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Delayed Cord Clamping - What Does It Mean, and Why Should You Do it

Delayed Cord Clamping - What Does It Mean, and Why Should You Do it

BY MANIDIPA MANDAL

 

Congratulations! We hear you have a baby on the way.

We hope you’re getting the best possible care, adequate sleep and rest, and good nutrition. We hope you’re surrounded by a healthcare team you have a great rapport with, as well as supportive friends and family members. Your nursery plans are likely up in air, but did you draw up your birth plan yet? Specifically, for just after the birth, do you have a preference on when your baby’s umbilical cord should be clamped?

If you hadn’t considered that the umbilical cord connecting your baby to the placenta is still important—critically important—even after he baby lands earthside, now’s the best time to take a closer look at the functions of the umbilical cord, the procedure of cord clamping and why it is best delayed a little.

We’re telling you this from the other side of the birthing chair: You really do want to consider when that cord should be clamped and you shouldn’t assume your doctor knows best and will do the optimum thing.

 

What is the usual procedure of cord clamping in India?

When your baby is born, they are still attached to your placenta—to you!—by their umbilical cord, which has so far given them nutrition and oxygen both. Now, while you are busy meeting your newborn and your body works to push out the placenta, the doctors will typically put a clip on the umbilical cord and cut it. When that clip goes on, the blood supply from the placenta and cord to your baby stops. (The clip typically stays on and comes home from hospital with your baby, sticking around till the umbilical stump dries up and falls off.) 

Now typically, most doctors in India will tend to briskly clamp and cut the cord as soon as the baby has emerged, then have them weighed, scrubbed dry and swaddled before returning them to you. Which means, the cord can get clamped within 15-30 seconds of your baby’s birth.

 

Why is cord clamping within 15-30 seconds not the best practice?

If the cord is left alone and not cut at once, it continues to pulse, just as your heart pumps. delivering a volume of blood leftover in the cord and placenta to the baby. This allows most of the residual placental blood to flow into the baby—the cord tends to keep pulsing with the mother’s heartbeat—this maximizes the blood volume of the baby and hence their iron stores (haemoglobin levels). This can make a difference of as much as 20ml blood from the cord alone, particularly important in a country where anaemia is all too common in both women and children, since it will decrease your baby’s anaemia risk.

The primary source of iron for a baby will be breastmilk (or formula designed to mimic it) in the first six months, and even through the first year, most babies are unable to eat large amounts of food or digest them fully. The better their iron stores are from the start, the less you need to worry about supplementation (which can have its own risks in terms of a potential source of infection or an overdose, besides being just hard to deliver into a reluctant older infant or toddler) or stunted growth.

 

So what is delayed cord clamping?

The ideal time for optimal cord clamping is to wait 1-3 minutes (defined as late clamping or delayed cord clamping) to clamp the cord for a healthy baby. According to the WHO, the umbilical cord should be clamped no sooner than 1 minute after birth. The small delay in cutting the cord can give your baby as much as 3.5 months’ extra supply of iron!

 

Why is delayed cord clamping so important?

That extra bit of blood volume and iron means delayed risk of iron deficiency even at 4 months, which is something that has a permanent effect on cognitive development years later. As an immediate benefit, it also reduces risk of breathing difficulties (respiratory distress) in the newborn. 

Studies by India’s own researchers too have shown that cord clamping not when the baby is born, but after the placenta too has been delivered shows more oxygen in the baby’s blood and better transition to breathing air in the first 5-10 minutes after birth.

The benefits are even greater for preterm babies, who show better blood iron status (hematocrit), higher body temperature, better blood pressure and more urine output when there is delayed cord clamping.

 

How is delayed cord clamping performed?

While you wait for the cord to be cut, your newborn baby can rest on your abdomen, lap or chest (as far as the length of the cord allows). It doesn’t even seem to matter how you hold the baby, though many hospitals follow a rule of keeping the baby at or below vagina-level so that gravity will help the blood to flow better; this is not needed! Having the baby rest on you allows skin-to-skin contact (important for bonding, for the baby’s breathing, heartbeat, hormone and temperature regulation, and to encourage a quick start to breastfeeding); the other parent or caregivers, even siblings, can gently stroke the baby too! (though it is best for them to wait a while, about an hour.

In the mean time, the doctors may gently draw out the umbilical cord (controlled cord traction) to help you to deliver the placenta more quickly and completely, reducing risk of heavy bleeding (haemorrhage). You may also get an oxytocin injection to help in delivering the placenta and speed up the uterine contractions that return it to normal size, reducing haemorrhage risk further. 

 

Can I still have delayed cord clamping with a c-section?

During a C-section, at first the baby’s head is ‘delivered’ and doctors can wait for the baby to start breathing on their own before they deliver the rest of the body, and then cut the cord. Other essential care (checking the baby over, delivering any essential supplementation such as vitamin K or eye drops) can continue while waiting for those 3 minutes. Also, your baby can be delivered to rest on your abdomen or even across your legs during this wait, so that skin-to-skin care begins at once.

As for your care, the ob-gyn team will likely be working on removal of the placenta in this time too—it’s not like they will be waiting for you to bleed out! (Sorry, but just making sure you are reassured in case that was your worry.) In fact, not only does this, this is good for you too—it has been established that it reduces postpartum bleeding for the parent too.

In fact, even a 30-second delay in clamping will give your c-section baby a comparable iron status to a vaginally delivered child whose cord is clamped after 3 minutes.

However, recent research also suggests that it might be most beneficial for your doctor to milk the cord by hand to get most of the blood to the baby, because when you have a c-section, the uterus does not continue to contract naturally the way it does in a natural birth. This may be particularly pertinent to preterm babies, which make up a considerable percentage of c-section births to protect the baby’s health (or the mother’s).

 

Then why is delayed cord clamping not common in India?

One of the foremost reasons remains convenience—the medical team’s (because supporting the baby and waiting for the extra few minutes requires doctors and nurses to be available for longer with the mother and baby). Many hospitals also put a premium on the doctors’ time and the availability of operation theatres, with strict timelines and targets. All of which, together, can dissuade doctors from being quite as patient.

Another is lack of knowledge. Many medical students still don’t see references to delayed cord clamping in their textbooks or in operation theatres. There are still misconceptions that they need to hold the newborn below the level of the operating table until the cord is cut—even though it has been proven that the baby’s position does not matter; the pulsing of the cord is what delivers the blood.

Also, a lot of doctors are better trained in c-sections than in supporting a natural birth in the first place. They are trained to help you when things go wrong—which is of course a life-saving need! This can mean they have less exposure to case studies or situations where things are progressing comfortably as nature intended.

A special case is sometimes made for cutting the cord quickly to enable stem cell banking, which we address below. 

However, healthcare teams themselves often fear neonatal jaundice and HIV transmission (in case the parent is HIV-positive) from delayed cord clamping. This is not a valid concern. These are both on a list of conditions that the WHO has found do not impact delayed cord clamping.

 

When is it truly more important to cut the cord than wait?

The real exception to delayed cord clamping, per the WHO, is when the baby needs positive-pressure ventilation (ie, mechanical help with breathing), whether because premature or for another reason. In that case, the cord may need to be cut quickly to allow the baby to be moved.

If the baby does not start breathing spontaneously after being thoroughly dried (often the towel rub gets them crying), first their back should be rubbed 2-3 times to stimulate them and then the cord clamped and positive-pressure ventilation begun.

 

Why having a birth plan can help with delayed cord clamping

We suggest you discuss your birth preferences with your doctor well ahead of time, in the first trimester itself, giving you time enough to shop around for someone who is more supportive if need be.

Another possible route is engaging a midwife/doula or looking for a birthing centre rather than a hospital (they can still have medical personnel and facilities, but the focus tends to be more on supporting pregnancy and birth as a natural phenomenon, which means less of a rush to get all the procedures over with).

Whichever you choose, ensure you have a birth plan and it is shared with all concerned.

  • A midwife or another supportive family member or friend may be especially critical in case your hospital’s rules prevent the co-parent from being present or offering an opinion.
  • We also hear of consent taken from the other parent (especially a male parent) instead of the birthing parent in an emergency. Having a birth plan means such decisions are less likely to be made under pressure, by someone unaware of your wishes.
  • It also means that critical members of your support team (including your own parents and the nurses on the ward) are aware of your wishes and plans for your body, your baby and the birth experience—and cannot excuse their decision as ‘what they thought was best’ while you were out of it!

 

Should I choose stem cell banking or delayed cord clamping?

It should be your choice to do what you believe is best for your baby. However, let us point out some facts:

  • The umbilical cord contains blood that rightfully belongs in the baby’s body. Would you feel as confident about removing blood from the baby’s own body for future transfusions or other protection/treatment?
  • It is an unfortunate fact that many stem cell banking companies use alarmist language and cherry-pick research to promote their (paid-for and costly) services. We have seen one well-known brand’s website talk of how the chances of more cord blood going to the baby mean a greater risk of jaundice; another argues delayed cord clamping reduces blood volume in c-sections!
  • Yet other sites are even more misleading, talking of ‘protection against’ autism and cerebral palsy, when one is not even a disease and the second cannot be ‘protected against’, only managed.
  • It is worrisome that the only sources we found in support of stem cell banking or cord blood collection versus delayed cord clamping were sites selling the service! No disinterested party seemed to consider this the correct balance of evidence!
  • Interestingly, some companies do offer the option of both delayed cord clamping and cord blood banking; you can also save the cord tissue itself after clamping (it contains stem cells too!).
  • It gets better: stem cell research is still in the early stages and actual applications are very limited. The necessary technology may or may not be ready by the time your child actually needs it. But the blood volume and iron stores they can definitely use right away!
  • You’ve heard about the stem-cell cure for cancer? Well, so far, we cannot use it to treat your child’s own cancers. They may help a sibling, yes, but so could a bone marrow transplant.
  • Plus, those all-important stem cells? They are also going to the baby when you opt for delayed cord clamping.
  • The best kind of banking for stem cell research to actually advance is public banking; the private banking is more like buying private health insurance, except it often paints a misleading picture.
  • Cord blood banking is expensive. That same money might serve your child better as a college fund or savings account, because even if they don’t have a specific few health problems (thank heavens!), they can still benefit in future.
  • The realities of banking, even abroad, can be quite different from the snazzy brochures.

In sum, let’s say stem cell banking is like buying car insurance. If you had limited money for fuel (in this case, iron stores in your baby), would you still spend more on insurance than on the fuel to actually run your car? That is betting against confirmed benefits (better weight and iron status, less risk of anaemia and poor growth) to your baby in order to gamble on something that may not happen (auto-immune disorders, cancers).

 

Final call: Delayed cord clamping should be default for most babies

 

For all these many good reasons, some healthcare advocates argue that the right phrase would be ‘optimal cord clamping’ and not ‘delayed cord clamping’. It is the minimum that should be done, and it should be the new normal rather than an exception. (The current normal is obviously too early!)

 

The WHO even notes that delayed cord clamping contributes towards the UN’s Millennium Development Goals.

 

If it only takes 3 minutes more to banish anaemia and arrested development from your child’s future, why wouldn’t you?

 

 

Further reading

https://www.bmj.com/content/367/bmj.l6611/rr

https://www.who.int/elena/titles/cord_clamping/en/

https://www.downtoearth.org.in/news/a-simple-yet-rare-solution-44758

 

Benefits per the WHO

  • Increased iron stores at birth, with a 61% reduction in the rate of anaemia requiring blood transfusion.
  • 59% decreased intraventricular haemorrhage (a risk for preterm babies).
  • A 62% reduced risk of necrotizing enterocolitis (an intestinal inflammation that kills the tissues in preterm babies).
  • A 29% reduction in the rate of sepsis (blood infection) for preterm infants.
  • In part, these are because of a 52% reduction in blood transfusions needed (in preterm infants, this is often due to low blood pressure.

 

Manidipa Mandal is a seven-year-old parent still learning about parenting. She also likes to read and write about ecology, biology (especially gender), food and travel.

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