Delayed Cord Clamping — an OB’s take

Likening routine immediate cord clamping to routine episiotomy, Dr. Nicholas Fogelson argues that delayed cord clamping should be standard practice in obstetrics, not immediate cord clamping. Although he would “humor” the occasional patient who requested delayed cord clamping, he accepted immediate cord clamping as being “the way to do things,” simply because that was what he had been taught to do — it was what all his teachers and mentors had done, so it was what he did, too.

Then he actually looked to see if the research bolstered his actions, and was disturbed by what he found.

“It feels like being a doctor 10-15 years ago looking to see if there is any data about episiotomy, and finding that there’s a lot, and it says we’ve been doing it wrong for awhile now.”

So he’s calling for a return to delayed cord clamping. I call it a “return,” because although immediate cord clamping has reigned in medical circles for as long as we can remember — probably as long as birth has taken place in hospitals — it is not what was normally or typically done prior to that time.

Considering this data, I have to think about evolution and function.  I am a strong believer in evolution, but even under creationist thinking I have to believe that if the system meant for babies to have been phlebotomized of 50-100 cc of blood at birth, we would have been born with higher hemoglobins.  Clearly the natural way of things is for this not to happen.

Obviously, as a creationist, I would agree with this statement (except for the “strong believer in evolution” bit). Surely it is not “natural” by either evolutionist or creationist standards to immediately clamp and cut the umbilical cord, since that is not what happens among placental animals, and babies are not born with a clamp in hand.😉 What is natural is Wharton’s jelly that naturally closes the blood vessels in the umbilical cord after some period of time after birth.

We are all familiar with the statement included in the Hippocratic Oath, “First, do no harm.” It is not the delayed cord clamping (or physiologic cord handling, as some call it) that needs to prove itself, but rather that immediate cord clamping and amputation should be made to prove itself. It may be that immediate cord clamping is somehow more beneficial on average than delayed cord clamping — I’m not discounting that as a possibility. There may be a few babies who might benefit from ICC. But since the motto is, “first, do no harm,” we need to make sure that the non-physiologic action we are contemplating is actually 1) not harmful and 2) beneficial. Currently, the data just doesn’t seem to support it.

16 Responses

  1. My thoughts and prayers are with you.

  2. Oh Kathy,
    I am so sorry for your loss. It is never easy.

    I am very interested in DCC, especially as it relates to the extremely premature. This is a relatively new field in medicine, so we do not have any “historical” data on how human beings handled those born so very early. Preliminary research shows decreases in IVH and early blood transfusions in the extremely premature when DCC is undertaken. Very exciting and promising news….to me anyway!

    • Thank you, RR!

      Re: xPTB — my guess is that many of these babies would have been stillborn, or died very soon after birth; that their mothers would have held them and loved them as long as possible. But if/since all that you do is necessary to keep them alive, then there is no way they could have lived very long, without all that, except perhaps the rarest of situations. And yet I think about this tiny baby whom doctors weren’t going to try to save; her mother couldn’t bear the thought of her dying alone and cold in the bassinet, so she picked her up and put her on her chest, and the baby started breathing and her heart started beating. The article doesn’t say what care she required afterward to keep her alive, though.

      Still, I’m glad that there is new/renewed interest in DCC, whether in preemies or full-term babies. I understand the dilemma (ethical and otherwise) that many healthcare professionals are under — the desire to do the “right” thing, and immediately start the preemie on the drugs and equipment, necessitating ICC; vs. this “new” practice of leaving the cord attached for some time. If I were in charge of the world😉 I’d at least try to combine the best of both worlds — leave the baby attached, and bring the equipment to the mother/baby if at all possible. I don’t know what all equipment is required in the immediate postpartum with the very premature, but I don’t think it’s encased in concrete, so could be moved if required. There may be space issues, of course — it might not be a workable situation for long, but I would at least suggest that as a possible avenue to take.

      • The story you linked to was a baby born at 24 weeks. Not sure why she (and preemie girls have better outcomes) was not resuscitated at birth. It is the standard of care to resuscitate infants at 23-24 weeks here in the US, even though the long-term outcomes can be devastating. Hopefully these outcomes will be better if interventions such as DCC prove to be beneficial. I am keeping my fingers crossed (and toes).

        • Several months ago, you wrote a post about the British mum who blamed the government for not attempting to save her baby born at 21-23 weeks (I forget the exact age). I think the article said that babies were not routinely given care born that early; the cut-off date was later. Perhaps this particular baby was too early or didn’t weigh enough to be given care; or it may have been just the way she looked — more dead than alive. I think you said in one of your posts that there are cases that are given up for lost, cases that are expected to make it, and then there are cases that could go either way, and a lot depends on if the baby is a fighter or not — that care might be given for a period of time, and if the baby responds well, then that’s a good sign; but many die despite the best care. The doctor may have judged this apparently gray and lifeless baby as being unable to make it.

          This is one of the shortcomings of most articles — the devil is in the details, and the details are few and far between.

  3. I’m so so sorry. It’s such a hard thing to go through.

  4. It’s never easy but I do understand about getting off the emotional roller coaster. Mourning is something that cannot really begin for me until I know the baby is truly gone and no longer a part of me. I am sorry you’ve had to go through this.

    I have never experienced delayed cord cutting. Wonder if I go to the midwife this time, if she’ll do this. It’s sort of one of those things you can request, but I know I’d have a very hard time physically preventing a cord clamping…they are so fast down there. I always feel the birth is far away from me…it is VERY odd, but they could do anything to me and I would never reach down to stop it….I have never reached down even to catch my own baby. I just feel far, far away at that moment…

  5. So sorry about the miscarriage.

    The delayed cord clamping, I think it is hugely important and so misunderstood by OBs who just do things they way they were trained without thinking about it. So it is great that this doctor thunk!

  6. I am really, really sorry about your miscarriage.

  7. I am so sorry to hear the miscarriage is official, you have my sympathies and prayers.
    I wanted to also comment on the preemie issue. I’ve done some research on the youngest surviving preemies during my first pregnancy because my husband and I were trying to determine when to put into my medical ‘advanced directives’ when baby’s life should be considered over mine if something tragic happened to me (think I’ve shared some of it on other posts on this blog), and I don’t believe 24 weeks should be considered the earliest ‘viable’ preemie. I wonder if DCC could give those 18, 19, and 20 week old babies a statisical chance of surviving (according to my research 21 weeks is the youngest with a statistically relavent change of survival at apx 10%) instead of them being a one in a million thing? I’ve thought about the possibility before. Is there anyway to extend the life of the placenta/cord once birth has occured? Can it be made to artificially stay attatched and healthy for a few hours instead of a few minutes? I’ve watched ‘conceptual’ medical specials (those ones that look at what the cutting edge researchers and theoreticalists are looking at next) that were discussing the possibility of an artifical womb to grow a baby independant from start to finish from a woman, which I think is ethically disgusting, but I wonder if a similiar concept couldn’t be applied to extend the placents/cord viability in extreme preemies? Unfortunately any research aimed at helping the youngest of our species is violently and vigoriously opposed by the huge monies of the abortion industry. But I think if I gave birth to a micro preemie that I knew the doctors were going to ignore, I would request they leave the cord along and let me hold him skin to skin. Maybe I’ll have longer to say goodbye, or maybe he’d be one of those rare few who survive. Just some theoretical food for thought.

    • Re: DCC & micro-preemies — I’ve wondered the same thing, as well — perhaps not about DCC per se, but doing more to mimic intrauterine life as much as possible. Looking at the issues surrounding these wee babes, it seems apparent that many of the long-term problems they have stem from not just being born too soon, but the extra-uterine environment. For instance, blindness is (or at least was) fairly common among preemie survivors; the uterine environment is pretty dark; hospitals are quite bright. I’m sure they have to be, so the doctors and nurses can see what they’re doing, so on the one hand, it’s life-saving to have bright lights around the baby (so they can read medications and machines and whatnot), but it might also be a source of harm. I know I’ve read at some point years ago about them putting some sort of blinders or blindfolds on these babies, to protect them from the light, but I’m not if they’re still doing that.

      But it’s things like that I’m talking about — babies that young are supposed to still be getting their nutrition and oxygen through the umbilical cord; their nutrition should be pre-digested from the maternal system, and routed directly into their bodies. Instead, once they’re born, they have to get it in other ways. I don’t know how some of these babies are fed — the older ones can probably have a tube into the stomach; others may be fed by IV (which more closely approximates the umbilical cord). An interesting thing is that the milk made by mothers of preemies is different from milk made by mothers of full-term babies. I think it’s higher concentrations of fat and calories, which these tiny babies need; and less volume, which these babies can’t handle. Whether you’re an evolutionist or creationist, I think you can say that that’s nature’s way of maintaining life, even when birth happens too soon. I’m not sure what (or if) there is a cut-off point when it is completely impossible.

      I agree that the idea of an artificial womb is absurd in some ways; yet if a baby is born prematurely for reasons other than “incompatibility with life” issues, this type of thing may be able to be used to sustain the wee one’s life, and push the envelope of preemie survival even further. We have heart-lung machines that can keep people alive during open-heart surgery, or to keep them alive while waiting for a transplant; perhaps some modification of this technology could be applied to preemies. One of the things that currently causes the biggest problems with preemies is their immature lungs — even babies born at 34 weeks are often given drugs to help their lungs mature and improve their survival, so I can only imagine the immaturity of babies born at 24 weeks or before. Could the umbilical cord be kept open (like with an IV), and oxygen be given through that, instead of forcing the baby to breathe with his lungs?

      I also think of the movie The Abyss, which takes place in a sub on the ocean floor, in which the main character ends up in a special underwater suit that is filled with fluid that he is supposed to breathe. This fluid allows him to go down into a crack in the ocean floor into great depths without being crushed or getting the bends, or something that would have happened had he had scuba gear or something else that allowed him to breathe air. I don’t know how much of that was science fiction and how much was reality; but I do know that the concept of breathing oxygenated fluid is real, and in thinking of that movie, I wonder if it might be possible to keep the babies in a fluid environment, an artificial womb; and if that is possible, would it be preferable? I can see that it might help minimize the stress and trauma these tiny babies undergo from being touched and handled; it might keep their lungs safe from the pressures of air-breathing.

      However, I don’t know (obviously) if it would work, and how the various IVs and machines and things might need to be changed and modified to accommodate a liquid environment. Also, changes happen when a baby is born, such as fetal circulation switches over to neonatal circulation, the duct in the heart closes, and the lungs open. I don’t know how all that might play into moving the baby from the womb to the artificial womb, what would be completely precluded by the cold facts of physical changes that occur at birth, and which could be modified.

      It is a fascinating line of thought, though! The possibilities of imagination are endless (especially when unencumbered by too much knowledge of where the line between possible and impossible lies!), and I enjoy giving my imagination free rein in things like this.🙂 This is where science-fiction writers reign supreme; and if I’m not greatly mistaken, have suggested things that have eventually become fact.

  8. Kathy, I’m so sorry to hear about your miscarriage. I’ve been praying for you and your baby and am so sorry he/she won’t be staying with us. I’m glad you’re doing well so far. When I miscarried I was horribly upset for the first few hours (it was sudden and unexpected) and then felt the same sort of acceptance, so I understand what you’re talking about.

    Great thoughts on cord clamping, and I love the discussions in the comments. Good ideas! Thankfully my midwives always practice delayed cord clamping, so I’ve never had to worry about this issue.

  9. I’m sorry about your miscarriage, Kathy. (((hugs))) Sounds like you started grieving in advance/were prepared. It is still hard no matter how “prepared”—make sure you give yourself some “time off” if you find you need to take some time to cry and ponder and say goodbye some more.

    Love,
    Molly

  10. First Kathy – sorry to hear about your loss. My thoughts are with you.

    Secondly, I routinely practice delayed cord clamping. Parents do not have to request it with me. However, while there are so many benefits to DCC I understand where the desire to immediately clamp comes from. Evidence has shown that active management of third stage of labor shows less blood loss and hemorrhages. So DCC is not part of active management, hence ICC.

    • Thank you.

      I understand about active management of 3rd stage; but I think I’ve read that ICC does not necessarily have to be part of it. Also, I’d be curious to see if there might be a difference between women birthing in physiologically normal positions (whichever position she chooses at the time, such as hands-and-knees or squatting), to see if those might make a difference in blood loss and hemorrhage, compared to horizontal / lithotomy / stranded beetle positions; and/or if the blood loss is significant enough to normal/low-risk women. I can see it being used in women who might be put at risk for significant problems due to normal or slightly excessive blood loss (women in the 3rd world, with anemia, etc.); but I wonder if it’s so beneficial/necessary for the average Westerner. [I’m not arguing — just pointing out other avenues of exploration.] In my experience, I bled quite a bit with my first birth and got a shot of Pitocin, though not in an “active management” sort of way; in my second, I had increased my intake of vitamin K from foods [more spinach and broccoli in my 3rd trimester], and had little blood loss at the birth. However, even in my first, I was not put at significant risk, because I had easy access to iron pills to combat the anemia I got from the excess blood loss. That can’t be said about a lot of women.

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