Cutting the Umbilical Cord: How Long Should You Wait?

For decades, clamping and cutting the umbilical cord within 30 seconds of birth was considered to be standard practise, especially in hospital settings (Gruneberg and Crozier 2015).

Today, however, following extensive research, the practice of immediate clamping is thought to carry potential risks and has largely been replaced by the practice of delayed cord clamping (DCC), unless there is an urgent need for intensive resuscitation (My Expert Midwife 2020).

Does Early Cord Clamping Cause Harm?

Downey and Bewley (2012) reflect on the fact that the suggested benefits of early clamping have changed in recent years in line with new research findings.

Yet, even though the benefits that were once thought to accompany early clamping have been proved to be irrelevant or false over time, the strong influence of tradition and the modern practise of umbilical cord blood banking has meant that immediate or early clamping still remains popular in many hospitals.

Particular concerns about early cord cutting are centred around increased risk of anaemia, and in the premature infant, an increased risk of intraventricular haemorrhage and respiratory complications (Downey and Bewley 2012).

In practice, one of the key drivers for early cord clamping is to make urgent resuscitation easier, should it be needed.

Yet Gruneberg and Crozier (2015) argue the opposite, suggesting that the benefits of delayed cord clamping apply as much, if not more, to the non-breathing baby.

To the question ‘does early cord clamping cause harm?’ they point out the following:

• Early cord clamping can cause bradycardia and create a need for resuscitation.
• Invasive measures such as drugs and volume expanders are not required as frequently when delayed cord clamping is practised.
• Allowing the placenta to perform its role in the resuscitation means that oxygen supply continues, despite the failure to achieve effective respiration immediately.

It’s also interesting to note that historically, leaving the cord intact until it had finished pulsating was considered beneficial, as this quote from Charles Darwin’s grandfather, a doctor practising in 1801, reveals:

'Very injurious to the child is the tying of the navel string too soon. It should be left till all pulsation in the cord ceases. Otherwise the child is much weaker than it ought to be, a portion of the blood being left in the placenta, which ought to have been in the child.'

(My Expert Midwife 2020)

Benefits of Delayed Cord Clamping

The World Health Organisation defines the optimal time to clamp and cut the cord as when it has stopped pulsating, which can be about three minutes or longer after birth.

They also specifically state that delayed umbilical cord clamping of at least one minute after birth is related to improved infant health outcomes (WHO 2014).

It’s a recommendation that’s now also supported by the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, and the National Institute for Clinical Excellence in the UK.

Key Points

Ibrahim et al. (2017) note that some of the most important benefits to the baby of delayed cord clamping are:

• Increased blood volume.
• Decreased iron deficiency anaemia.
• Increased total iron stores by over 50% at 6 months of age.

These potentially valuable effects are thought to extend beyond the neonatal period and include improvements in long-term neurodevelopment (Ibrahim et al. 2017).

As Hutton and Hassan (2007) report, delaying clamping of the umbilical cord in full-term neonates for a minimum of two minutes offers benefits extending into infancy. Even though there was an increase in polycythemia among infants in whom cord clamping was delayed, this condition appeared to be benign and easily managed.

Gruneberg and Crozier (2015) also support delayed cord clamping and comment on the fact that early clamping, before initiation of respiration may cause a reflex bradycardia and increase the need for resuscitation.

They add to the list of benefits with the following points:

• Maintaining cord integrity allows the placenta to fulfil its respiratory function, providing a continued source of oxygen to a non-breathing baby.
• The prevention of hypovolaemia achieved through delayed cord clamping is especially important for preterm babies.
• The increased blood volume from delayed cord clamping leads to a decreased need for drug therapy and volume expanders, reversing bradycardia and restoring blood pressure.
• If needed resuscitation can begin while maintaining cord integrity.

Delayed Cord Clamping in the Premature Infant

One of the primary concerns about delayed cord clamping has been that waiting more than 30 seconds might prevent some of the sickest babies from receiving urgent resuscitation.

It’s a concern reflected in recent research suggesting that as many as 25% of babies needing resuscitation did not receive delayed clamping of the cord (Katheria 2018).

Despite this, recent reviews from ten randomised trials found that a delay of cord clamping time of at least 30 seconds stabilises the circulatory system during the first day of life, leading to less requirement for volume therapy and transfusion.

Delayed cord clamping also decreased the incidence of intraventricular haemorrhage, and improved neurodevelopmental outcomes (Rabe et al. 2011).

Ibrahim et al. (2017) add that several studies have reported that delayed cord clamping can reduce the risk of intraventricular haemorrhage (IVH) and necrotizing enterocolitis in preterm babies and was found to be both safe and feasible in infants with congenital heart disease.

Umbilical Cord Milking

An alternative method that can provide newborns with the necessary additional blood volume is umbilical cord milking (UCM).

It’s a simple technique, performed by gently grasping the uncut umbilical cord and squeezing several times from the placenta towards the infant. In contrast to delayed cord clamping, milking provides a placental transfusion without postponing resuscitation and can be completed as quickly as immediate cord clamping.

Ibrahim et al. (2017) suggest that this can be an efficient method of improving blood volume, particularly in premature infants who may need resuscitation as well as infants delivered by caesarean section.

It’s been suggested that milking the cord four times immediately after birth achieved a similar amount of placenta-fetal blood transfusion compared to delaying clamping the cord for 30 seconds. However, further studies are needed to assess the effect of cord milking on long-term outcomes (Rabe et al. 2011).

Conclusion

Is it time for a more liberal approach to delaying the clamping and cutting of the umbilical cord?

McDonald et al. (2013) suggest that it is, particularly in the light of growing evidence that delayed cord clamping increases early haemoglobin concentrations and iron stores in infants. As long as phototherapy is readily available should jaundice develop, they conclude that delayed cord clamping is overwhelmingly beneficial.

Perhaps as Gruneberg and Crozier (2015) suggest, it may be time for practitioners to put physiology before technology and move away from immediate routine removal for resuscitation, so as not to cause further compromise to the non-breathing baby.

They also suggest that with advances in the development of resuscitation equipment bedside resuscitation is becoming more common, making it easier to delay clamping and cutting of the cord for those precious extra seconds.

References

• Downey, C and Bewley, S 2012, 'Historical Perspectives on Umbilical Cord Clamping and Neonatal Transition', Journal of the Royal Society of Medicine, [online] 105(8), pp.325-329, viewed 27 January 2020, https://journals.sagepub.com/doi/full/10.1258/jrsm.2012.110316
• Gruneberg, F and Crozier, K 2015, 'Delayed Cord Clamping in the Compromised Baby', British Journal of Midwifery, [online] 23(2), viewed 27 January 2020, https://ueaeprints.uea.ac.uk/id/eprint/57561/1/bjom.2015.23.2.pdf
• Hutton, E and Hassan, E 2007, 'Late vs Early Clamping of the Umbilical Cord in Full-term Neonates', JAMA, [online] 297(11), p.1241, viewed 27 January 2020, https://jamanetwork.com/journals/jama/article-abstract/206143
• Katheria, A 2018, 'Umbilical Cord Milking: A Review', Frontiers in Pediatrics, [online] 6, viewed 27 January 2020, https://www.frontiersin.org/articles/10.3389/fped.2018.00335/full
• Ibrahim, N, Sukkarieh, H, Bustami, R, Alshammari, E, Alasmari, L and Al-Kadri, H 2017, 'Current Umbilical Cord Clamping Practices and Attitudes of Obstetricians and Midwives Toward Delayed Cord Clamping in Saudi Arabia', Annals of Saudi Medicine, [online] 37(3), pp.216-224, viewed 27 January 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6150582/#!po=73.0769
• McDonald, S, Middleton, P, Dowswell, T and Morris, P 2013, 'Effect of Timing of Umbilical Cord Clamping of Term Infants on Maternal and Neonatal Outcomes', Cochrane Database of Systematic Reviews [online], viewed 27 January 2020, https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004074.pub3/full
• My Expert Midwife 2020, What is Delayed Cord Clamping?, [online] My Expert Midwife, viewed 27 January 2020, https://myexpertmidwife.com/blogs/my-expert-midwife/what-is-delayed-cord-clamping
• Rabe, H, Jewison, A, Fernandez Alvarez, R, Crook, D, Stilton, D, Bradley, R and Holden, D 2011, 'Milking Compared With Delayed Cord Clamping to Increase Placental Transfusion in Preterm Neonates', Obstetrics & Gynecology, [online] 117(2, Part 1), pp.205-211, viewed 27 January 2020, https://journals.lww.com/greenjournal/Fulltext/2011/02000/Milking_Compared_With_Delayed_Cord_Clamping_to.2.aspx
• World Health Organization (WHO) 2014, Delayed Umbilical Cord Clamping for Improved Maternal and Infant Health and Nutrition Outcomes, WHO, [online] viewed 27 January 2020, https://apps.who.int/iris/bitstream/handle/10665/148793/9789241508209_eng.pdf;jsessionid=19C6C40ADBA2E66D46F1DE5B95DAECAC?sequence=1