The cord clamping debate: should it be done immediately after birth, or not?

Midwife calls for NHS guidelines to change, suggesting delayed cord clamping could benefit newborns

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Midwife Amanda Burleigh, from Leeds, is campaigning for the NHS to change its current guidelines, which detail that after a baby is born, the placenta should be clamped within 30 seconds.

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In the womb, your baby’s blood flows through the umbilical cord to and from the placenta bringing oxygen and nutrition from your blood. If after delivery the umbilical cord is left unclamped for a short time, some of the blood from the placenta passes to the baby (this is called placental transfusion), increasing the baby’s blood volume, aiding the flow of blood to your baby’s vital organs.

Immediate cord clamping, which stops this transfer of placenta blood from happening, has been linked to developmental issues including anaemia, learning difficulties and sudden death syndrome. Although delayed cord clamping has also been linked to jaundice, there’s mounting evidence to suggest it is more beneficial for babies.

NHS guidelines aren’t set to change, although it’s been suggested there’s enough evidence for the National Institute for Clinical Excellence (NICE), whose word the NHS follow, to review the evidence before its new guidelines are announced in November 2014.

NICE currently detail that in the third stage of a normal labour (the birth of the baby and the expulsion of the placenta and membranes) there are two options:

  • Active management: which includes routine use of uterotonic drugs, early clamping and cutting of the cord and controlled cord traction.
  • Physiological management: which includes no routine use of uterotonic drugs, no clamping of the cord until pulsation has ceased and delivery of the placenta by maternal effort.

Amanda, whose petition is supported by The Fertility and Birth (FAB) network says, “When NICE do eventually issue their new guidelines, I really hope that they fully utilise this opportunity to offer sound, evidenced-based guidance on actively managing the third stage of labour, including timing of administration of uterotonic drugs, along with optimal timing of clamping the cord.

“I would anticipate a delay of three to five minutes or more. I would also like NICE to recommend that more women receive informed choice leading to more physiological (natural) third stage management in low risk women. In natural third stage there is no drug administered to help deliver the placenta and no clamping and cutting of the cord.”

Evidence

The Cochrane report from 2011 concludes: “Providing additional placental blood to the preterm baby by either delaying cord clamping for 30 to 120 seconds, rather than early clamping, seems to be associated with less need for transfusion, better circulatory stability, less intraventricular haemorrhage (all grades) and lower risk for necrotising enterocolitis.”

Moreover, a 2011 Swedish study of 400 full term babies born after a low risk pregnancy, published in the British Medical Journal, concludes that, “Delayed cord clamping, compared with early clamping, resulted in improved iron status and reduced prevalence of iron deficiency at 4 months of age, and reduced prevalence of neonatal anaemia, without demonstrable adverse effects. As iron deficiency in infants even without anaemia has been associated with impaired development, delayed cord clamping seems to benefit full term infants even in regions with a relatively low prevalence of iron deficiency anaemia.”

Changing guidelines

The World Health Organisation moved in 2007 to change its guidelines, recommending a three minute wait and The Royal College of Midwives‘ guidelines were amended in 2011, with the latest guidelines stating that while the Cochrane report demonstrated both benefits and harms for late cord clamping that, “Delayed cord clamping is currently the recommended practice known to benefit the neonate in improving iron status up to six months but with a possible risk of jaundice that requires phototherapy (Resuscitation Council 2010; McDonald and Middleton 2009; WHO 2007; Mercer et al. 2007).

“‘Benefits and harms’ of both physiological and active management of third stage of labour have been identified (Begley et al. 2011) and midwives need to be aware of these when discussing management choice with women and applying clinical decision making,” it continues. 

The Royal College of Obstetricians and Gynaecologists also amended their guidelines in 2011 and now advise:

The RCOG guideline states that the cord should not be clamped earlier than is necessary, based on a clinical assessment of the situation.   Delayed cord clamping (more than 30 seconds) may benefit the neonate in reducing anaemia, and particularly the preterm neonate by allowing time for transfusion of placental blood to the newborn infant.  For the mother, delayed clamping does not increase the risk of postpartum haemorrhage.

However, early clamping may be required if there is postpartum haemorrhage, placenta praevia or vasa praevia, if there is a tight nuchal cord or if the baby is asphyxiated and requires immediate resuscitation.

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Amanda concludes,“If NICE lead the way in delivering clarity in the management of the third stage whilst taking into account the considerable benefits of allowing optimal cord clamping this will lead the way for other countries such as Australia, New Zealand, Sweden, Norway and America to follow suit.”

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