The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
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Late
vs early clamping of the umbilical cord in full-term neonates: systematic
review and meta-analysis of controlled trials.
Hutton EK, Hassan ES.
JAMA. 2007 Mar 21;297(11):1241-52.
Conclusions Delaying clamping of the umbilical cord in full-term neonates for a minimum of 2 minutes following birth is beneficial to the newborn, extending into infancy. Although there was an increase in polycythemia among infants in whom cord clamping was delayed, this condition appeared to be benign.
NEWS FLASH!
"Pediatrics", the Official Journal of the American Academy of Pediatrics, has published an article recommending delayed cord clamping.
Let's see if we can't make sure all those OBs at our local hospital know about these new recommendations. (Realistically, some of them are going to wait for ACOG to give the official imprimatur, but we can help the process along by sharing this with clients, nurses, etc.)
"CONCLUSIONS.: Delayed cord clamping at birth increases neonatal mean venous hematocrit within a physiologic range. Neither significant differences nor harmful effects were observed among groups. Furthermore, this intervention seems to reduce the rate of neonatal anemia. This practice has been shown to be safe and should be implemented to increase neonatal iron storage at birth." [Ed.: It's odd that they call "delayed cord clamping" an intervention, since it's essentially delaying the actual intervention, which is clamping the cord. But I guess that from their point of view, it's "natural" for them to rush to clamp the cord, so they have to intervene in their own rush to intervene.]
The
effect of timing of cord clamping on neonatal venous hematocrit values
and clinical outcome at term: a randomized, controlled trial. [Full
text]
Ceriani Cernadas JM, Carroli G, Pellegrini L, Otano L, Ferreira M,
Ricci C, Casas O, Giordano D, Lardizabal J.
Pediatrics. 2006 Apr;117(4):e779-86.
The following information is from Volume 3, Issue 3 of Research Summaries for Normal Birth, July 2006, from the Lamaze Institute for Normal Birth:
Summary: In this prospective, multi-center trial researchers examined the effect of delayed cord clamping on iron-deficiency anemia and clinical outcomes in term newborns. Two hundred seventy-six healthy women with uncomplicated pregnancies were randomized to three groups: cord clamping immediately after birth, at 1 minute and at 3 minutes. Venous hematocrit (to measure anemia) and bilirubin (to measure pathologic jaundice) were drawn at 6 hours and 24-48 hours after birth. Newborn physical exams were performed by clinicians who did not know to which group the infant was assigned.
Anemia at 6 hours of age was significantly more common in newborns who were randomized to the immediate cord clamping group. There was also a significant difference at 24-48 hours of age (16.8% of newborns in the immediate clamping group versus 2.2% at 1 minute and 3.3% at 3 minutes). Significantly more infants in the 3-minute group had elevated hematocrit levels (polycythemia) at 6 hours of age. However, none of the polycythemic babies exhibited symptoms or required treatment, and this difference did not persist to 24-48 hours of age. There were no significant differences in bilirubin values, rates of neonatal adverse events, or the infants’ weight gain and rate of exclusive breastfeeding in the first month of life. There were no significant differences in maternal outcomes such as blood loss or maternal hematocrit levels.
Significance for Normal Birth: Immediate cord clamping is a practice
that has been performed routinely for decades without evidence of benefit.
Placental transfer of oxygenated blood, nutrients and stem cells continues
for several minutes after birth. Physiologic principles suggest that the
optimal transition to life outside the womb depends on this transfer. The
study authors note that higher newborn iron levels at birth correlate with
less likelihood of childhood anemia, a condition with long-term neurologic
consequences. Some pediatricians recommend iron supplementation for breastfed
infants, but it may be that by providing the full complement of iron, delayed
cord clamping is the only iron supplement healthy babies need. As an added
bonus, delayed cord clamping keeps babies in their mother’s arms, the ideal
place to regulate their temperature and initiate bonding and breastfeeding.
This may be an important first step in promoting non-separation of mother
and baby after birth.
Here's the study showing that the placental tissue contains pluripotent stem cells, in addition to the blood stem cells in the baby's blood. Advocates of lotus birth have claimed that there are immune system benefits to leaving the cord intact for multiple hours after the birth. I wouldn't be surprised if future research showed that some of the pluripotent stem cells from the placental tissue migrate along the cord into the baby's body to help heal birth trauma. It would sure be a huge adaptive advantage!
Stem
Cell Characteristics of Amniotic Epithelial Cells.
Miki T, Lehmann T, Cai H, Stolz DB, Strom SC.
Stem Cells. 2005 Aug 9
"Amniotic epithelial cells develop from the epiblast by 8 days after fertilization and prior to gastrulation opening the possibility that they might maintain the plasticity of pre-gastrulation embryo cells. Here we show that amniotic epithelial cells isolated from human term placenta express surface makers normally present on embryonic stem and germ cells. In addition, amniotic epithelial cells express the pluripotent stem cell specific transcription factors octamer-binding protein 4 (Oct-4), and nanog. Under certain culture conditions, amniotic epithelial cells form spheroid structures which retained stem cell characteristics. Amniotic epithelial cells do not require other cell derived feeder layers to maintain Oct-4 expression, do not express telomerase and are non-tumorigenic upon transplantation. Based on immunohistochemical and genetic analysis, amniotic epithelial cells have the potential to differentiate to all three germ layers-endoderm (liver, pancreas), mesoderm (cardiomyocyte), and ectoderm (neural cells) in vitro. Amnion derived from term placenta following live birth may be a useful and non-controversial source of stem cells for cell transplantation and regenerative medicine."
Potential stem cell source found in placentas - Scientists seeking less controversial alternative to human embryos [Reuters, 8/5/05]
US scientists find flexible stem cells in placenta [Reuters, 8/5/05]
Evidence-based practices for
the fetal to newborn transition - Many common care practices during
labor, birth, and the immediate postpartum period impact the fetal to neonatal
transition, including medication used during labor, suctioning protocols,
strategies to prevent heat loss, umbilical cord clamping, and use
of 100% oxygen for resuscitation. Many of the care practices used to
assess and manage a newborn immediately after birth have not proven efficacious.
Immediate
Cord Clamping: the Primary Injury - Immediate clamping of the umbilical
cord before the child has breathed has been condemned in obstetrical literature
for over 200 years.
Neonatal
Resuscitation: Life that Failed by George Malcolm Morley, MB ChB FACOG
- a great article about leaving the cord intact, ESPECIALLY for distressed
babies!
Effect
of timing of umbilical cord clamping on iron status in Mexican infants:
a randomised controlled trial
Camila M Chaparro a, Lynnette M Neufeld b,
Gilberto Tena Alavez c, Raúl Eguia-Líz Cedillo
c and Kathryn G Dewey a
Summary
The Lancet 2006; 367:1997-2004
Delay in cord clamping of 2 minutes could help prevent iron deficiency
from developing before 6 months of age, when iron-fortified complementary
foods
could be introduced.
Current
best evidence: a review of the literature on umbilical cord clamping.
Mercer JS.
J Midwifery Womens Health. 2001 Nov-Dec;46(6):402-14.
Delayed
cord clamping increases infants' iron stores.
Mercer J, Erickson-Owens D.
Lancet. 2006 Jun 17;367(9527):1956-8.
Neonatal
transitional physiology: a new paradigm.
Mercer JS, Skovgaard RL.
J Perinat Neonatal Nurs 2002 Mar;15(4):56-75
"Early clamping of the umbilical cord at birth, a practice developed without adequate evidence, causes neonatal blood volume to vary 25% to 40%. Such a massive change occurs at no other time in one's life without serious consequences, even death. Early cord clamping may impede a successful transition and contribute to hypovolemic and hypoxic damage in vulnerable newborns. The authors present a model for neonatal transition based on and driven by adequate blood volume rather than by respiratory effort to demonstrate how neonatal transition most likely occurs at a normal physiologic birth."
This unnecessary episode of transient hypoxia may contribute to anorexia in later life:
Obstetric
complications predict anorexia onset
Source: Archives of General Psychiatry 2006; 63: 82-8
Perinatal
factors and the risk of developing anorexia nervosa and bulimia nervosa.
Favaro A, Tenconi E, Santonastaso P.
Arch Gen Psychiatry. 2006 Jan;63(1):82-8.
CONCLUSIONS: A significantly higher risk of eating disorders was found for subjects with specific types of obstetric complications. An impairment in neurodevelopment could be implicated in the pathogenesis of eating disorders.
Delayed Cord Clamping
at Birth May Reduce Neonatal Anemia - CME from Medscape
cordclamp.com - To educate the childbirth professions and the public regarding the functions of the umbilical cord and placenta before, during and after birth, and the injuries resulting from disruption of those functions by a cord clamp.
The
archived web site www.cordclamping.com - The Dangerous Practice of
Early Clamping of the Umbilical Cord - this is an extensive collection
of writing pertaining to the subject of cord clamping. This site
is striving to be the main web repository of scientific and medical support
for allowing the baby to receive an optimal placental transfusion at the
time of birth via an intact cord.
Cutting the Umbilical
Cord from the UK Midwifery Archives
Other sites by Donna:
Dr. Sarah Buckley's Declaration,
Don't Clamp the Cord.
Clamp the Umbilical Cord Early and Risk Injuring Your Child's Brain by G. M. Morley, MB, ChB (Ed.), FACOG
AUTISM,
ADD/ADHD, AND RELATED DISORDERS - IS A COMMON CHILDBIRTH PRACTICE TO BLAME?
By George Malcolm Morley, MB ChB
Chorioamnionitis
and Neonatal Brain Damage: The Unrecognized Iatrogenic Cause
- 20 December 2002 by Cory A Mermer - An article about a specific risk
factor (chorioamnionitis) that is made worse by clamping/cutting the cord
prematurely.
It's always bothered me that umbilical cord clamps are rigid and relatively large and firmly attached to the baby for at least the first day of life. What fun is it for a baby to be belly-to-belly with mom when there's this nasty clamp sticking into the tummy? I've seen babies who weren't latching on well because the clamp was pinching, twisting, pulling or poking some part of their body. That's not the easiest way to get breastfeeding off to a good start!
Fortunately, there's an easy solution to this problem . . . the Averbach Cord Bander, invented by Dr. Louis Averbach; it leaves only a tiny rubber band securely "clamping" baby's umbilical cord. It's a bonus that they're environmentally more responsible as the disposable rubber band is very tiny compared to the bulky plastic disposable clamps. (Those reusable, metal clamps were most reusable of all, but they are no longer available, and they were still very poky to babies! Cord tie is also soft and flexible, but may come off as the cord dries and shrinks; this isn't really a problem but can be troubling to new parents.)
The Averbach cord bander is significantly more cost effective as well
- the instrument itself costs $85, but each little rubber band costs only
eight cents, compared with sixty-five cents per plastic cord clamp.
The cost of the instrument is recovered after only 132 births! All
the subsequent births actually save the hospital money, in addition to
helping mom and baby get off to a better start with breastfeeding.
The Averbach Cord Bander can be purchased from Cascade,
1-800-443-9942, item #3376.]
There's a new type of cord clamper and cutter that is even WORSE than
the traditional metal or plastic clamps - it's The
Joey™ Clamp & Cutter - you won't believe this, but it leaves a
big plastic teddy bear face on the baby's belly button. That's got
to feel awful belly to belly (for both baby AND mom), and it would catch
even more on the diaper than the other types of clamps. In addition,
even though this is a very new device, their information about cord care
is outdated - they're still recommending alcohol on the cord four times
a day. It's Byzantine!
From a parent:
I've been wading through the issues on this and came across an observation that really grabbed me (one of those "A-ha!" moments).
At the moment of birth, the placenta holds a portion of the baby's blood in reserve. Nature (God) designed an amazing system for insuring a smooth transition from womb life to breathing. The blood passing between the baby and the placenta carries oxygen to the newborn (possibly even after the placenta has detached and delivered!) This system is especially useful to the distressed newborn. Midwives have performed medical "miracles" by simply leaving a floppy baby attached instead of clamping, cutting and whisking off to the warming table. Try broaching the idea of performing newborn resuscitation on your belly or bed while the cord remains attached and see what your practitioner says. Might make a good litmus test for determining how committed a midwife/doc is to "natural" birthing.
OK, my A-ha... I read a post from a midwife that called
the placenta one of the baby's organs. How thought-provoking!
What rational human being would even consider amputating a live organ when
waiting just an hour or so will cause it to expire naturally? The
whole idea seems distasteful when considered in this light. Doctors
swear to, "First, do no harm..." Clamping off a child's blood supply seems
pretty harmful to me.
At separation, the placenta still has oxygenated blood in it, and this continues to be transfused into the baby for an undetermined amount of time, even after the cord stops pulsing.
Really recent research shows that the placental tissue contains pluripotent stem cells, in addition to the blood stem cells in the baby's blood, euphemistically called "cord blood" as if it's any different from the blood in the rest of the baby's circulatory system.
Advocates of lotus birth have claimed that there are immune system benefits
to leaving the cord intact for multiple hours after the birth. I
wouldn't be surprised if future research showed that some of the pluripotent
stem cells from the placental tissue migrate along the cord into the baby's
body to help heal birth trauma. It would sure be a huge advantage!
Don't Cut The Cord! - a great summary article
with tips for parents planning to give birth in the hospital.
Early
or Late Cord Clamping? by Gloria Lemay
Potential
Dangers of Childbirth Interventions - "Early clamping of the umbilical
cord: Cutting the ties that bind" by Cory A. Mermer - a longer article,
but well worth the read!
Five Good Reasons to Delay Clamping the
Cord
Risks of Premature Cutting of the Umbilical
Cord, with some tips on encouraging the hospital staff to provide the
best care for your baby.
Civil Action to Protect Baby's Umbilical Cord
- a caring parent suggests threatening legal action against providers who
clamp or cut the umbilical cord without the parents' permission.
OK, this one takes the cake. One of our local OBs told a pregnant
woman that delaying the cutting of the umbilical cord would, "cause the
baby's body temp to drop too low." No, it won't.
One of my labor coaching clients discussed delayed clamping with her OB - the response was that if they didn't clamp the cord, all the blood would drain out of the baby.
Oh, now it occurs to me that maybe the OB didn't understand that the
point was to delay both clamping and cutting. Maybe she thought
the woman was talking about cutting the cord and not clamping it?
That's the only way the OB's remark makes any sense.
I cut my daughter's cord about 2 hours after birth and there was not
a single drop of blood coming out. So, delayed cutting needs no clamping
if you wait long enough.
The idea re-surfaces every couple of years that a baby's circulation will be overloaded with RBCs and he'll develop polycythemia or severe jaundice if he's held "below the level of the placenta". The idea gets dumped each time and then rises again!
There is NO relation to polycythemia, jaundice and time of cord clamping. RBCs are higher when cord-clamping is delayed. Immediate cord clamping deprives babies of their NORMAL blood counts, delayed cord-clamping gives them their NORMAL blood counts. The lower rbcs of immediately clamped babies are associated with anemia and jaundice. The higher rbcs of delayed clamp babies are associated with normal hct/hgb as late as age one year -- and are NOT associated with jaundice.
The position of the baby is irrelevant unless there is a two foot difference.
A baby held elevated more than two feet above the cord can become hypotensive
if the cord is still patent, and if there is a fetal/placental transfusion.
A baby held more than two feet below can acquire more RBCs -- although
this hasn't been linked to any problems (an earlier claim from the 70s
was debunked). It was even routine for many decades for doctors to hold
the baby below the level of the placenta in order to encourage a
higher blood transfer.
In 1801, Erasmus Darwin, grandfather of Charles Darwin, warned against
the early clamping off the cord. He wrote, "it would be very
injurious to tie 'the navel-string' too soon" and urged that clamping be
delayed until the infant has breathed repeatedly and all cord pulsation
ceased. [Darwin E. Zoonomia. Vol III 3rd ed.
London 1801:302]
From Williams' Obstetrics, 1929, p. 358: "The question as to the proper time for tying the cord has given rise to a great deal of discussion. Formerly it was the custom to ligate it immediately after the birth of the child; but Budin showed that 92 cubic centimeters more blood escaped from the maternal end of the cord after early than after late ligation, thus indicating that that amount was lost to the fetus by early ligation. Schucking demonstrated the same fact by weighing the child just after birth and again after the cord has ceased to pulsate. Budin believed that this amount of blood was drawn in the circulatory system of the foetus by thoracic aspiration, while Schucking held that it was driven into it as a result of the compression of the placenta by the contracting uterus.
"I have always practiced late ligation of the cord and have seen no injurious effects following it, and therefore recommend its employment, unless some emergency arises which calls for earlier interference.
"After ligation of the cord, the child should be wrapped in a piece
of flannel or blanket prepared for the purpose and laid in a safe place
until the placenta is born and the mother has been cleaned up and made
comfortable." [I include this last sentence as a glimpse into another
time when the newborn was regarded as an object, unconscious and unfeeling.]
Early umbilical cord clamping risky
10 May 2007
University of Granada
MedWire News: Clamping the umbilical cord early is not justified and may do more harm than good, research shows.
Recently there has been a trend towards clamping the umbilical cord immediately after the baby is expelled instead of letting the blood flow stop naturally.
But Catalina de Paco Matallan, from the University of Granada, says that this new practice lacks studies to confirm its benefits.
She analyzed the umbilical cords of 151 newborns from full-term pregnancies, 79 were cut within 20 seconds and 72 cut within 2 minutes of the baby being expelled.
Umbilical cords cut a few seconds or a few minutes after birth contained similar amounts of hematocrit or hemoglobin.
It also took a similar amount of time to remove the placenta among babies with early and late clamping and there was no difference in the mother's bleeding after birth.
De Paco Matallana says this means her study "has not found any scientific evidence to suggest that the practice of early clamping is advisable or to justify the abandonment of late clamping in newborns from full-term pregnancies."
Early clamping also meant that babies were more likely to need oxygenotherappay after birth.
De Paco Matallana concludes: "There are convincing findings for and
against the two different types of clamping analyzed in this study, which
shows not only the complexity of the problem, but also that research in
this field may not be controlled enough or designed correctly."
A
practical approach to timing cord clamping in resource poor settings.
van Rheenen PF, Brabin BJ.
BMJ. 2006 Nov 4;333(7575):954-8.
Placental
cord drainage after spontaneous vaginal delivery as part of the management
of the third stage of labour.
Soltani H, Dickinson F, Symonds I.
Cochrane Database Syst Rev. 2005 Oct 19;(4):CD004665.
AUTHORS' CONCLUSIONS: It is difficult to draw conclusions from such
a small number of studies, especially where the review outcomes were presented
in a variety of formats. However, there does appear to be some potential
benefit from the use of placental cord drainage in terms of reducing the
length of the third stage of labour. More research is required to investigate
the impact of cord drainage on the management of the third stage of labour.
[Note that cord drainage can be effected even after cutting the cord by
not clamping the placental side of the cord, or unclamping it after the
cord is cut. The open cord can simply be allowed to drain into the
placenta bowl.]
The
early effects of delayed cord clamping in term infants born to Libyan mothers.
Emhamed MO, van Rheenen P, Brabin BJ.
Trop Doct. 2004 Oct;34(4):218-22.
"Delaying cord clamping until the pulsations stop increases the red
cell mass in term infants. It is a safe, simple and low cost delivery procedure
that should be incorporated in integrated programmes aimed at reducing
iron deficiency anaemia in infants in developing countries."
Umbilical
cord clamping. An analysis of a usual neonatological conduct.
Papagno L
Acta Physiol Pharmacol Ther Latinoam 1998;48(4):224-7
This research found that delayed cord clamping does increase the number
of red blood cells in the baby's body, causing a transitory polycithemia
not associated with any problems. [Editor's note - I wonder if the
peak at 12 hours is because that's the crossover point where the baby is
able to replace fluids in the blood from the digestive tract. It
would be interesting to have some studies to show the correlation between
the baby's "using up" the fluid from the blood and beginning to break down
the bonus red blood cells for iron stores.] This study postulates
that much of the jaundice attributed to clamping the cord after it stops
pulsing is actually caused by routine vitamin K administration, which was
omitted in this study.
Anne Frye had this in her Holistic Midwifery (Vol II: Care During Labor and Birth, 492):
(Regarding postbirth uterine ctx): The placental venous pressure (the pressure in the umbilical vein) is 49 mm Hg between contractions; as the contraction peaks, it rises to as high as 102 mm Hg. High venous pressure during pushing and immediately after birth moves blood from the placenta into the baby. The spiral arteries of the uterus under the still-attached placenta supply oxygen as the blood is transfused in successive spurts with each uterine contraction. Thus an uninterrupted supply of oxygen-saturated cord blood continues to flow to the baby for as long as the placenta is attached to the uterine wall, normally at least three minutes after birth....
However, she goes on to quote a study by Gunther (1957): Poor
uterine contractility allows umbilical venous blood to flow in either
direction. Thus, the baby should be held below the level of the placenta
in these cases. [I'm not entirely sure what is meant by 'poor uterine
contractility,' but if the placenta followed the baby right out, perhaps
it would be a good idea to bring it right up level with the baby,
which she mentions several times as a good idea for a completely
physiological third stage.]
A
study of the relationship between the delivery to cord clamping interval
and the time of cord separation. Oxford Midwives Research Group.
Midwifery 1991 Dec;7(4):167-76
There was an unexpectedly higher rate of breast feeding at home in the late clamped group which did reach statistical significance. Overall the trial provides no clear evidence for the benefit of early cord clamping.
[Cord
clamping at birth - considerations for choosing the right time].
Z Geburtshilfe Perinatol 1982 Apr-May;186(2):59-64
. . . Renal function is increased and effective renal blood flow associated with the blood volume of the newborn. In cases of caesarean section a higher incidence of respiratory distress occurs if placental transfusion does not take place. In utero placental transfusion occurs if the fetus is hypoxic obviously to increase the oxygen supply to the fetal tissue. In conclusion: "In order to give the newborn the blood, that it need physiologically cord clamping should be performed not immediately after birth, but one should wait as long until the umbilical vein has been empty and is collapsed."
Timing of Cord Clamping is section 5.5 in CARE DURING THE THIRD STAGE OF LABOUR (from the World Health Organization's Care in Normal Birth: A Practical Guide Report)
Late clamping (or not clamping at all) is the physiological way of treating the cord, and early clamping is an intervention that needs justification.
Have you read joseph chilton pearce's book ""He was concerned about childbirth practices. specifically 2 questionable
procedures: the widespread, automatic use of premedication and anesthetics
and the usual practice of cutting the umbilical cord as soon as the baby's
body was clear. there has never been a textbook on obstetrics that
did NOT stress leaving the umbilical cord strictly alone so long as any
activity is detectable in it.
"He made the simplest of tests. he took pg monkeys and treated
them to all the benefits of modern medical practices: he administered
anesthetics in a body-weight ratio equivalent of that given the average
laboring human mother in the hospital. at the birth of the infant,
he cut the umbilical cord at the average time he had found practiced in
hospitals. in every case, his newborn monkeys could not get their
breath and had to be resuscitated.
"The mothers, dazed by the drugs and greatly lengthened labor (which
anesthetics automatically cause), could do little assist. windle
had to step in to keep the little creatures alive. and how long was
it before these medically delivered infants achieved some normality, got
their limbs under them, and began some preliminary semsorimotor learning?
some two to three weeks.
"He performed autopsies on some of these helpless infants and found
in every case that their brains harbored severe lesions of a type resulting
from oxygen deprivation. he was able to keep some of the monkeys
alive (and it took outside help; it was beyond the monkey's abilities)
until they had matured and achieved apparent normality. when he autopsied
some of these apparently recovered monkeys, he found that their brains
STILL harbored exactly the same lesions found at birth. the damage
done at the beginning proved irreparable.
"He next studied human infants who had died following known birth histories
of anesthetics, low apgar scoring, premature cutting of the umbilical cord,
and so on. autopsies showed that these infant brains harbored exactly
the same lesions he had found in his oxygen-deprived monkeys. cases
of children who had similar birth histories but who died at age three or
four were then studied, and where possible, autopsies were made.
again the brains were found with the same lesions.
"Windle pointed out the obvious. in those first critical moments
when the lungs must make the transition to producing all the oxygen for
the young body, the system expects to call on the reserve supply held in
the placenta. a drugged mother immediately means a drugged infant, and
a drugged infant cannot get his breath. artificial means must be
used. breathing is then clumsy, slow, inefficient. the
cutting of the umbilical cord at this time denied the infant the reserves
of oxygen at the most critical pint in his life. a vicious double
bind is imposed.
"Newell kephart, director of the achievement center for children at
purdue university, finds learning and behavior problems resulting from
minor undetected brain injury in 15 - 20% of all children examined.
goldberg and schiffman estimate that 20-40% of our school population is
handicapped by learning problems that may be related to "neurological impairments
at birth."
"Windle closed his report, published in Scientific American in 1969,
with this comment: our experiments have taught us that birth asphyxia lasting
long enough to make resuscitation necessary always damages the brain.....
a great many human infants have to be resuscitated at birth. we assume
that their brains, too, have been damaged. there is reason to believe
that the number of human beings in the USA with minimal brain damage due
to asphyxia at birth is much larger than has been thought. perhaps
it is time to reexamine current practices of childbirth with a view to
avoiding conditions that give rise to asphyxia."
Anatomy of A
Fetus: Circulation and Breathing by Gerard M. DiLeo, M.D., F.A.C.O.G.-
I finally got some insight into why obstetricians like to cut the cord
so quickly. This OB states that it is necessary to cut the cord because
it's the oxygen deficit that causes the baby to start breathing.
I wrote a long response to this misconception.
Early Clamping Denies Baby Blood Supply
for Pulmonary Perfusion
There's a lovely article entitled Cord
Closure: Can Hasty Clamping Injure the Newborn? by George M.
Morley in the July 1998 OBG Management (pp 29, 30, 33-4, 36). Brief
description: "While exploring the feasibility of saving placental blood
for autologous NICU transfusion, the author found a disturbingly obvious
alternative: If cord clamping is delayed to permit normal placental
transfusion, the need for newborn transfusion often could be eliminated."
The article goes into a lot more detail than I have seen before on the
mechanism for how delayed clamping benefits the baby), and he actually
advocates leaving baby attached for resuscitation until cord stops pulsating
.
Ob. Gyn. News, Feb 15, 1992
"If the cord is not clamped, the placenta gives the infant the equivalent
of 20 cc of blood per kilogram of body weight within these first 3 minutes.
This placental transfusion in the normal infant is equivalent to the amount
of blood given to an infant in profound shock, he said at the conference
also sponsored by Boston Univ School of Medicine."
"When cords are not clamped early, the third stage of labor is one-third
shorter and the total mean blood loss after delivery is substantially less
than when cords are clamped early.
This might be because when cords are not clamped, the placenta is allowed
to give up its volume of blood. It thereby contracts and separates
more easily from the uterine wall, Dr. Maisels said."
Ob. Gyn. News
"...the placenta provides a safety valve for any raised central venous
pressure because blood may flow backward through the umbilical vein."
"Hence, this provides the infant with the best opportunity for achieving
a normal blood volume and hematocrit and avoiding many of the problems
of maladaptation to extrauterine life."
"With cord clamping immediately after deliver, as much as 166 ml of
blood may be trapped within the placenta, with the baby showing signs of
hypovolemia, low blood pressure, and intense vasoconstriction. Then
engorged placenta is likely to be bulky, stiff, and enlarged, presenting
problems of passage through the retracting cervix."
"A typical placenta delivered after immediate cord clamping weighed
725 g and would just pass through a ring 79 mm in diameter. After
draining out the blood, the placenta passed through a 62 mm ring..."
Avoid all clamping. One of those old texts that said the pressure on
the vessel by clamping, can have some sort of effect in keeping the foramen
ovale open (and I'm sorry, I can't remember the exact mechanism.) Here
we began to realize that it might be foolish to assume that all the switch
from fetal to neonatal circulation really occurs in that first five minutes,
and that it is more reasonable to assume that some changes and equalizing
happens AS LONG AS ANY CIRCULATION EXISTS OUTSIDE THE BABY. So, in order
to prevent circulatory problems, the WV midwives started not clamping the
cord at all. And this necessitated waiting (usually 2 hours) for there
to be NO PULSE at the umbilicus. So when the placenta delivers, we wrap
it in a chux with a twist tie, place it next to the baby, and bundle both
in a blanket. [Only clamp stump if bleeding when finally cut.]
"Discuss
fetal circulation and the changes in it at birth." - This is a nice
discussion, but some of the information is in conflict with the direct
experience of those who attend births. In particular, the neonatal
changes are alleged to happen very quickly, within a few minutes, which
is not supported either by the research or by the experience of birth attendants.
One minute delay in umbilical cord clamping boosts iron status of newborns.
Investigators at the University of Connecticut, Farmington, and the
University of California, Davis, told the Experimental Biology '96 audience
that newborns whose umbilical cords are clamped one minute after pulsation
stops have much higher hematocrit levels than infants whose cords are clamped
immediately after delivery. Dr. Rafaela Perez-Escamilla reported that 88%
of infants with immediately-clamped cords had hematocrit levels below 33
at the age of two months. In comparison, only 42% of infants whose cords
were clamped after the one-minute delay exhibited iron deficiency anemia
at two months of age.
I always cut the cord rather fast I must say, within a few minutes.
I suppose because I was taught that the longer it takes, the more problems
with jaundice you can expect. And I know this is not always true, but somehow
it is very hard to change a habit of years.
Most of my parents request that the cord not be cut until it's done
pulsating, and I like that transitional source of oxygen, as limited as
it might be. Our babies are generally held above the level of the placenta,
so we're not draining blood into the baby, and I don't see jaundice problems.
Have only had one kid in the last 50 or so under bili lights. Most cords
are cut before the placenta delivers, but not always. It doesn't matter
to me either way - I'm quite flexible with the whole thing.
Our local hospital loves to send transported home birth babies to NICU
for polycythemia because the "midwives let the cord pulse too long". So
which is it, babies receive too much blood, or babies are being drained
of too much blood?
There's no simple answer to the question. If there was, it would have
been found long ago.
Most of the components of the question have been stated already.
In the cord: Blood in the pulsing arteries is going toward the placenta.
Philosophically speaking, it may help to remember that this is not away
from the fetus, since the placenta is an organ of the fetus. It is
away
from the heart, not away from the fetus. So the arterial blood
in the umbilical cord is not leaving the fetus, any more than the blood
going to the head is leaving the fetus. The non-pulsing venous flow is
away from the placenta and toward the heart. No body knows what shuts it
down or even if it shuts down. Personally, I think it does, in response
to fluid volume. There's some evidence that it does.
In the baby's abdomen/pelvis: The umbilical arteries take off the iliac
system. They seem to be oxygen sensitive (or something) such that when
the oxygen levels rise from fetal low levels to neonatal much higher levels,
the arteries squeeze down tightly and cut off further use of the placenta.
In the baby's chest: The ductus arteriosus seems to react the same way
to the drop in pressure of the pulmonary vasculature (or something) to
shut down the shunt of poorly oxygenated blood to the aorta.
My spin on all this is that the baby may still benefit from the use
of the placenta as an organ of respiration until the cord pulsing stops.
I presume that the reason it's still pulsing is that the baby's system
is not yet satisfied with oxygenation from the lungs and wants to keep
on the placenta a little longer as an auxiliary source. To put it another
way, cutting the cord is an amputation of a body part. I want to be sure
that body part is useless before I amputate it, the same as I would want
to know that your arm was useless before I amputated it. Only if I thought
your arm was a danger to you would I amputate it before it was useless-for
example if it had cancer. So I can think of perfectly good reasons to amputate
a placenta prematurely, for example in certain bleeding circumstances.
So if the primary issue is not wanting to amputate an organ prematurely,
the secondary issue is blood volume shifts. After birth, if the arteries
stop pulsing, there is no more blood going to the placenta. The only thing
that can now happen is blood coming from the placenta, unless the vein
shuts down, which nobody knows. So maybe the whole issue is moot. But if
the vein shuts down in response to fluid volume, that would be perfect,
so that each part of the transformation cascade from fetal to neonatal
circulation would be orderly. First, in response to lowering the pulmonary
vessel resistance, the ductus arteriosus closes, sending oxygen depleted
blood to the lungs instead of to the lower body. This raises the oxygen
content of the lower body automatically. Then the blood in the lungs gets
oxygenated, raising total body oxygen enormously. In response to this,
when the babe feels good and oxygenated, the umbilical arteries shut down,
preparing for the amputation of the placenta. Then the baby's blood volume
sensors monitor fullness, and when the time is right, shut down the vein
so that no more blood comes from the placenta. If all this is correct,
then nothing you do with the baby's position (within limits, now; I don't
mean holding them as far up or down as you can just to make a point) should
determine what the final blood volume is. And sure enough, so far no one
can point to any evidence that you can influence final blood volume, except
mess with it by premature amputation of the placenta and hope that everything
goes all right (and usually it does.)
ummmm, not true on this one. There is an extensive volume of literature
that you can influence hematocrit and iron stores by delayed cord
clamping. A recent reference is
Neonatal
prevention of iron deficiency: Placental transfusion is a cheap and physiological
solution.
I've snipped a bit of the text of this article:
Prevalence of Iron Deficiency in US Remains Above 2010 National Health
[Medscape registration is free]
Iron
Deficiency --- United States, 1999--2000 - CDC's MMWR October 11, 2002
/ 51(40);897-899
I intended to make the point that whatever you did with the baby, within
reason, was neutral as far as ultimate blood volume, and that the problem
was not what you did with the baby, but whether or not you amputated the
placenta prematurely. The references above support that idea, especially
with regard to the increased blood volume in babies who were placed
on mom's abdomen compared to those who were prematurely amputated. According
to legend, if you hold baby high, blood drains into the placenta, and if
you hold baby low, blood drains out of the placenta. Lindercamp showed
that even putting baby high (on belly) blood volumes were still higher
anyway, compared with premature clamping.
Sorry to be unclear. The literature supports not clamping until baby
indicates she doesn't want any more placental function by shutting down
arterial flow to the organ, signaling she's ready to have it amputated.
I agree with the way this is phrased. Let's shake ourselves of the notion
that delayed clamping gives "extra blood" to the baby! Early cord clamping
prevents the baby from getting the blood he would have gotten if the birth
had occurred under normal, natural circumstances. It deprives the baby
of a variable amount of blood.
If we can prove that interfering with this NORMAL process is beneficial,
then we should clamp/cut cords immediately. If we can't prove a benefit
- or if we can prove a harm -- then we should continue or return to the
historical timing of cord clamping. Humans did not, COULD not, do immediate
cord clamping before the invention of a clamping device (about 150 years
ago, I think). Immediate cord clamping is a very recent routine advocated
in the US in the 30s as a means to lessen the amount of maternal anesthesia
passing to the baby, and pushed in the 50s to "reduce the incidence of
jaundice".
Where's the evidence that early cord clamping is beneficial? There is
theoretical worry of increased jaundice and polycythemia. But there is
NO evidence to support this.
I really don't give the Guide to Effective Care quite the same status
as the Bible[GRIN] - --I DO think it helps us to gain perspective, and
I seriously believe we should refer to it more often.
According to the research analysed by the Guide, there is no difference
in early versus late cord clamping in one and five minute APGARS. There
are higher hct at later dates BUT no increase in jaundice in delayed clamped
babies (yes, it DOES increase hct, but not enough to raise the incidence
of clinical jaundice ). It does no harm to the baby to delay cutting the
cord....
But, catch this. GTECPG pg 239
As an independent midwife in Melbourne Victoria, I can give you my experience
of not having cut a cord, even when the babe is wearing it like a handbag
(over the shoulder, around the neck, at least once around the body!!!)
in more than 10 years and I find that these babies don't get jaundice.
In fact I cannot think back to a babe I have had recently who HAS been
jaundiced.
If the pulsating cord is showing that the baby has a beating heart then
surely some blood could be getting through to the placenta. Then because
fetal pO2 is lower than maternal pO2 there is a diffusion gradient and
it will diffuse into the baby's blood.
If the placenta is still attached, then it can form part of the resuscitation
process....
(It makes one wonder just how much pitocin/syntocinon a baby gets if
mom is given a routine shot with the birth of the baby's shoulders?)
I find, though, that in those severe situations, the cord most likely
has already gone limp, so at that point, the baby is not benefitting anyway
from the umbilical support.
I guess I weigh procedures in order of priority at the given situation.
Does that make sense?
Respectfully, no it doesn't.
If there is no heartbeat, and no respiration, artificial respiration
may kick-start the entire process and therefore the pulmonary route of
oxygen administration should be used if possible. However, sometimes that
route just isn't available, and resuscitation may still proceed by cardiac
stimulation/compression independently of efforts to establish the airway,
if only you haven't already burned your bridges behind you by screwing
up and cutting the cord. Let me give an example.
Mom comes in to hospital without calling ahead. Says she thinks she's
about to have baby. Taken to L&D where nurses don't take very long
finding that the head is already out. They stat me from the call room only
about 60 feet away.
I arrive dressed in trousers (put on trousers literally as I ran down
the hall, honest, didn't want to terrify mom) and nothing else 20 seconds
later to find baby out and covered with thickest mec I'd ever seen. It
resembled old dry toothpaste. Couldn't see any facial features, not even
the nose, secondary to too much mec paste. Wiped it off in a hurry, nurse
monitored the cord after offering to cut and being told NOT. Couldn't suction
the mec-plugged the full strength wall suction.
I had to literally curette the mec out with a ring forceps. Don't you
know I was so horrified I was crying? I bet that upset the mom, but what
do you do? I finally got down to the vocal cords, and for some reason the
mec was thinner below the cords and could be suctioned. Total time to get
mec out enough to suction and establish an airway was nearly 7 minutes.
You know that's long enough to completely fry a brain, don't you?
Meanwhile the nurses had been doing chest massage the whole time. Pulse
rate at first assessment was 0, but with massage, which could be felt in
the cord, and therefore technique monitored to get best cardiac output,
eventually a spontaneous pulse rate of about 40 was felt at 4 minutes.
We kept the chest massage going anyway and spontaneous pulse climbed up
to 120 and pulse became full and strong by about 5 minutes, at least 2
minutes before the baby received so much as a whiff into the lungs.
That baby last I heard was in school doing OK.
If you try to convince me that babe would have survived at all without
the use of the placenta, you've got a tough uphill battle ahead of you.
It
is precisely in the most dire emergencies that cutting the cord is the
worst of all possible things you can do. In our humble little remote
hospital in the middle of nowhere, we accomplished a better result than
the finest medical center could have done with cutting and handing off
to the neo team. In fact, the neo did call us later after the transfer
and asked us how we accounted for the baby's survival with so long without
air. When we said we didn't cut the cord, he was amazed and said he'd like
to try it sometime. Duh.
As for instructional courses to the contrary, do what the instructor
tells you to do, pass the course, and then go forth and do the right thing.
It is my strong belief that once the majority of a baby has passed through
the mid pelvis the supply of 02 through the cord is non-existent. A pulsating
cord ONLY indicates that the baby has a beating heart and a stable blood
pressure. Oxygenation is contingent upon gases diffusing across the placental
membrane. And that just ain't happening anymore. If you have a shoulder
dystocia you feel a strong need to get the baby born; because the longer
the baby is stuck, the lower the Apgar. Same with breeches. Once the uterus
has been significantly reduced in size, the placenta starts to buckle,
and placental function goes down. A drowning person has a strong pulse
for a period of time; but he ultimately dies from anoxia. The advantage
to not cutting the cord quickly is that the baby gets more of his blood.
This whole notion that a pulsating cord is indicative of oxygenation is
a great leap of faith. There has been more then a few underwater birthed
babes that have required resuscitation because they were left under water
till the cord stopped pulsating.
WHAT???? I have got to hear your basis for this...can you quote some
sort of evidence that supports this...or even explain the physiology behind
this theory in more detail? Any books that explain it? Why do you have
this belief, it must come from somewhere. This is not anything I have ever
heard before anecdotally, and I have never read it anywhere. My experience
in 550 births surely doesn't support this theory either. MID-pelvis? You
mean the whole baby? Once the baby is OUT? I'd love to hear more.
If the pulsating cord is showing that the baby has a beating heart then
surely some blood could be getting through to the placenta. Then because
fetal pO2 is lower than maternal pO2 there is a diffusion gradient and
it will diffuse into the baby's blood
Diffusion ALWAYS happens as long as there is a concentration gradient
(1st Law of thermodynamics applies here). The greater the gradient, the
faster the diffusion.
How can you be sure that it isn't happening any more?
With shoulder dystocia and some breeches, I thought that the problem
came from pressure on the cord from the pelvis exceeding the baby's arterial
pressure and therefore the blood can't circulate to the placenta and back
again to the baby - the problem is a mechanical one not one of lack of
diffusion. Yes, and the longer the baby is stuck then the worse the Apgars
would be; because until that pressure is relieved there's no effective
circulation and no possibility of O2 reaching the babe.
If the baby is then delivered and his/her heart is still beating (or
can be induced to beat by resus.), then because fetal oxygenation has reached
such low level, the diffusion gradient is greater both across the placenta
and between foetal blood and foetal cells - and therefore O2 transfer would
be expected to be more efficient.
It's probably not enough to stop brain damage once it's has happened,
but surely it could give the baby a boost. The possibility seems strong
enough reason not to cut, because once it's gone the only way to get O2
into the baby is via the lungs. If it's still intact, then surely there
are two possible routes for oxygenation?
I also wanted to ask about the post saying that there is no more oxygen
perfusing the placenta once the uterus starts to buckle. Therefore there
is no worry about cutting the cord even while it is still pulsing. I would
think that if that were so then all the more reason not to cut the cord
and so reduce the baby's blood supply. Isn't there still O2 in the blood
after a complete pass through the body. My understanding is that blood
reaches the lungs/placenta still containing O2 just not at 96-100% capacity.
so if there is a 40% saturation level wouldn't a greater blood volume increase
the O2 level as a whole? Or are you saying that the amount of blood reserved
in the placenta is not sufficient to make a difference?
OK, let's leap our faith out in a different direction.
Oxygen is a very small, simple molecule, which diffuses extraordinarily
well through the placenta, but its transplacental effects in pinking up
a baby are somewhat ambiguous when the babe is being resuscitated and also
receiving oxygen via the lungs.
So let's look at a different molecule. Narcan. It's a large, bulky molecule
that diffuses poorly through the placenta compared to oxygen. So if there
is no oxygen enrichment via the placenta as you suggest, then there should
be even less chance of getting Narcan to a baby via the placenta after
the baby has been born.
Yet one of the tricks that I find most satisfying working in a technology-intense
environment is that babies are not-infrequently born depressed from being
born too quickly after narcotics were given to mom, and the whole unit
panics as the floppy baby is born. Since I always order a syringe of Narcan
drawn up any time one of my gravidas is given any narcotic, in the midst
of the panic, I order the amp of Narcan to be given IV push to mom. The
nurse is invariably stunned and asks me if I don't mean IM to the baby,
and I usually have to repeat myself. She then gives the amp to mom, and
in less than 20 seconds the baby abruptly wakes up and becomes fully alert,
without me doing any stimulation or any other resuscitative thing at all.
In fact, sometimes I've already given the baby to the mother by that time.
It's a lot of fun, is usually quite disruptive to the OB unit, which
gets all abuzz about it and wants to know where I learned it. When the
neo team gets there they are always puzzled about why they were called.
Then by the next time it happens, everybody has forgotten the previous
event and the whole thing repeats as if it were the first time such a thing
had ever happened on the unit before.
So if Narcan goes swiftly across the placenta to baby, and diffuses
much more poorly than oxygen, I rest my case.
I have a practical question to ask about all this. How is your delivery
set-up configured so that you can resuscitate with O2 while cord is intact?
Where I work, the O2 is attached to the infant warmer, and would not reach
the mom in bed. Hmm, I guess we could always detach the Laerdal and attach
it to the maternal O2 supply in the room...
You've answered your own question. You grab mom's O2 cause she isn't
needing it at the moment.
Of course, there would be some that would complete the circular reasoning
that O2 is on the cart because that's where babies are resus'ed, therefore
babies need to be resus'ed on the cart because that's where the O2 is.
I say, the best O2 is in the cord, so everything else has to be built around
the cord's location.
Coincidentally, on the ob-gyn list, somebody posted the speculation
that the placenta continues to serve as a depressed infant's major O2 source
for several minutes. Somebody else had the same thought that I did, which
is to doubt this based on the likely decreased perfusion of the placenta
as soon as the uterus collapses with the expulsion of the fetus; it seems
that it would lose much of the total surface area of contact, though it
retains enough to still be physically "stuck" there.
I think the timing of when this occurs is influenced by the use of pitocin.
In a physiological birth the placenta stays attached (and we assume functioning)
for longer than with active third stage management (pitocin IV or IM with
the shoulders). I don't think The uterus "collapses" a great deal --immediately
--with expulsion of the baby. We usually see a gradual firming up before
contractions resume five or ten minutes after birth (without pitocin).
Also, someone asked about cord tying and mentioned the drop in temperature
being an possible influence on the cessation of bleeding. I've got an old
physiology book which looked at such things -- and referenced experiments
which would be forbidden now. (these are excerpts from an prior post)
Cords- cutting, etc -- "physiology of the newborn infant -- Clement
Smith 1946 --it has a lot of research reports would would be banned for
ethical reasons today). The author refers to the "constriction effect caused
by oxygen increase". Testing showed that in response to the baby's breathing
the O2 levels in the cord ((Sorry bob, I don't know how they checked this))
nearly triple within 60 seconds of respiration. .
He cites experiments demonstrating three effects on the cord after birth:
He concludes that we would probably function as well as any other mammal
without cord clamping "particularly if, as with animals, a long remnant
were left attached, but tradition, convenience.... and a certain amount
of care against unlikely accident decree that the cord be clamped and severed".
There's also experimentation which shows continuation of placental circulation
after expulsion, the placental circulation doesn't cease immediately with
the birth of the baby.
It reports an experiment by Haselhorst and Stromberger in 1932. They
"injected Congo red dye into the umbilical vein of the pulsating cord and
measured the time elapsing before the dye reappeared at the same site.
The observers found that in one series of infants born in the normal manner
this period was 60 seconds, while in others delivered by elective Caeserean
section from the non-contracting uterus, the time was 30 seconds. .. The
circulation so measured must have included the extensive circuit of the
placenta as well as that through the body...."
So I think this rather proves that the baby's circulation still includes
the placental unit -- rather than the frequently taught modern view that
the cord just pulsates without any placental involvement. The circulation
continues its' rapid course through the baby, through the cord, through
the placenta, for "a period of time" after birth. Even if it's only a few
minutes, those first moments can be the most significant of the baby's
life. If the placenta is still attached, (and if we presume it's still
functioning) then it can form part of the resuscitation process.
Your last sentence gets to the critical "if." That fetal blood still
circulates through the placenta does not imply that it is still exchanging
gases with the maternal intervillous spaces. I think the best way to test
this would be to have the mother breathe 21% O2, but an isotope of oxygen,
not regular oxygen. Then cord blood could be tested for the presence of
the isotope, and perhaps a correlation between time of clamping and what
% of the O2 in the cord blood is isotopic could be determined. There should
be no ethical problems with this at all.
I don't mean a radioactive isotope. Just one with a couple of
extra neutrons. Detectable and measurable, but the effect on the body is
precisely the same as with regular oxygen. (This is used commonly in metabolic
experiments where the oxygen utilization needs to be measured precisely.)
Has anyone seen the birth video of water births in Russia? I watched
one in school. It seems VERY clear to me that the cord and placenta in
those births are continuing to do their jobs of supplying O2 to those babies.
They are allowed to stay under water for so long after birth! I don't remember
exactly how long, but it was a lot longer than done at water births in
the States. I'm not supporting this practice, but I do think it tells us
a lot about what's going on with the cord and placenta after the birth
of the baby.
Detailed Information from an Expert in Circulatory
Physiology
The Fall 1986 issue of Mothering has an article entitled "Delayed Cord
Clamping". This is the only article I have come across with great references
on this seemingly "controversial" topic. I am interested to hear if there
are others with more "current" studies done on this.
According to this article: "If a blood pressure gauge is placed on an
unclamped umbilical cord, it will pick up pressure rises as high as 60
mm Hg with each uterine contraction. This indicates that these contractions
are intimately involved in the transfer of placental blood through the
cord. A striking pressure rise, which persists through the first few hours
of life, is also evident in the baby's vena cava and right atrium of the
heart. All studies on this indicate a significantly higher systemic pressure
in infants who have been clamped late (90% in the first nine hours) and
conversely, a significant drop in those early clamped infants (70% of systemic
by the second hour, and almost 50% of systemic by the fourth hour). [Moss,
Arthur J, MD "Placental Transfusion", PEDS 40:1 ^V July 1967]"
Some interesting statistics:
"The placental blood normally belongs to the infant, and his/her failure
to get this blood is equivalent to submitting the newborn to a severe hemorrhage
at birth. [De Marsh, QB, et al "The Effect of Depriving the Infant of its
Placental Blood", JOUR AMA ^V 7 June 1941]"
"Deprivation of placental blood results in a relatively large loss of
iron to the infant. [De Marsh, QB, et al "The Effect of Depriving the Infant
of its Placental Blood", JOUR AMA ^V 7 June 1941]"
"The time of cord clamping may be involved in the pathogenesis of idiopathic
respiratory distress syndrome (the earlier clamped, the more respiratory
distress). [Saigat, Saroj, et al. "Placental Transfusion and Hyperbilirubinemia
in the Premature" PEDS 49:3 ^V march 1972]"
"Placental blood acts as a source of nourishment that protects infants
against the breakdown of body protein. [De Marsh, QB, et al "The Effect
of Depriving the Infant of its Placental Blood", JOUR AMA ^V 7 June 1941]"
"Studies have shown that immediate cord clamping prolongs the average
duration of the third stage and greatly increases maternal blood loss.
[Walsh, S. Zoe "Maternal Effects of Early and Late Clamping of the Umbilical
Cord" LANCET ^V 11 May 1968]"
And for the argument that delayed cord clamping will increase a babe's
risk of hyperbilirubinemia (jaundice), Mothering eloquently says this:
"Among other drugs, pitocin inductions and epidurals have been conclusively
linked with nonphysiological neonatal jaundice (this is not normal, breastfed
jaundice). Any drug administered to mother or baby must be viewed with
a "jaundiced" eye, for it is likely to compete with bilirubin sites on
blood protein, causing more bilirubin to be free to contribute to jaundice.
In an all-out effort to prevent the possibility of jaundice, obstetric
practitioners have reasoned against delayed cord clamping, since it increases
the volume of red blood cells ^V which, in breaking down, will produce
increased levels of bilirubin. True, hyperbilirubinemia may be prevented
in premature and "medicated" infants by early clamping; however, in a normal
delivery of a full-term, unmedicated infant, there are untold advantages
to delaying cord clamping until after the placenta has delivered itself."
Enkin, Keirse, Renfrew, & Neilson, (1996). A Guide to Effective
Care in Pregnancy & Childbirth, (2nd ed), p. 239. New York: Oxford
University Press.
Active management of the third stage of labour usually entails clamping
and dividing the umbilical cord relatively early, before beginning controlled
cord traction. Pre-emptying physiological equilibration of the blood
volume within the fetoplacental unit in this way may predispose to retained
placenta, postpartum haemorrhage, fetomaternal transfusion, and a variety
of unwanted effects in the neonate, respiratory distress in particular.
Delayed cord clamping results in a placental transfusion to the baby varying
between 20 and 50 per cent of neonatal blood volume, depending on when
the cord is clamped, at what level the baby is held before clamping, and
whether oxytocics have been administered.
Early cord clamping leads to higher residual placental blood volumes
and heavier placentas, but these observations have no clinical relevance.
The duration of the cord clamping does not appear to influence the frequency
of postpartum haemorrhage, although numbers are small.
Allowing free bleeding from the placental end of the cord reduces the
risk of fetomaternal transfusion, which may be important with regard to
blood group isoimmunization.
Early cord clamping results in lower haemoglobin values and haematocrits
in the newborn, but these effects are minimal at six weeks of age and undetectable
at six months after birth. Neonatal bilirubin levels are lower in
babies born after early cord clamping. It is difficult to draw relevant
information from the trials about the effect on clinical jaundice.
No detectable differences were noted in the trials that reported on this.
This issue is of particular interest in the care of preterm babies,
where early clamping is often carried out to facilitate resuscitation.
Theoretical considerations suggest that a delay of as little as 30 seconds
may have important clinical benefits for these babies. Further information
is needed.
We don't clamp until right before dad (or whoever) cuts. So it goes
like this: Baby comes out, mom & dad ooh and ahh while we dry Baby,
cord pulses for a bit (sometimes dad's like to feel that and think it's
really cool), cord pulsing becomes faint or quits, Mom has separation gush,
midwife holds onto cord with a sterile gauze square and guides placenta
out while Mom pushes. Then we or sometimes dad put cord clamp near Baby,
we clamp a few inches away with a hemostat, steady everything with a gauze
square underneath to catch any blood, Dad cuts cord, mom and baby get into
bed or in a chair to nurse. The End. :-)
I used to cut the cord as soon as it stopped pulsing. Now for most of
the births, the cord is cut after the birth of the placenta, when we are
ready to take the placenta to the other room. Occasionally I cut it sooner
if I feel there is some reason to get the placenta birthed but the maternal
end is left unclamped to allow the placenta to drain, shrinking it down,
shearing it from the uterine wall. If a baby is at risk for jaundice, the
cord is cut sooner and very close to the umbilicus to limit the amount
of blood being reabsorbed back into the infant. I sometimes even allow
the cord stump to drain JUST A LITTLE to further reduce the amount of risk
with jaundice. NOT ENOUGH TO CAUSE ANEMIA!!!!!!!!!!!!!!!!!!!!!
Many here have delayed cutting the cord for two or more hours. If you
notice, the cord is still pulsating at the umbilicus for about this length
of time, even though there is no pulsation in the middle. So what we do
is deliver the placenta into a chux, loosely twist it around the cord and
tie it off with a twist tie. We bundle baby and placenta together in a
position much like in utero, and wrap both with blankets. When we do cut
the cord, there is very little bleeding if any, and more often than not,
we use no clamp at all. Obviously, if the cord leaks, we clamp it, as we
do if there is a medical emergency necessitating clamping the cord.
Yes, we also find it makes us do whatever baby needs in terms of resuscitation
right there with mother since being still attached keeps baby close. But
also my partner feels there must be some physiologic message between baby
and placenta in essence saying, "I don't need you anymore; you can go ahead
and detach." (Stretch receptors, biochemical signals,...????) Anyway, she
says she waits on placentas much less now than when she clamped first.
I've only been a part of the cut after the placenta is delivered routine,
and I realize the numbers aren't very big, but we rarely wait more than
10 minutes for a placenta--usually much less. It seems very natural to
me. Baby comes out and goes into mom's arms, is dried and stimulated if
necessary, everyone oohs and ahs over baby for a few minutes while one
of us gets clean chux and a pan under mom, the cord might still be pulsing
a little by now. Soon it looks limp and we tell mom that whenever she gets
a little contraction she can push out the placenta and get into bed. (She
might be sitting beside the bed on the floor, having delivered in a squat
or hands & knees.) Often suggestion is enough and the placenta soon
comes. Then we are free to help dad, mom, siblings or whoever the parents
want to cut the cord in a leisurely fashion.
We routinely let the cord completely stop pulsing at the umbilicus.
This takes anywhere between 1 1/2 to 2 1/2 hours after birth. We cut the
cord, and ligate only if it keeps bleeding, which is rare. My partner insists
she has seen less jaundice as a result, not more.
The doc said that clamping the "mom side" of the cord (or, worse yet,
milking it) can cause reflux of the baby's blood into the mother's circulation
and lead to Rh sensitization and other antigen/antibody disasters. I was
amazed to see that hardly any blood came from the cord--I'd always thought
that mothers could bleed out from not having the cord clamped.
I do this mostly also, by letting the extra blood out from the placenta
you allow the volume of the placenta to diminish and I feel that allows
it to come out quicker in some cases. I have tried it both ways and feel
this way is preferable.
This thread on NNR made me wonder if anyone has noticed a tendency for
maternal hemorrhage, when not cutting the cord, to be reduced. I have never
seen a full resuscitation but have heard that when the baby needs it the
mom often hemorrhages. Perhaps this is her distress for the baby or less
attention being paid to the mom, which ever, I would think keeping things
close might help her too.
I think that trauma tends to lend itself to more bleeding. I have always
suspected that the cry and touch of a baby tells the mother's body that
the baby is here and that is some way protective, just as I have noticed
that having lots of skin to skin contact with babies seems to stimulate
milk supply increase even if the baby is not nursing (moms pumping for
preemies and doing kangaroo care have consistently commented on increase
in milk supply with the skin to skin care).
Obviously certain complications of labor that may lend themselves to
the need for resuscitation of the baby such as a long hard second stage,
or worse, shoulder dystocia, also are associated with more hemorrhage period.
After discussing the practice of not clamping/cutting the cord until
after the delivery of the placenta a year ago last Jan., I have not had
even one pp hemorrhage and have waited no longer than 20 minutes for any
placenta. I AM SOLD.
I have had a very noticeable reduction in moms who not only pph but
just bleed heavily. I have not been cutting the cord until the placenta
is born for a year and a half now and I have had one pph since then which
was a mom with a very short cord who wanted to hold her baby closer, I
cut the cord, and SHE BLED!!.
More bleeding? Absolutely! Weeping womb--literally!
I think I might be able to answer this one. Since I am hospital based
(mostly) and do hct the day after birth on the baby, I can tell you that
I see don't see much difference on babies where I deliver the placenta
before cutting the cord and when I cut the cord before it quits pulsing.
Occasionally I see higher hcts if I cut the cord early, but the hct is
really high - like > 60, which sets the kid up for jaundice, IMO.
If the kid comes out really bad, and I have to cut quick and rush him
to warmer for resuscitation, I DO see hct in the range of 45, instead of
the usual 50-55.
You probably only really "need" to clamp and cut the cord quickly when
the baby requires active resus.
Actually, this is when we especially DON'T cut the cord unless it is
completely flat with absolutely no pulse, and then don't think we've taken
the time to cut the cord if we are busy resuscitating!
Well.....there are some who would say that during a resus is exactly
when you DON'T want to cut the cord. Why cut the baby off from it's oxygen
supply? Just so you can administer your own oxygen out of the shiny container
(please note sarcasm)? Depending on where the birth takes place (i.e. in
a not-broken bed) and whether or not peds is around to take over and exactly
how bad the baby looks, you can resuscitate a baby without detaching it
from it's life line first. Just throw a towel down on the bed and work
on the baby between the mother's knees (or even on her abdomen).
I did a waterbirth a few weeks ago where the mom pushed for three hours
(not all of them in the tub, thank you). We had a slight (is there such
a thing) shoulder dystocia (as expected) and the baby came out a little
"slow". The kid was just laying there on mom's chest, seemingly not quite
getting it that he should breathe now. The nurse was getting worried and
came at me with the instruments to clamp and cut the cord. I thought for
about five seconds....when the baby was underwater, as I was bringing him
around he was moving his arms and legs, so I hadn't been worried, despite
the trouble getting him out......well, since the baby seemed so happy underwater,
and I really thought he was OK and I didn't want to unnecessarily put the
baby through a resus and get the parents all freaked out.....so I quickly
picked up the baby and dunked his body back in the water, carefully keeping
the head out...the baby immediately wailed and we were all happy.
The only comment my boss made the next morning was to ask me where in
the NALS book it recommends full body immersion as the first step in resus.
Well, yeah, if the cord is white we might as well cut it to make working
on the kid a bit easier. But if the placenta is till functioning (if the
cord is still patent and pulsing) . I think sometimes an intact functioning
placenta helps the baby bridge the gap to extra-uterine life , far better
than our resus skills do. I think it helps buy us some time during resuscitation.
Might as well keep it intact and use that extra minute or so of extra life
support.
I know there's another school of thought that clamping the cord "forces"
the baby to breathe and thus encourages better resuscitation response.
I've never seen research comparing the two methods: resus with intact (functioning)
versus resus with cut cords. Of course in standard settings the baby is
detached and handed to the person doing resus on the warming table on the
other side of the room[GRIN] so it would involve a whole redecorating to
set up a comparison study!
I know this is going to sound off the wall (maybe it is off the
wall) but I consider resuscitation a contraindication to cord clamping.
I think of the placenta as the primary respiratory organ until full
lung function is evident. I don't like to ask a baby to be dependent on
lung function alone when the lungs are struggling. Furthermore, I sometimes
want to give a babe a drug during resuscitation, and the easiest way to
do that is to give it to the mom, where it can go straight IV pretty easily,
and thence across placenta to babe. When babes are in trouble they have
almost no IM absorption whatever.
Especially when I get a depressed baby from epidural or narcotic, I
won't let the cord be cut while I'm working on the babe. IV narcan to mom
wakes up the babe inside of 15 seconds if the card is still open.
I find you can do any resuscitation you can think of with babe right
in mom's lap or beside her in bed, and although it's terrifying to watch
somebody working on your baby 2 feet from your nose, I bet it's even worse
not knowing what's going on because babe was whisked away out of your sight.
So even though I'm an outlier on this one, I especially don't
do aggressive placental amputation when babe is doing poorly.
I completely agree!! Even in cases where the cord has been limp and
white, I have resusced a baby to find that the cord then pulses again...and
it starts before the baby really does, so it's giving me extra help.
I have also seen completely limp white cords come back to life when
the baby does. I theorize that at that point baby gets much needed oxygenated
blood. At any rate, I know that babies can be resuscitated on mom, and
why bother to take the time to cut? My stillborn baby, 18 years ago, had
that kind of mec. Of course cord was cut -- and he was only worked on for
FIVE minutes -- protocol at the time. His heart rate was 140 ten minutes
before he was born,(cesarean) and then started plummeting. What difference
would it have made if I had held him, or even talked to him, while his
cord was attached, and they worked on him? Will never know. Was present
at a transport several years ago where baby's heart rate was 144 in the
minute before his forceps, OP birth. His cord was cut and they attempted
to resuscitate him, but he never drew a breath. Parents were never given
a reason for his death. We always have grieved that his cord was cut, and
are less likely to transport now, than before.
[from ob-gyn-l]
Regarding waiting for the cord to stop pulsating before clamping. I
think this makes physiologic sense because it allows gradual shunting of
blood flow from fetal circulation to infant circulation with the initiation
of respiration. If you look at the faces of the newborn if you clamp the
cord right away they do grimace, and I am not sure if this is painful to
them or not, but I would rather err on the side of gentleness. That is
there is no emergent or distress situation. Also, holding the infant below
the level of the placenta while waiting for the cord to stop pulsating
may increase bilirubinemia down the line. Most term newborns can probably
handle it but I wouldn't chance it with pretermers or otherwise at-risk
newborns. At one time we used to milk the cord toward the infant before
clamping. And before that I can remember not clamping the cord, but delivering
the placenta and hanging it above the resuscitating unit to transfuse as
much blood as we could into the newborn. That was a long time ago.
Though I (unfortunately) have NO reference, I was taught in training
that an extended time to cord clamping with the infant below the perineum
was a risk factor for hyperviscosity and neonatal jaundice (do to increased
rbc breakdown in the newborn period). Too much rbc mass is a greater and
much more frequent problem than too little in the newborn - at least in
my well fed US population.
When I was in medical school, there was a study going on at Boston City
Hospital, in measuring the amount of blood transfused into the infant by
clamping after pulsations were stopped. and the conclusion was that the
hct rose around 2% if you did not clamp the cord right away. I do not know
if this was published.
Studies have been done on delayed clamping of the cord and it leads
to a significant transfusion of blood to the baby, which may not be a big
deal for the term neonate, but significantly increases subsequent hyperbilirubinemia
in the premature infant.
I have seen reports recommending that the cord not be clamped until
it has quit pulsing. I'm not impressed with the reasoning or the science
behind it.
I would be interested in hearing synopses of any research on
the subject. I had always thought that this recommendation was made for
emergency and home births only because there was no completely reliable
way to prevent hemorrhage from the cord. If there is effective oxygen transport
still occurring through the placenta, I suppose it could be somewhat protective
until the infant succeeds in transition to postnatal circulation.
I was able to find several articles regarding the timing of cord clamping.
It looks to me that the routine practice of early cord clamping arises
from concerns related to significant placental to fetal transfusion. This
practice, particularly when performed with the fetus in a dependent (below
the placenta) position results in a impressive transfusion and rise in
neonatal hematocrit and blood viscosity. This appears to be of particular
concern in the preterm infant where hyperbilirubinemia is exacerbated (1,2)
However one could postulate that the placement of the infant on the
maternal abdomen at term may result in less gravitational effect and have
limited physiologic significance. Nelle et al. appear to have published
one experiment 3 times and demonstrated that with the newborn on the maternal
abdomen that the delay in cord clamping still results in a significant
transfusion and increase in blood viscosity.(3) I did not see any data
on the physiologic consequences of this transfusion at term.
I personally do not rush to cut the cord, neither do I await complete
cessation of pulsing before clamping. It probably is unwise to clamp the
cord early in fetuses who may be anemic or volume depleted (i.e. tight
nuchal cords or hemolytic disease) and equally unwise to clamp the cord
late for fetuses at risk for polycythemia (i.e. IDM's)
what is the deal about waiting until cord pulsations stop? I hear this
from time to time, and have certainly seen patients put it in their requests
for birth management, but I've never been able to figure out why anybody
thinks this is a physiologically significant event or transition point.
Anybody care to explain the rationale to me?
well, waiting means mom and baby get to stay together a bit longer since
no-one can grab the baby to stick it under the warmer! And it's pleasant
to just hold the baby without feeling there's a rush to cut and clamp the
cord. But there are physiological reasons too...
Yes, For instance: Isn't the baby entitled to receive ALL of his or
her blood supply? If we whack the cord 3 seconds after the kid is out,
then we leave 1/3 of its blood supply in the placenta. HELLO? Is anybody
getting this????
I know that the medical people think that this goes against the physiology
of jaundice.... but I (as do many,many other EXPERTS) believe that this
is precisely why my clients babies do NOT get jaundiced. I usually do not
cut the cord for at least an hour. I tuck the placenta gently next to the
mother in a chux pad. When SHE asks... then we have her or the daddy cut
the cord. There is enough going on in the early period following birth.
So why worry about something as trivial as cutting the cord?
Well, this assumes that more blood is better, and that remains to be
proven. Surely there is some upper limit of what is an optimal blood volume
and hemoglobin concentration, but I doubt that we really know what it is.
Since the baby will be working furiously to break down all its fetal hemoglobin,
it's not clear to me that more is better.
well, I think I'd take the opposite line. I'm sure we all agree that
early cord tying/clamping is a VERY recent invention -- practiced routinely
only in a few countries and only since the forties (with some old-doc and
midwife holdouts). It is neither natural, normal, evolutionary or historical.
Early cord clamping is an innovation -- an intervention in a natural
process -- and I would suggest that IT needs to prove itself. It shouldn't
need to be proven that "more" blood is better, but that LESS BLOOD is better!
Shouldn't the question be to prove that the baby does NOT need the extra
blood, and that early cord clamping is an improvement over a 2+ million
year evolutionary process?
Why should the burden of proof fall on those who wish to return to the
natural practices of childbirth, rather than to those who have implemented
the (many) interventions without RTC to prove that they are necessary (or
even an improvement of the process)?
So how much more blood is needed to perfuse those system which weren't
essential before birth? Lungs. Certainly the digestive track needs greater
perfusion, liver, etc.
William's obstetrics says, "At term about 3/4s of the total hemoglobin
normally is hemoglobin F. During the first 6-12 months of life, the proportion
of hemoglobin F continues to decrease eventually to reach the low level
found in erythrocytes of normal adults." I can't off hand recall the normal
lifespan of erythrocytes but this to me does not seem a furious pace.
I'm a great one for a spot of comparative physiology. Humans, as far
as I know, are the only placental mammals who routinely clamp the cord.
The practice probably originated with a handy bit of string or something
similar. In most others, birth happens and then the placenta is delivered
sooner or later. (Many bite the cord and eat the placenta - but I can't
think for now what other primates do.)
I don't quite know WHY the practice of cord clamping first started.
Maybe something to do with a very human need to keep busy and "tidy things
up"? Always wondered. But it's amazing just how many students will blithely
write (in their essays about the fetal/adult circulation) something about
the baby being delivered, taking a breath and the cord being clamped -
even for other species!!! - everyone seems to take it completely for granted
that it is done.
Another of the things I'd been wondering about for a very long time
is what is the actual stimulus for a baby to take his/her first breath?
This came to the forefront of some discussions about the safety of waterbirth
and whether the baby would breathe while under the water. There's review
of this topic in Br. J. Obs. Gyn about April 1996 written by Johnson.
I think it's pretty hard to sort this one out because there is often
such a difference between what actually happens at human births and what
might be described as physiological birth. I haven't read the WHO article
Patrick has quoted yet, but there was an earlier one (1985, I think - Having
a baby in Europe) which began by accepting the fact that no-one really
knew what physiological birth is. Because they are rare. Even traditional
birth practices almost always involve some kind of "intervention" in the
strictest sense of the word. So taking a look at what other mammals do
can be one way (and I hasten to add that it's only one way) of looking
at this issue. Homebirth midwives can tell us all a lot I think.
In the normal course of events, the second stage of labour is over and
the newborn is delivered. The next section (without the accompanying diagram
- sorry, but I can't get the computer to include it but you'll find something
similar in most standard textbooks) comes from one of my handouts:
Establishment of Independent Existence
Throughout development in the uterus, the foetal lung and digestive
tract do not function (in terms of ventilation and digestion/absorption
of dietary nutrients) since gaseous exchange and nutrients are provided
from the mother via the placenta. Fig. 2 shows a simplified diagram of
the ante-natal and post-natal circulation. Before birth, pressure is highest
in the foetal pulmonary artery and this determines the direction of blood
flow through the foetus and placenta.
At birth, the sudden inflation of the lung reduces the resistance of
pulmonary vessels and blood flows through them rather than the ductus arteriosus
causing a fall in pulmonary arterial pressure. Cessation of flow to the
placenta increases foetal blood volume, leading to an increase in the pressure
in the systemic circulation. Valves guarding the foramen ovale close and
prevent blood from flowing from the right atrium to the left atrium. The
reversal of pressure gradients further increases blood flow in the pulmonary
artery to boost the supply of blood to the lungs. In addition, the ductus
arteriosus contracts in response to increased pO2 and its closure is complete
within 10-15 hours of delivery. It is not clear how the ductus venosus
closes but this step is essential in completing the transformation from
antenatal to postnatal circulation.
In other words, once the newborn has taken the first breath (probably
the major physiological stimulus for this is the temperature change from
birth canal to air), blood is diverted to the lungs and the systemic circulation
and away from the placenta. And as this "shunt" happens, the cord will
begin to stop pulsating because placental perfusion with fetal blood is
no longer necessary. At this point, whether the placenta is delivered or
not, the newborn has established a greater degree of independence from
the mother and is now breathing air for the first time. And it cannot go
back to the previous existence. Seems a physiological transition of some
significance to me.
Clamping the cord before the newborn has spontaneously taken a breath
and/or before pulsations stop will serve to raise arterial CO2 and the
newborn will become acidotic and hypoxic. Both, in their own ways, powerful
stimuli for breathing. The baby gasps for air.
1. route to the low resistance placental circulation remains patent
providing a safety valve for any systemic raised blood pressure. can be
critical if baby asphyxiated or [preterm as raise pulmonary and central
venous pressures may exacerbate difficulties in initiating resps and accompanying
circulatory adaptation (dunn 1985)
2. shortening of time to placental separation and reduced maternal blood
loss - when cord is left unclamped Botha (1968) demonstrated mean duration
of third stage was reduced from 10.5 to 3.5 mins & blood loss reduced
by half
3. reduction in length of time for the cord to separate postnatally
4. transfusion of full quota of placental blood to the newborn - may
constitute as much as 40% of the circulating volume and therefore is important
in maintaining haematocrit levels
( care should be taken re height at which baby positioned in relation
to mum and effect of gravity on returning blood volume also not to use
oxytocic prior to completion of labour as this may precipitate a strong
uterine contraction with resultant over transfusion to baby).
I attended a birth this morning where the mom birthed a beautiful placenta
with a plump pulsating cord. Does that mean that the baby was stall getting
O2 and nutrients from the mother? A pulsating cord indicates fetal
circulation not a functioning placenta.
I have seen this, too. It sure blew my theory that the baby was
getting O2 as long as the cord pulsed.
Well, it makes sense that a detached placenta won't be getting more
oxygen from the mom, but since the blood in the placenta and cord are already
oxygenated, then the baby is still getting oxygen, even from a detached
placenta.
The baby actually continues to get oxygenated blood from the placenta
even after the cord has stopped pulsing. After all, the pulsing is
the blood moving away from the baby in the two shallow arteries.
The deeper vein apparently remains open even after the cord has stopped
pulsing. There is, in fact, no scientific evidence of when or if
this flow stops. The best thinking is that the baby's body closes
the umbilical vein when the baby's blood volume has reached the right levels.
So, it seems that you can't go wrong leaving the umbilical cord alone
. . . the baby's body will normally do all the right things at the right
times.
As far as "nutrients" go, I think the primary value of the extra blood
volume is the iron (for the next six months) and the fluid (to make up
for low-volume colostrum).
My concerns for c-section babies having violations of immediate cord
clamping done on their pulsating umbilical cords, are the facts that even
c-section babies can have the Lotus Birth, no clamping of the umbilical
cord, ever. The baby can be correctly taken from the womb as a sealed
unti with the placenta and cord still attached. The secret of healthy
babies, whether vaginal born or c-section is a warm room, keeping both
the placenta and cord warm and baby too. This prevents hypothermia,
cold, stopping the flow of blood into the owner/baby. Thus, babies
who had sufficient blood volume and pressure intended to flow through the
lungs, are deprived. They then become the next victims of anemia,
one of the greatest problems of youth today. Starts at birth of blood deprivation
between 4 ounces to 6 ounces of blood denied the baby by the clamp.
Clamps are only necessary for two conditions: (1) a torn cord and (2) placenta
previa. Placenta previa needs an justification why a surgeon cut
through the child's lifeline. It means the surgeon did a horizontal
cut rather then a vertical cut for placenta previa. Likely because he/she
made haste for a c-section birth.
We did a lotus birth and loved it. The placenta is such an amazing organ,
I have a profound new respect for it. We often make plans for our births
but we forget about the how to manage the birth and postpartum of the placenta.
We were amazed how connected and sensitive our little boy was to our placenta.
He released his cord on the fourth day which coincided with the day that
he became grounded on this earth. Lotus birth kept us in bed, the biggest
journey was once from the bedroom to our birthing room for a change of
scenery. It taught us to respect the transition time and incredible changes
that newborns are making as well as giving me time to heal and rest. Lotus
birth provided us with sacred space in which to bond as a family, it brought
a new awareness to both of us. There are many reasons to lotus birth, most
are personal, some are just common sense (like leaving the cord uncut so
that baby can get the vital stem cells that people are choosing to take
out of the cord and store in blood banks). Letting nature work is an incredible
and healing process. We also did placenta prints and on the full moon following
his birth we planted the placenta in a pot with a tumbling rose bush on
top. We kept the cord which sits on our altar. It is an amazing reminder
of how close we needed to be and how close he still needs to be.
Lotus
Birth - A Ritual for our Times, by Sarah
J. Buckley, MD
Umbilical Cord Clamping -- It Seldom,
If Ever, Needs to Done - Lots of great resources at www.lotusbirth.com
A new book, Lotus Birth by Shivam Rachana, has finally been published
in November 2000. For order information, contact her at golden@xtreme.net.au.
LOTUS
BIRTH - What it is all about - It is when you do not cut the baby's
umbilical cord from the placenta. You let it fall off
Cutting the Cord
- Or Not! - Lotus birth
You can read about lotus birth in Sacred
Birthing, Birthing a New Humanity© by Sunni Karll, You can
read more at the Sacred
Birthing web site
The Uncut Cord -
a book by Donna Yemaya (formerly Donna Losoya), and her web page
- Yemaya Lotus Birth
Resources
Some beautiful pictures
of a lotus birth baby.
The above article encourages keeping the placenta as dry as possible.
Other people have told me that keeping the placenta in a casserole dish
with cool water that is regularly refreshed will keep it from smelling
unpleasant. These same folks said that the umbilicus is a muscle
that cuts off the cord on its own. I'm not sure whether they meant
the stemming of blood flow through the blood vessels of the cord or the
entire cord itself.
My midwife keeps the placenta attached for 2 hours following the birth,
she says this is the 'old fashioned' way but it's her practice and her
babies don't lose weight following the birth. After 2 hrs, the umbilicus
atrophies and there is no bleeding. What has everyone else seen?
I've had a thought for my birth - tie the cord and burn the cord with
a candle to severe it. I like that there are no surgical instruments separating
me from my child and I think that burning the cord would actually cauterize
and sterilize it, however I do think there may be some dangers like dripping
hot wax on very delicate new skin and what about the smell of the burning
cord?
A friend of mine, who is also a midwife tried this, burning through
the cord, last year on her own baby. It didn't work very well. The cord
was so thick that it took forever, it sizzled and crackled, the smell was
"interesting", and it was really hard to position everything so that the
baby was protected but the cord wasn't left really long. I think they got
about half way through before they gave up and cut it the rest of the way.
I remember reading in Special Delivery that Rh- moms should have cords
cut immediately.
Might have been. I think that our efforts to protect the baby by clamping
the cord immediately might have contributed to rh-sensitization . I'll
see what some old posts say...
Is there anything we can we do to help protect their babies? We've always
been taught that we should do early cord clamping when expecting an Rh
positive baby from an Rh negative mom -- in order to reduce any 'extra"
blood and antibodies getting to the baby. Probably still a reasonable idea
-- but what about that other end of the cord?
From Guide to Effective Care (etc!) discussing early versus late cord
clamping..... "Allowing free bleeding from the placental end of the cord
reduces the risk of FETALMATERNAL TRANSFUSION, which may be important with
regard to blood group isoimmunization". In other words, let it bleed free
unclamped... This effort to reduce fetomaternal transfusion rather supports
the claim that our routine management of third stage -- immediate clamping,
controlled cord traction, manual removal etc -- may exacerbate blood incompatibility
problems (by creating a higher risk of 'blood mixing"). Comments?
On early cord clamping, "It increases the likelihood of FM TRANSFUSION
as a larger volume of blood remains in the placenta."
yes, that's what GECPC says too. Early cord clamping causes fetal- placental
transfusion. But "we" were taught to clamp early to help the baby avoid
extra maternal antibodies and the extra load which might increase the (potential)
pathological jaundice in an Rh positive baby! But we were "potentially"
increasing the possible sensitization of the mom! As would practicing active
third stage management (early clamping an controlled cord traction)....
Is the best advice to clamp the cord to the baby immediately and open
the maternal end to drain (assuming no undiagnosed second twin!)? Or can
we just assume that if we keep the baby level with the placenta, we can
keep the cord intact and unclamped -- baby will not get any "extra' blood,
and mom won't get any fetal blood? What are others doing?
Stats show no difference in apgars, there are higher hct at later dates
BUT no increase in jaundice in delayed clamped babies (yes, it DOES increase
hct, but not enough to raise the incidence of clinical jaundice ). Check
out Guide To Effective Care Etc.... It does no harm to the baby to delay
cutting the cord....
But, catch this. GTECPG pg 239 "Pre-empting physiological equilibration
of the blood volume within the fetoplacental unit (early cord clamping)
in this way may predispose to retained placenta, postpartum haemorrhage,
FETOMATERNAL TRANSFUSION, and a variety of unwanted effects in the neonate,
respiratory distress in particular."
So there may be some HARM to early cord clamping!
Collecting Cord Blood for Typing - Guide
for Student Midwives By Gloria Lemay
The directions for obtaining the cord blood are usually written and
included in the cord blood collection kit, but are pretty much standardized.
They want you to collect the sample between the birth of the baby and the
delivery of the placenta. I never do that, however, because we do
not cut the cord until after the placenta has birthed. You will obviously
get more blood volume if you collect the sample the way they suggest.
If you delay until after the placenta births, there will be less blood
in the cord vessels, and the venipuncture will be more difficult.
You should wipe the cord Vein with an alcohol wipe, and do a simple venipuncture
as close to the vein insertion at the placenta as possible. Hold
the placenta in a container slightly above you so at least you have gravity
on your side somewhat. I am usually able to get at least 50 c.c.'s
in this manner.
If we need cord blood (usually only for Rh- moms) we get it with a syringe
from the vessels on the fetal side of the placenta. Only once has this
not worked--at my own birth! The vessels were very, very small and collapsed
when the midwife tried to insert the syringe. The cord was very limp by
this time and they couldn't milk any blood out of it by then. This time
we're planning on getting cord blood while the placenta is still attached,
via a syringe in the cord. I have an Rh- mom due right now where I intend
to try this method for obtaining cord blood.
When the woman has had a physiological third stage, you can take the
placenta out of the basin and plop it onto a disposable incontinent pad
on a table. Bring the pad/placenta to the very edge of the table
and allow the cord to hang over for a minute or two with a hemostat on
the end. All the blood that's trapped in the veins on the placenta
will run down and you can get an inch of blood in the bottom of a test
tube easily when you remove the hemostat. You might need to trim
the end of the cord by a half inch.
It was on this list one year ago that I got the hint to use a Vacutainer,
tube, and needle to obtain the cord blood without clamping or cutting the
cord. I have been doing this ever since and it is GREAT!! I always get
the blood I need easily, and I have had NO PPH since beginning this practice.
I have also not had to wait more than 15 minutes for any placenta to deliver
itself.
An alternative is to draw blood from a large vessel in the placenta
using a vacutainer and tube.
I do not cut the cord until after placental delivery - (mostly, I have
waited an hour and half for the placenta and had no
I just looked this up today. In Anne Frye's "Understanding Diagnostic
Tests..." She states that you can draw blood from the still pulsing vessels
with a large syringe. You have to cover the hole you've made with a finger
or blood will spray. Pierce the top of your Vacuum tube with the needle,
and let the vacuum draw the blood out of the syringe. Or, if your syringe
was big enough that you don't need any more blood than you have, you can
remove the stopper from the tube and the needle from the syringe and gently
squirt the blood into the tube. You have to get the blood in the tube right
away before it has a chance to clot.
Obviously, you need an assistant to help with this - or to grow an extra
set of hands.
I use a 50cc beaker to let the blood run into then pour it into the
tubes. I do not do cord bloods on all birth, only Rh- and hx ABO incompatibility.
I have to collect blood too, but I also often cut the cord AFTER the
placenta is out. I just get a 10 cc syringe with an 18 gauge needle and
suck some from one of the veins in the cord. Sometimes have to hit 2-3
veins but no problem getting the blood. I do mostly hospital births.
We are required to get 2 tubes of cord blood to send to the lab. If
you wait until the cord stops pulsating before you clamp and cut, are you
still able to get your cord blood sample?
Don't know about 2 tubes, 1/2 to 1 usually no problem. You can still
draw blood out of the placenta vessels as well as milk the cord.
Yes, I rarely cut the cord until after the birth of the placenta and
routinely draw bloods from the veins close to the body of the placenta
or directly from the veins on the placenta itself.
One of my moms went into labor and I ended up talking them through it
over the phone. She is Rh neg so I knew we needed to get cord blood. I
had them find something similar to a blood tube that we could use. The
dad found a medicine syringe. It worked great! Fortunately the lab techs
were flexible :-)
One other trick for these situations; labs can use a section of cord
for the sample.
Clamp or tie a LOOP of umbilical cord (just double it over and tie it
or put a rubber band tight) then cut from the placenta and put it in a
plastic bag or leakproof container.
This trick saved me once when I was called unexpectedly to a birth with
only my prenatal bag -- no tubes, kelly's etc.
This subsection addresses issues of collecting blood from the umbilical
cord at a waterbirth, both for Rh determination or any other kind of bloodwork,
or for stem cell harvesting/storage.
I have done both but not at the same birth. It's hard enough getting
the routine cord blood specimen at a H2O birth. When you do the cord blood
collection for banking, that's all you do at the birth. You just hope that
mum and baby don't have any problems because you will be "with cord."
One of the main reasons I like the waterbirth is the smoother transition
to extra-uterine life for the baby and it would detract from one of the
most intense moments that life has to offer if you had to drag the new
mother from the tub to try to collect cord blood. I personally think the
two options are mutually exclusive.
I disagree -- I don't think collecting cord blood is that big a deal.
And we do get routine specimens as well. You would probably want
to get her out of the water pretty quickly after the birth, but we do that
anyway. Then just clean off the cord, collect the blood, voila.
Usually, I get the mom out of the water for the birth of the placenta,
and am able then to do venipuncture on the cord for the blood sample, or
just open the clamp (if the cord has completely stopped pulsing and the
cord has been clamped), run the blood into a container and immediately
pass that off to an assistant to collect it into the tubes. I am
not sure here whether you are asking about collecting blood for stem cells
or merely for Blood Group and Rh for RhoGam determination. Stem cell
collection requires a significant amount of blood (about 30 cc.s around
here, but probably varies with the facility). Obviously, you only
need about 3-4 cc.'s for Type, Rh, and Coombs.
Once, I missed the birth by 12 minutes; mom was Rh Negative, and I was
easily able to obtain sufficient blood from the placenta by venipuncture
for the necessary samples.
It is easier to do out of the water than in, I am sure, and I typically
encourage mom to get out of the water for the placenta anyway, for aesthetic
reasons ( even that amount of blood in the water, seems like a whole lot
of blood and makes people nervous!). I keep the birth stool next to the
tub for just that purpose...
Collection of cord blood for stem cells needs to be done immediately
following the birth of the placenta, which needs to be facilitated rather
immediately. I swear I will make a nurse come to do it next time,
because it takes a lot of time, time that should be spent monitoring the
mom and baby and enjoying the holy moment instead of messing around with
cord blood. So anyhow, water birth is cool, but she needs to go to the
bed within a few minutes to get the placenta coming.
I get mom out of tub for placenta -- usually about ten or fifteen minutes
after birth (I think the placenta stage seems more leisurely in waterbirths
-- seems to take a while for contractions to start again after the birth
of the baby). Anyway, I get mom out as the others do, but I much prefer
to move to a chair beside the tub instead of getting her lying down!
Mom gets comfy in her chair, wrapped in blankets cuddling with baby while
we wait for placenta -- which usually seems to come relay quickly after
the mom's movement into an upright position.
Collecting blood for sample is easy with mom in the chair beside the
tub --- seems this might be a good time for doing stem cell collection
(have never done it though).
Don't horse around with needles in a water tub. I usually get
the Mom out of the tub and lying down on a plasticized surface--couch with
shower curtain over it and then thick, warm towels on top of that.
Cord is left alone until the placenta births. After birth of placenta,
in a leisurely fashion, cord is cut by Dad and placenta is taken to kitchen
and plenty of blood can be dripped from the cord into a test tube for Rh
determination. I'm against cord blood collection for stem cells.
I think it's a ridiculous money making scheme with dubious possibility
of benefits.
I have taken cord blood for stem cell preservation, yet never clamp/cut
the cord before it completely stops pulsing, and in some cases not until
after the placenta has birthed. I have to assume that the necessary
volume of blood has already been transferred to the newborn if the placenta
has been discarded by the body!
I think it is possible to use umbilical cord blood for research or storage
purposes without compromising the newborn's volume. Although, the
tendency in the hospital would be to efficiently withdraw the blood before
the cord stops pulsing or the placenta has birthed - you are correct on
that score - especially if there is monetary gain to be made......
In our home births, I believe both purposes could be accomplished.
We have collected stem cells after several water births. The mother
stayed in the tub about 5-10 minutes after the birth then got out to the
birth stool so that we could clamp the cord and insert the syringe into
the cord. It was definitely a quicker exit from the tub than we would advocate
normally, but it was acceptable because the parents knew beforehand that
they were making that choice.
This is from the office of
New
York State guidelines for cord blood banking. Department of Health.
"The collection of cord blood should not result in any deviation from
normal obstetric procedures (e.g. for time of clamping).
"3. In utero (prior to placental delivery) and ex utero (following placental
delivery) collection methods are both acceptable and have comparable efficacy.
Use of a closed or semi-closed system (bag or syringe) by venipuncture
of the umbilical vein under aseptic conditions is recommended.
"a. The collection procedure should present no foreseeable harm for
either the mother or child or compromise the cord blood sample."
I like these guidelines
from the National Marrow Donor Program.
"Cord blood can be collected from the placenta either while the placenta
is still in utero after the cord is clamped and cut and the baby is removed
from the area, or after the placenta has been delivered, referred to as
ex utero"
They talk about waiting until the placenta has been delivered normally
and then collecting the cord blood from what's left. They probably
would prefer that the cord be clamped immediately after the birth, but
they're not explicit about this. I'm glad to see that they're sensitive
to the baby's need for oxygenated blood from the placenta for at least
a few minutes after birth, anyway.
How soon after birth does the cord need to be clamped and/or cut in
order to collect blood from the cord or placenta?
Research is clear that cutting the cord less than five minutes after
the birth deprives the baby of oxygen as it takes some time for successful
completion to newborn circulation. And it also takes the blood away
from the baby, who needs the blood to fill the newly expanded pulmonary
vessels and to re-fill blood vessels elsewhere in the body that were squeezed
during the birth process. In addition, when the cord is clamped/cut too
soon after the birth, the baby is at higher risk for requiring a transfusion
or late-onset newborn anemia.
So, I was wondering whether technology has progressed to the point where
cord blood can be collected later than five minutes after the birth, so
that the baby's well-being is not compromised.
A Rich New Stem
Cell Source: Research on Umbilical Cord Matrix [Kansas State University
- 24-Sep-2004]
"Kansas State University researchers have discovered a novel and potentially
inexhaustible source of stem cells isolated from the matrix of umbilical
cords. These cells have a remarkable propensity to develop into neural
stem cells. . . .The cushioning material or matrix within the umbilical
cord known as Wharton's jelly is a rich and readily available source of
primitive stem cells, according to findings by Troyer and Weiss."
For more about stem cells, see the National Institutes of Health's
Stem
Cell Basics
UK
Experts Warn Against Commercial Cord Blood Banking - (Nov. 19,
2001) - [Medscape registration is fre] "The Royal College of Obstetricians
and Gynaecologists said commercial umbilical cord blood banking, in which
stem cells are stored indefinitely in the hope they might help treat future
illnesses, could not be recommended at present. "
Cord
Blood Banking for Potential Future Transplantation [1/1/07] from the
AAP
The total circulating blood volume in a neonate at birth is 70 - 80
ml/kg birthweight with early clamping and slightly higher with delayed
clamping (Myles). the placenta and cord generally contain 45 ml/kg birthweight.
In absolutely optimal conditions (in other words, not a drop of cord blood
remains in the cord, you would have to have a baby of around 5 to
6 kg to get your "more than a cup" of stem cells.
Cryo-Cell - America's Fastest Growing
Commercial Cellular Storage Company, Offering Affordable Cord Blood Stem
Cell Preservation
Cord Blood Registry - 1-888-CORDBLOOD
Steps
for Collection using the Cord Blood Registry Collection Kit - "Cord
blood should be collected as soon as possible, within 10 minutes of birth.
" and "(To maximize collection from placenta, aspirate cord blood while
placenta remains in utero. In utero collection is also preferred for cesarean
deliveries.) "
For most births, we were able to collect an adequate amount of blood.
The time between birth of baby and birth of placenta had little to do with
the success of the collection. The time between birth of placenta and collection
of the blood had more impact - if we waited too long, the blood clotted
in the vessels. We generally set up a spot to do the collection when getting
set up for the birth so that one of the midwives could be responsible for
getting it started and still be attentive to the needs of the woman or
the other midwife. I sometimes taped the tubing to the cord so I could
just let it flow while doing other things.
I've been reading with great interest the current thread regarding early
vs. late cord clamping, which has brought a question to mind. From reading
that I've done on my own, as well as discussions I've had with birthing
professionals (midwives and OBs), the consensus seems to be that most lean
towards delayed clamping.
My question is this: How does this issue relate to cord blood storage?
It's my understanding that the cord must be clamped as quickly as possible
in order for the procedure to be worthwhile. As a doula, I will undoubtedly
have clients who have some knowledge of cord blood storage, and I want
to be able to inform them of both the pros and cons of the early clamping
that this requires.
I had been approached by a cord blood bank representative prior to the
birth of my first child, and after researching the concept, decided that
I wanted my baby to receive the benefits of her own cord blood, and discussed
this issue with my caregiver. Her cord wasn't cut and clamped until it
ceased pulsating From the information I had at the time, I didn't want
to deprive that particular child of the benefits gained by receiving the
cord blood after birth. Are there any references that anyone can cite stating
the pros and cons of letting the child receive their own cord blood at
birth (delayed clamping) vs. potential benefits to that child (or other
children in the family) by clamping early and storing the cord blood? The
bulk of the information I've found has been from the cord blood storage
companies, and the data was decidedly one-sided, with no tangible references
cited. I don't want to pass on hearsay - I'd love to hear your opinions,
of course, but I would really like to have some concrete data regarding
this topic, so my clients can make truly informed decisions in this matter.
Last week I had a client give birth and she wanted her cord blood collected.
Have you performed this task yourself? Did it take a lot of time, do you
see it interfering with the other needs of the woman and newborn? I am
asking you this because some midwives here are concerned about it and suggest
that a nurse be hired by the couple to draw the cord blood?
I find the stem cell collection process is very 'compatible' with the
majority of hospital deliveries due to the physical set ups and the practice
of routine immediate cord clamping, however, I find that this practice
in a 'active' (H20?), physiologically managed home birth potentially 'intrusive'.
It seems to redirect the energy in a way which is different from the usual
focus. I make a point of using 'informed consent' when parents request
this service by reminding them that my first responsibility is to mom and
baby and that I will not guarantee collection if my attention is demanded
elsewhere.
Some midwives are concerned about the risks to them of using a
very large bore hollow needle to do a venipuncture on the cord. Some
practices are now declining to recommend or encourage for-profit cord blood
donation, and will not provide any literature on it to any of their clients.
Being a doula, I have not personally done this, but have been present
when it was done. The collection is a simple procedure. After cord is cut
(1-2 min max after delivery) and baby is removed, a supplied alcohol prep
pad swabs a site near the end of the cord and a syringe that contains heparin
is inserted in the site on the umbilical vein and the blood is slowly extracted.
This is repeated twice more, once about 1/2 way down the cord and again
close to the placenta. 40CCs is considered a good collection, and I know
that in at least one case, almost 200ccs was extracted. It's simple, over
in a couple of minutes and then the whole kit goes to dad who is responsible
for sending it to the storage facility.
This procedure takes only about 5 minutes total. Usually a nurse handles
the collection in a hospital setting while the doctor or midwife deals
with the mother and baby.
This seems a little extreme to hire a nurse to do the draw. Even the
dad could do it with a little instruction. I have seen nurses do it after
the placenta is removed in a c/s. I could do it. It's really not a tough
thing. Several of the midwives I know who do the procedure leave their
assistant to do the collection if there is a reason for them to be VERY
busy with mom and baby. Otherwise, it can be done with the baby on mom's
tummy while waiting for the placenta to be delivered.
How many of you are getting requests about saving cord blood for stem
cell storage for future bone marrow transplants? We have had a few ask
about it (home birthers, too) and we got the literature. It seems very
daunting...you need to collect about 150 cc, be absolutely sterile, etc.
etc. No cord pulsing for sure. The potential for liability around this
is incredible IMHO....what if the specimen gets contaminated? You've only
got the one chance to get the blood.
Actually the procedure is really not terribly difficult. As a Cord Blood
Educator for the Cord Blood Registry, I can assure you it is a simple procedure
and I have personally been present to see it done. The cord may be pulsing
or not. The sterilization process is simply using a sterile needle and
heparined syringes (provided in the kit) and wiping off the insertion points
with an alcohol swab. There is no liability to the health care professional
doing the phlebotomy and if the specemin is not usable, the couple does
not have to pay the storage facility anything beyond the 1 time family
registration fee.
There are several forms the health care provider gets from CBR. One
is a form absolving the health care professional of liability. Another
is a form that documents that the family got information on the procedure
and whether they elected to do it or not (in case they need it later and
want to charge the health care provider that they never got the information
indicating that they could have this collected). Other material indicated
the survival rate in related transplants vs. unrelated transplants and
the relative costs, diseases that are currently being treated with cord
blood stem cells, and other pertinent information. There are a couple of
videos available if you want to use them in your practice and CBR will
provide them for free. These are currently being redone to reflect a change
in the collection procedure because the heparin is no long already in the
syringes when the collection kit is received.
Information package that we got from a Vancouver BC company stated that
the cord had to be clamped within 15 seconds of the birth.
No offense, but with all the other things that I am required to do informed
choice discussions on (Maternal Serum Screening, Group B strep swabbing,
home Vs hospital, pain relief, etc., etc., etc., etc.)...this is going
to be one more thing that I am going to have to discuss, whether parents
wish to talk about it or not.
I still feel that "simple" or not, it can be difficult to obtain the
amount of blood that our information told us we were to obtain...this,
plus cord blood for group and type, cord blood for gases (which is routinely
required in some hospitals). I've seen it difficult enough to get routine
cord bloods...let alone everything else!!!
I recently attended a lecture presented by an RN who works for a cord
blood collection/storing company. A major part of her job is talking to
hospital lawyers about liability. The woman consenting to cord blood banking
signs a consent form that releases the hospital, physician or midwife of
any liabilities surrounding the collection and handling of the cord blood.
The company is Cord Blood Registry. For an info packet, containing studies,
a sample consent form, a pamphlet to put in your office for clients, and
a video of the correct collection procedure, call:
The presenter stressed that they need 60 to 150 cc of blood, although
any sample should be sent because they were able to save 30cc once. The
client is responsible for bringing the kit to the birth with heparinized
syringes and instructions for collection. She is also responsible for the
blood once it has been collected. It gets FedExed to the Cord blood Registry.
The studies in the packet are: Sugarman, Reisner, & Kurtzberg. (1995)
Ethical Aspects of Banking Placental Blood for Transplantation. JAMA, Vol.274,
No. 22
Wagner et al. (1995) Allogeneic sibling umbilical-cord-blood transplantation
in children with malignant and non-malignant disease. The Lancet, Vol.
346, No. 8969, pp.214-219.
We've gotten several requests from clients to donate when they show
up at the hospital, and we didn't know anything about it. But it has to
be set up months in advance between the client and the company. It's a
good thing to talk about during prenatal visits so they can decide and
have time to arrange it.
We saved cord blood for the baby's own use (as well as siblings) but
we definitely did NOT cut the cord early! Not at all. You can still do
it after cord stops pulsing!
Wow! I am so impressed. There certainly is some blood left
in the cord and placenta after the baby gets everything it needs, but this
is the first time I've heard this fact used for the baby's benefit.
Every time I've heard anyone talking about getting cord blood for stem
cells, they've mentioned the "need" to clamp/cut early. I've heard the
time for clamping/cutting as being between 15 seconds and 1-2 minutes max.
I worked with CBR for 2 years. I found it quite controversial with many
on the subject of clamping and cutting. On the other hand, I have heard
heartwarming stories of children being successfully treated with their
sibling's cord blood when they couldn't find a bone marrow match. Medically
there are many benefits to cord blood over bone marrow and with anything
there are advantages and disadvantages. It is important for families to
discuss these issues in detail with their health care provider to determine
what is their best option in their individual circumstance.
As for the instructions that come with CBR's collection kit, it states
"as soon as possible". It is up to the family and the doctor to determine
what that time frame is. I really am not sure of the collection procedures
for other companies. I am sure they are basically the same. The biggest
difference in the cord blood companies is their storage methods and price.
The mission of Lamaze Publishing and iVillage is to bring important
medical information to expectant parents. I have stored both of my
children's Cord blood and am proud to join them in this effort. Together
it is our hope that someday the collection of cord blood from every newborn
will become a routine procedure.
It is my hope that someday newborns will not be asked to be blood donors.
According to the Red Cross, "To give blood, you must be healthy, at least
17 years old, and weigh at least 110 pounds." Most babies at birth
are unstable, 0 minutes old and weigh less than 10 pounds.
"Cord blood" is a euphemism for "your baby's blood". It belongs
in your baby's body, which is where it would naturally flow if the process
weren't interrupted. If you wouldn't let someone take blood from
your baby's arm, don't let them take blood from your baby's umbilical cord
because it's heading towards the arm.
Donation of "cord blood" and premature cutting of the umbilical cord
both carry some serious risks:
Fetal Circulation
Advises Against Early Umbilical Cord Clamping
Kauai, Hawaii
Dr. M. Jeffrey Maisels
Vol 19, No 24
Advises Not to Clamp Cord Immediately
Dublin, Ireland
Fetal Iron Stores
Physiologic jaundice is not an illness, it is an adaptation of the newborn
to provide for iron stores!!! Pathologic jaundice is a problem, and I do
think it should be treated, and that it is important to differentiate the
two types of jaundice (yes I know there are others...) But... There is
no research that shows that physiologic jaundice in a term newborn without
other health problems, (i.e. sepsis) can cause kernicterus. Taking bili
levels just makes the practitioner have to treat because no one will randomize
newborns in a real trial to see, just in case... Is there a positive coombs?,
is there evidence of sepsis? is the baby lethargic, is the baby dehydrated?
is the baby feeding well? If the answers are no,no,no,no,yes... there would
be no action taken. I think that delayed cord clamping increases blood
volume to the newborn, thereby "causing" jaundice as the baby set aside
beneficial iron stores.
Pisacane A
BMJ 1996 Jan 20;312(7024):136-7
estimated volume of placental transfusion varies from 20%-60%
of the existing blood volume (54-160 ml) depending on the time of clamping
and the position in which the infant is held before clamping. Linderkamp
and colleagues estimated that the amount of placental transfusion is 35
ml/kg of birth weight when term infants are kept at the level of the vaginal
opening and the cord is clamped 3 minutes after birth. The same authors
have recently investigated placing the neonate in the mother's abdomen
and clamping the cord only once it stops pulsating....They found that these
babies had blood volumes 32% higher than babies whose cords were clamped
immediately after birth.
There were a bunch of other studies on prevention of iron deficiency anemia
in kids in 3rd world countries (Guatemala) and benefits of delayed cord
clamping in preemies. My medline review did not find any major problems
with delayed cord clamping....there is some hyperviscosity and decreased
lung compliance, but this seems to be overcome by the benefits of increased
iron stores.
"The estimated prevalence of iron deficiency was greatest among 1-
to 2-year-old toddlers (7%) "
Pre-empting physiological equilibration of the blood volume
within the fetoplacental unit (early cord clamping) in this way may predispose
to retained placenta, postpartum haemorrhage, FETOMATERNAL TRANSFUSION,
and a variety of unwanted effects in the neonate, respiratory distress
in particular.
So the evidence seems to demonstrate HARM in our American routines of immediate
cord clamping! Unless someone can document benefits, then I think it's
far past time to abandon the practice!
A pulsating cord ONLY indicates that the baby has a beating
heart and a stable blood pressure. Oxygenation is contingent upon gases
diffusing across the placental membrane.
I'm confused! :)
The advantage to not cutting the cord quickly is that the baby
gets more of his blood
And so, as long as it is still there, there's always the possibility that
whatever O2 is in the umbilical vein can get back to the baby as long as
his/her heart is beating adequately to maintain enough pressure for blood
to return to the baby's circulation. Isn't that what others have been using
as their argument against cord amputation?
Once the uterus has been significantly reduced in size, the
placenta starts to buckle, and placental function goes down.
Yes, I think size is part of it; but it's the arterial pressures in the
baby that change immediately after it's taken a first breath. At the same
time, oxytocin makes the uterus contract and the "living ligatures" around
the uterine blood vessels stop the flow of blood on the maternal side.
Either way it alters the pressure differences across the placenta and then
it starts to peel away and fold down.
A drowning person has a strong pulse for a period of time;
but he ultimately dies from anoxia.
True, but in a drowning person, the lungs have already been inflated and
alveoli can become filled with water - then the concentration gradient
is no longer maintained and O2 can't diffuse across the alveolar membrane.
Anoxia will follow. In a baby, if the lungs haven't yet inflated - different
situation.
There has been more then a few underwater birthed babes that
have required resuscitation because they were left under water till the
cord stopped pulsating.
The problem in those situations seems to have been exactly that; the babies
were left under the surface for far too long. Guidelines in this country
from the Royal College of Midwives is to bring the baby to the surface
IMMEDIATELY. Babies should NOT be left under the water.
He says that clotting is a minor factor and not really important in stopping
cord circulation (reminds us that blood is often fluid in the cord for
some time after birth -- and a GOOD THING too or we would have a hard time
getting those late cord blood samples,!!
In air the bleeding from the vessels stops more quickly than in water
of the same temperature. "Their severed ends may receive an additional
stimulus to contracture in air by direct contact with the oxygen of the
atmosphere; air also makes for a rapid decline in temperature".
The text "Physiology of The Newborn Infant" references much
work which is unduplicatable now -- for obvious ethical reasons.
Delayed Clamping/Cutting
See also: Spiritual Issues - the poem
Umbilicus
Cord Cutting - Round 2
Cord Cutting - Round 3
Delayed Cord Cutting in a Cesarean Birth
Lotus Birth - Really Delayed Cord Cutting
when it is ready.
Burning the Cord Instead of Cutting
Early Cord Clamping - Rh Negative
Collecting Cord Blood for Testing Baby's Blood
problem getting cord blood (1 Vacutainer) off the fetal placental surface
aiming from the cord entry site down the blood vessels toward the outside
of the placenta.
Collecting Cord Blood at a Waterbirth
When to Clamp the Cord When Collecting Cord Blood for
Stem Cell Storage or Donation
Linden JV, Preti RA, Dracker R.
J Hematother. 1997 Dec;6(6):535-41.
A number of private for-profit companies have been established
that encourage parents to bank their children’s cord blood for their own
autologous use or for directed donor allogeneic use for a family member
should the need arise. Parents have been encouraged to bank their infants’
cord blood as a form of "biological insurance." Physicians, employees,
and/or consultants of such companies may have potential conflicts of interest
in recruiting patients because of their own financial gain. Annual disclosure
of the financial interest and potential conflicts of interest must be made
to institutional review boards that are charged with the responsibility
of mitigation of these disclosures and risks. Families may be vulnerable
to the emotional effects of marketing for cord blood banking at the time
of birth of a child and may look to their physicians for advice. No accurate
estimates exist of the likelihood of children to need their own stored
cord blood stem cells in the future. The range of available estimates is
from 1 in 1000 to more than 1 in 200000.51 The potential for children needing
their own cord blood stem cells for future autologous use is controversial
presently.51 There also is no evidence of the safety or effectiveness of
autologous cord blood stem cell transplantation for the treatment of malignant
neoplasms.51 Indeed, there is evidence demonstrating the presence of
DNA mutations in cord blood obtained from children who subsequently develop
leukemia.52 Thus, an autologous cord blood transplantation might even be
contraindicated in the treatment of a child who develops leukemia.
Delayed Clamping with Cord Blood Collection
For delayed clamping and cutting (and yes, it could be as delayed as post
birth of the placenta), we cleansed the surface of the placenta and put
the needle of a blood transfusion collection set directly into one of the
big vessels - usually at the cord implantation site. The rest is easy -
put the bag lower than the placenta and let gravity and the vacuum in the
bag do the rest of the work.
1-888-CORD-BLOOD
(1-888-267-3256)
From a Cord Blood Educator:
They usually do clamp and cut the cord early BUT it depends on the family's
preference and the doctor doing the collection. If the family is doing
the collection out of need for stem cells (for the baby's sibling or mother),
they almost always clamp and cut early to guarantee an adequate collection,
for families collecting it "just in case" many delay.
If there is an acute need for your newborn to donate blood to a member
of your family who is deathly ill and known to be a suitable recipient,
this may offset the risks to your baby. It's hard to imagine many other
good reasons for stealing a newborn's blood before it's even breathing
on its own.
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