Delayed Cord Clamping Has It's Day

By Eva Martin, MD of Elm Tree Medical Inc.

During my obstetric training, I was taught to delay cord clamping whenever possible for about 30 seconds to 1 minute. The simple idea was that it allowed the baby to receive one last infusion of blood from the cord, but not so much blood that it led to complications like jaundice. The reasoning was sound, and I found I could easily deliver a baby, hand him to mom for skin to skin, and then calmly cut the cord (or help a family member cut the cord) when the time came, without endangering anyone's wellbeing in the majority of deliveries. However, this practice was not always the norm. Only recently did ACOG publish support for delayed cord clamping for all healthy infants. Read on to learn more about this practice-changing recommendation.

Traditionally, the obstetrician cuts the umbilical cord immediately following birth. In the old-school model, the doctor immediately hands the baby to a waiting nurse or pediatrician and continues with delivery of the placenta. These days, we are lucky to benefit from decades of research that allow us to make more evidence-based decisions (like promoting skin-to-skin immediately after birth instead of a baby warmer).

90% of the blood transfer from the placenta to the baby happens when the infant takes his first few breaths of air. 80 mL of blood is transfused from the placenta to the baby in the first minute of life. With this blood, the infant receives about 40-50mg/kg of iron. Iron helps to prevent anemia. Because of this benefit, ACOG has recommend delayed cord clamping for preterm infants since 2012. One study showed that preterm infants who received delayed cord clamping had a 39% lower chance of needing a blood transfusion for anemia. They also benefited with a 41% lower chance of a brain bleed (intraventricular hemorrhage) and 38% lower chance of a gut disorder (necrotizing enterocolitis). Now, ACOG reports that enough research has been published for term infants to support the practice for them, too. The new recommendation even got some airtime in the mainstream press!

What is the downside of delayed cord clamping? Too much of a good thing. If the baby receives too much blood, he is at risk of hyperbilirubinemia and jaundice. Bilirubin is a byproduct of red blood cell break-down. When there are too many red blood cells, bilirubin builds up in the infant's system. Hyperbilirubinemia is the condition in which there is too much bilirubin in the blood and causes jaundice (yellowed skin). It is commonly treated with light therapy. Term infants who receive delayed cord clamping have a small increase in jaundice that requires light therapy. So, it's extra important to monitor for jaundice and hyperbilirubinemia when practicing delayed cord clamping.

There are also clinical scenarios when cord clamping is harmful- specifically, if cord clamping gets in the way of treating a condition that requires immediate intervention. For instance, if a baby is not breathing, it's more important to treat the respiratory arrest immediately than wait 30-60 seconds to clamp the cord. Another scenario is maternal hemorrhage. If a mother is experiencing brisk bleeding after delivery, stopping the bleeding must be the number one priority. Delayed cord clamping has not, however, been shown to increase the risk of hemorrhage or increase the amount of blood loss during stable deliveries.

One last note- delayed cord clamping should not get in the way of skin-to-skin. Because the placenta is still attached and pumping blood and the baby's breathing is facilitating the transfer of blood, gravity is not necessary. The baby will still receive the blood from atop the mother's chest. From there, you can dry and warm and stimulate the baby. 

We want to hear from you! Do you practice delayed cord clamping? Why or why not?