baby would be on the bed with her, possibly on her belly, possibly nestled beside her, and again, would be approximately at the level of the placenta, or perhaps a little higher.

    Very interesting conversation!

  11. For the record, Nursing Birth addressed the deleted comment issue, and said she had archived it. She wanted to answer it personally, and not have her readers comment on it first. That is reasonable. I give Nursing Birth major props for addressing the issue. All is well in the blogosphere🙂

  12. RR — glad to hear that about NB. If you would like to, you can have her send your comment (and Pinky’s) back to you so you have a copy of it, and then you can paste it here.

  13. Too late: http://nursingbirth.wordpress.com/2009/05/22/response-to-a-comment-re-the-deal-with-delayed-cord-cutting/

    NB said she will address my very long comment, when she has time. Great discussion.

  14. Pinky & RR,

    I understand the desire, logic, and reasoning behind trusting NICU docs to know their stuff — after all, they had the medical training and it’s their job… but I have a couple of bones to pick with that. First, Pinky, on a recent post, you said that you had to call down a doctor for doing low-dose pitocin without having medical literature and research to back up his practice: “Here is the thing. If you are dealing with patients who come to your hospital, they don’t give a rat’s ass what you think works, they want to know what is supported in the literature. What probably will work because it has been studied and supported by literature. For every intervention or plan, there should be good data to support what we do. Especially if it could cause harm.”

    Well, I call clamping the umbilical cord within seconds (or even minutes) of birth an intervention, and one which should have good data to support that invention, especially since it appears that it could cause harm — particularly anemia (not typically a problem in the wealthy US, but a major problem in many other countries).

    Also, just because doctors have been trained in a certain way does not mean that it is accurate, just what they’ve done. For example: pubic shaving, enemas, 100% episiotomy-and-forceps births, etc. But something more pertinent to this discussion — newborns and particularly preemies who were operated on without any anesthesia at all, based on the insane and ridiculous presupposition that babies don’t feel pain, or at least don’t feel it as strongly or in the same way as adults do. How many babies died of the shock and trauma of such surgeries, even after a variety of studies demonstrated that babies *duh* do feel pain, and that pain relief and general anesthesia are appropriate in most if not all situations, and that babies do better if given pain relief, rather than being sliced open with full awareness, but complete inability to move due to paralytic agents.

    So, forgive me if I don’t think that just because doctors do something or are trained that something is the right way that it really is right, and is supported by research and literature.

  15. Not sure why I am being lumped into the “yes, doctor” argument. I have the pleasure of working in a Family Birthing Center where 30-40% of births are attended by midwives (including my own daughter), and no one blinks an eye at delayed cord clamping. I presented a counter argument on delayed cord clamping only in compromised neonates. I honesty can not remember exactly what I wrote. I hope Nursing Birth posts it. I did not even address preemies. As far as pain control in neonates, I have done research on this and have always been an advocate for pain control, against doctors wishes: http://realityrounds.com/2009/04/25/enter-dr-god-act-1/

    “So, forgive me if I don’t think that just because doctors do something or are trained that something is the right way that it really is right, and is supported by research and literature.” I agree, and the posts on my own blog support this.

  16. Perhaps I’ve read too much in one sitting, and it’s all getting jumbled up in my brain.🙂

    Besides, my husband was watching the ‘Hawks beat the Red Wings on his computer right next to mine, so I was just a tiny bit distracted.😉

  17. The Doc with the low dose pit was an OB. I have never had to call out a Nicu Doc. But then again, I don’t work in the Nicu. I just find it very very interesting that many of the Nicu Docs are against it. I have found their arguments solid.

    I am still unconvinced that delayed cord clamping is the best thing to do. And of course it varies with each birth. I have noticed some babies turning white as a sheet when they are on the Moms belly and the Midwife has not clamped the cord. They do pink up later. But it looks like they are losing blood, not gaining it. So my personal experience has a role to play too.

  18. Pinky,

    “The Doc with the low dose pit was an OB. I have never had to call out a Nicu Doc. ” — Yes, but you said that you called out the OB, not on the basis of whether or not it worked, nor whether or not everybody else on the floor was doing it, nor even whether their arguments were solid, but on the basis of whether or not he had good statistical proof or studies — reliable research behind him for his actions. The difference is that you agree with the NICU docs in their intervention, but you disagree with the OB, although they are both basing their treatment on the same amount of research, which is little or none. Now, the NICU docs may be right and I’m wrong. Their “gut instinct” may be more reliable than the studies that demonstrate benefit or at least no harm. But that’s a shaky argument at best.

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