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Home > Obstetrics, Rants and Raves > Delayed Cord Clamping Should Be Standard Practice
in Obstetrics
Delayed Cord Clamping Should Be Standard Practice
in Obstetrics
December 3, 2009 Nicholas Fogelson Leave a comment Go to comments
There are times in our medical careers where we see a shift in thought that leads to a
completely different way of doing things. This happened with episiotomy in the last few
decades. Most recently trained physicians cannot imagine doing routine episiotomy with
every delivery, yet it was not so long ago that this was common practice.
Episiotomy was supported in Medline indexed publications as early as the 1920s(1), and
many publications followed in support of this procedure. But by as early as the 1940s,
publications began to appear that argued that episiotomy was not such a good thing(2). Over
the years the mix of publications changed, now the vast majority of recent publications on
episiotomy focus on the problems with the procedure, and lament why older physicians are
still doing them (3) (4). And over all this time, practice began to change.
It took a long time for this change to occur, and a lot of data had to accumulate and be
absorbed by young inquisitive minds before we got to where we are today, with the majority
of recently trained OBs and midwives now reserving episiotomy only for rare indicated
situations.
Though this change in episiotomy seems behind us, there are many changes that are ahead of
us. One of these changes, I believe, is in the way obstetricians handle the timing of cord
clamping.
For the majority of my career, I routinely clamped and cut the umbilical cord as soon as it was
reasonable. Occasionally a patient would want me to wait to clamp and cut for some
arbitrary amount of time, and I would wait, but in my mind this was just humoring the patient
and keeping good relations. After all, I had seen all my attendings and upper level residents
clamp and cut right away, so it must be the right thing, right?
Later in my career I was exposed to enough other-thinking minds to consider that maybe this
practice was not right. And after some research I found that there was some pretty
compelling evidence that indeed, early clamping is harmful for the baby. So much evidence
in fact, that I am a bit surprised that as a community, OBs in the US have not developed a
culture of delayed routine cord clamping for neonatal benefit.
I think that this is a part of our culture that should change. This evidence is compelling
enough that I feel like a real effort should be made in this regard. So to do my part in this, I
am blogging about it.
As this is Academic OB/GYN, of course I am going to lay out this evidence I speak of. But
before I do that, I want to present some logical ideas under which this evidence ought to be
considered.
Prior to the advent of medical delivery, and for all time in animals, it has been the natural way
of things for a baby to stay on the umbilical cord for a significant period of time after
delivery. Depending on culture and situation, the delay in cord separation could be a few
minutes or even a few hours. In some cultures the placenta is left on for days, which of
course I find excessive and gross (5). But whatever the culture and time on cord, the absence
of immediate cord clamping allows fetal blood that was previously in the placenta to transfuse
back into the baby. Studies have demonstrated that a delay of as little as thirty seconds
between delivery and cord clamping can result in 20-40 ml*kg-1 of blood entering the fetus
from the placenta (6).
Considering this data, I have to think about evolution and function. I am a strong believer in
evolution, but even under creationist thinking I have to believe that if the system meant for
babies to have been phlebotomized of 50-100 cc of blood at birth, we would have been born
with higher hemoglobins. Clearly the natural way of things is for this not to happen.
So does this mean that early cord clamping is necessarily harmful? Absolutely not. But what
it means is that the burden of proof is on us to prove that early cord clamping, which amounts
to planned fetal phlebotomy, is a beneficial thing. Otherwise, all things being equal we ought
to give the tykes a few minutes to soak up what blood they can from the placenta before we
cut’em off.
So the question is whether or not there is strong data either way.
It is easy to imagine a randomized study of immediate vs. delayed cord clamping, with
quantitative analysis of fetal lab values and clinical outcomes. So easy in fact, that it has been
done many times – and in just about every study, there is a clear benefit to delaying cord
clamping, even if it is just for 30 seconds after delivery. These benefits include important
outcomes such as decreased rates of intraventricular hemorrhage and necrotizing enterocolitis
in preterm neonates. Furthermore, aside from some intermittent reports of clinically
insignificant polycythemia and hyperbilirubinemia in term infants, there appears to be no
harm that can be linked to delayed cord clamping. It feels like being a doctor 10-15 years ago
looking to see if there is any data about episiotomy, and finding that there’s a lot, and it says
we’ve been doing it wrong for awhile now.
So here’s the data:
Delayed cord clamping in very preterm infants reduces the incidence of intraventricular
hemorrhage and late-onset sepsis: a randomized, controlled trial(7)
Randomized 72 VLBW infants (< 1500 grams) to immediate or delayed cord clamping (5-10
vs. 30-45 seconds). Delayed cord clamp infants had significantly less IVH (5/36 in delayed
group vs. 13/36 in immediate group, p = 0.03) and less late onset sepsis (1/36 vs. 8/36, p =
0.03).
The Influence of the Timing of Cord Clamping on Postnatal Cerebral Oxygenation in
Preterm Neonates: A Randomized, Controlled Trial (8)
Randomized 39 preterm infants to immediate clamping vs. 60-90 second delay, and examined
fetal brain blood flow and tissue oxygenation. Results showed similar blood flow between
groups, but increased tissue oxygenation in the delayed group and 4 and 24 hours after birth.
Effect of timing of umbilical cord clamping on iron status in Mexican infants: a
randomized controlled trial(9)
Randomized 476 infants to immediate or 2 minute delayed clamping and followed them for 6
months. Delayed clamped babies had higher MCVs (81 vs. 79.5), higher ferritins (50.7 vs.
34.4), and higher total body iron. Effects were greater in infants born to iron deficient
mothers. Delayed clamping increased total iron stores by 27-47mg. A follow up study
showed that lead exposed infants with delayed clamping also had lower serum lead levels
than immediate clamped infants, likely due to iron mediates changes in lead absorption.
A randomized clinical trial comparing immediate versus delayed clamping of the
umbilical cord in preterm infants: short-term clinical and laboratory endpoints(10)
Infants delivering at 30 to 36 weeks gestation randomized to immediate vs. 1 minute delay.
Delayed group had higher RBC volumes (p = 0.04) and hematocrits (p < 0.005), though there
was no difference in RBC transfusions. There was a small increase in babies requiring
phototherapy in the delayed group (p = 0.03) but no difference in bilirubin levels between
groups.
Immediate versus delayed umbilical cord clamping in premature neonates born < 35
weeks: a prospective, randomized, controlled study (11)
Randomized 60 infants to clamping at 5-10 seconds vs. 30-45 seconds. Delayed clamping
infants had higher BPs and hematocrits. Infants < 1500 grams with delayed clamping needed
less mechanical ventilation and surfactant. Trend towards more polycythemia in delayed
group, but not statistically significant.
And that’s just some of it. I’ll be happy to send you an Endnote file with a pile more of you’d
like it. If the burden of proof is on us to prove that immediate clamping is good, that burden
is clearly not met. And furthermore, there is strong evidence that delaying clamping as little
as 30 seconds has measurable benefits for the infant, especially in premature babies and
babies born to iron deficient mothers.
So basically, we should be doing this. I’m going to try to effect some change in my
department, but there are a lot of things that need to happen for us to change as a general
culture. It can’t just be the OBs. L and D nurses and pediatricians need to buy in as well.
Some people will argue that premature babies need to be brought to the warmer right away for
resucitation. I don’t know the answer to this, but it’s worth study. One might think that it is
important to intubate a very premature baby right away, but I have to wonder if that intact
cord will be better at delivering oxygen to the baby for 30-60 seconds than the premature
lungs. Particularly in cases of fetal respiratory acidosis, there is strong logical argument that a
baby might be better resuscitated by unwrapping the cord and letting it flow a bit than trying
to oxygenate it through its lungs. Until that placenta is detached, you have a natural ECMO
system. Why not use it? Certainly there are exceptions to this logical argument, abruption
being the biggest one, and perhaps even severe pre-eclampsia and other poor feto-maternal
circulation states.
I wonder at times why delayed cord clamping has not become the standard already; why by
and large we have not heeded the literature. It is sad to say that I believe it is because the
champions of this practice have not been doctors, but midwives, and sometimes we are
influenced by prejudice. Clearly, midwives and doctors tend to have some different ideas
about how labor should be managed, but in the end data is data. We championed evidence
based medicine, but tend to ignore evidence when it comes from the wrong source, which is
unfair. It is fair to critique the research and the methods used to write it, but it shouldn’t
matter who the author is. In this case, Mercer and other midwives have done the world a
favor by scientifically addressing this issue, and their data deserves serious consideration.
To quote Levy et al (12) “Although a tailored approach is required in the case of cord
clamping, the balance of available data suggests that delayed cord clamping should be the
method of choice.” We ought to heed this advice better. Like episiotomy, this change in
practice may take awhile, but we should get it started. I’m going to work on it myself. How
about you?
1.
Martin DL. The Protection of the Perineum by Episiotomy in Delivery at Term. Cal
State J Med 1921 Jun;19(6):229-31.
2.
Barrett CW. Errors and evils of episiotomy. Am J Surg 1948 Sep;76(3):284.
3.
Rodriguez A, Arenas EA, Osorio AL, Mendez O, Zuleta JJ. Selective vs routine
midline episiotomy for the prevention of third- or fourth-degree lacerations in nulliparous
women. Am J Obstet Gynecol 2008 Mar;198(3):285 e1-4.
4.
Gossett DR, Su RD. Episiotomy practice in a community hospital setting. J Reprod
Med 2008 Oct;53(10):803-8.
5.
Westfall R. An ethnographic account of lotus birth. Midwifery Today Int Midwife
2003 Summer(66):34-6.
6.
Weeks A. Umbilical cord clamping after birth. Bmj 2007 Aug 18;335(7615):312-3.
7.
Mercer JS, Vohr BR, McGrath MM, Padbury JF, Wallach M, Oh W. Delayed cord
clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and
late-onset sepsis: a randomized, controlled trial. Pediatrics 2006 Apr;117(4):1235-42.
8.
Baenziger O, Stolkin F, Keel M, von Siebenthal K, Fauchere JC, Das Kundu S, et al.
The influence of the timing of cord clamping on postnatal cerebral oxygenation in preterm
neonates: a randomized, controlled trial. Pediatrics 2007 Mar;119(3):455-9.
9.
Chaparro CM, Neufeld LM, Tena Alavez G, Eguia-Liz Cedillo R, Dewey KG.
Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomised
controlled trial. Lancet 2006 Jun 17;367(9527):1997-2004.
10.
Strauss RG, Mock DM, Johnson KJ, Cress GA, Burmeister LF, Zimmerman MB,
et al. A randomized clinical trial comparing immediate versus delayed clamping of the
umbilical cord in preterm infants: short-term clinical and laboratory endpoints. Transfusion
2008 Apr;48(4):658-65.
11.
Kugelman A, Borenstein-Levin L, Riskin A, Chistyakov I, Ohel G, Gonen R, et al.
Immediate versus delayed umbilical cord clamping in premature neonates born < 35 weeks: a
prospective, randomized, controlled study. Am J Perinatol 2007 May;24(5):307-15.
12.
Levy T, Blickstein I. Timing of cord clamping revisited. J Perinat Med
2006;34(4):293-7.
Possibly related posts: (automatically generated)
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Grassroots Network: Delayed Cord Clamping
Cord clamping
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Categories: Obstetrics, Rants and Raves
Comments (65) Trackbacks (6) Leave a comment Trackback
1.
Amy Romano
December 3, 2009 at 6:15 am | #1
Reply | Quote
I couldn’t be happier to see this post. I agree that the evidence is about as clear as you
can ask for, but we’re far from having delayed clamping be the standard of care. I
hang around enough blogs and online communities to know that many women face
push-back or outright refusal by OBs when they ask for delayed clamping, so it’s great
to have a rational, evidence-based OB source to send these women to.
I appreciate the hat-tip to midwifery researchers. I’ll be the first to admit that not all
midwives know, understand, or follow evidence. But there are some truly brilliant
academic midwives out there whose work should be changing practice but is not
because of preconceived notions of what constitutes the “right” evidence. Thanks for
doing your part to reverse that bias.
Prepare for the onslaught of natural birth advocates! I’m posting this on Facebook and
Twitter.
2.
Chukwuma
December 3, 2009 at 6:25 am | #2
Reply | Quote
Amy is absolutely on the money. This is one of many areas in medicine in general and
obstetrics in particular where the standard practice has been remarkably inflexible and
unchanged despite significant research to the contrary.
I appreciate the way that you have presented the evidence as well as the physiologic
rationale.
Keep up the good work and spreading the evidence.
3.
Angela England
December 3, 2009 at 6:55 am | #3
Reply | Quote
Saw you post this on Twitter. Fantastic! I will agree with Amy having been-theredone-that….I wish all OB’s “humored” their patients as willingly as you have. I am
glad you wrote this as a doctor – a peer-voice that mothers can print out and take to
their prenatal doctors.
This will be a beneficial stepping-stone of communication for patients and doctors I
believe. An easy way to create that all-important dialogue to reach a common ground
understanding before labor begins.
Bravo! Angela <
4.
Knitted in the Womb
December 3, 2009 at 7:32 am | #4
Reply | Quote
I’d also like to suggest that delayed (or should we say “physiologic” and the current
practice is “premature?”) cord clamping may also have benefits to the mother.
Mouloud Agajani Delavar at the Faculty of Midwifery at Babol University of Medical
Sciences, Iran published an article titled “A Study on Comparison between the Effect
of Early and Late Cord Clamping on Third Stage of Labor” (I wish I had a date–I have
a print out of this that does not have a date on it nor where I got it from–I think it was
presented at a FIGO conference though) that found that in women with delayed
clamping there was a statistically significant shortening of the 3rd stage and a
statistically significant reduction in post-partum blood loss when delayed clamping
was practiced.
My personal experience has been that I have hemmorhaged 500-1000 cc in my first 3
births, which all had immediate cord clamping. My next two births I insisted on
waiting for the placenta (which, admittedly, took 30 and 75 minutes), and I had less
than 50 cc blood loss in the immediate post partum period, and my lochia was
significantly lighter. I’ve also had one client who hemmorhaged with her first birth
(which did include prostaglandin and Pitocin induction), but also had less than 50 cc
blood loss with her second–again, immediate vs. delaying until the placenta came.
5.
My OB said WHAT?!?
December 3, 2009 at 7:37 am | #5
Reply | Quote
Thank you for writing this post and including the research sources that supports the
evidence that delayed clamping has proven benefits. Such a simple, low cost, no risk
action can have such benefits to the newborn!
There have been several submissions to the http://www.myobsaidwhat.com site about
the comments made by birth professionals to support immediate clamping!
http://myobsaidwhat.com/2009/09/10/the-babys-blood-will-run-back-into-mom/
Glad to see you working to change it from the inside out in your facility!
My OB said What
6.
Sharon Muza, New Moon Birth
December 3, 2009 at 7:45 am | #6
Reply | Quote
Dear Dr. Fogelson:
What a great resource you are providing in creating an avenue of discussion for
evidence based practice that has somehow not yet become “mainstream” in general
practice. I enjoyed this article very much and will be sharing it with students, clients,
and others!
I have also, always said, (as a strong believer in evolution) that if the cord was meant
to detach right away after birth, it would, all on it’s own! And since it does not, that
leads me to believe that there are some benefits to allowing the baby to continue to
receive oxygenation and blood volume from the placenta.
I encourage my students and clients to learn more about this and share what they have
learned with their providers, so that their wishes can be supported in full at the time of
birth.
I am so enjoying your blogposts and am glad I have found you! keep it up please!
Sharon Muza BS, CD, CDT (DONA) LCCE
newmoonbirth.com
7.
Nicholas Fogelson
December 3, 2009 at 7:45 am | #7
Reply | Quote
Thanks for all the comments. I am thinking of developing this further into a peerreviewed article. There are a number of reviews already, but clearly we need more!
NewMoonBirth>. I have also, always said, (as a strong believer in evolution) that if
the cord was meant to detach right away after birth, it would, all on it’s own! And
since it does not, that leads me to believe that there are some benefits to allowing the
baby to continue to receive oxygenation and blood volume from the placenta.
I appreciate this comment, but have this to say. We should not assume that what is
natural is necessarily the best way. There are plenty of examples where we have not
yet evolved into beings capable of dealing with natural problems. Certain conditions
still require intervention to staunch the flow of nature. You could easily say “If we
were meant to survive a placenta previa, we would have higher hemoglobins in
pregnancy!” Certain conditions are so deadly that there is no chance to evolve
resistance over time.
That being said, I believe as evidence based physicians and practitioners, we should
have a good evidence base to support us when we want to divert nature off its path, or
in the absence of evidence, at least good physiologic reasoning.
Nicholas Fogelson
8.
Danielle Arnold
December 3, 2009 at 8:54 am | #8
Reply | Quote
Thank you very much for this fantastic blog. I have been researching delayed cord
clamping for many years and have had to argue with 2 seperate OB’s about it. (though
it needs to be said that I have never had this argument with either of my
midwives….food for thought?). I am going to post a link you this blog on my own
blog- informed parenting- and my Facebook profile, as I know that many people will
feel vindicated by your blog.
9.
Sharon Muza, New Moon Birth
December 3, 2009 at 12:24 pm | #9
Reply | Quote
“If we were meant to survive a placenta previa, we would have higher hemoglobins in
pregnancy!” Certain conditions are so deadly that there is no chance to evolve
resistance over time.
Of course! there are some things that need intervention or mom and/or baby would
die! and I am glad that we have the ability to identify those problems and take
appropriate action. Deviation from the norm (ie, previa) will always occur, but I
consider that to be different then the premature clamping. Thank you for participating
in such a great discussion
10.
Lynette M Elizalde-Robinson
December 3, 2009 at 12:33 pm | #10
Reply | Quote
I agree, and validate the delayed cord clamping argument with experience that has
taught me, there is no rush to cut the baby’s life line immediately. You never know
what will happen. I recently delivered a term baby girl who arrived by a beautiful
water birth, and never took her first breath unassisted. As I lifted her to her mother’s
arms, she grabbed my gloved finger and held tightly to it, eyes wide open. Despite my
earnest efforts, seconds ticked by and even with rigorous stimulation, she would not
cry, breathe or gasp. Instructing my RN to begin PPV with oxygen, the cord continued
to support her as I then raced to clamp and cut the cord that had finally stopped
pulsing. Artificial ventilation continued for 18 minutes while an endotracheal tube was
placed. Her color remained pink throughout those slow motion-like minutes of
uncertainty from her birth to when she was transported to the NICU (NEVER without
oxygen because I left her attached as we prepared to bag and mask her.) Upon extubation in the NICU, she crashed again, and it was there, we discovered she had a
congenital growth (teratoma sac on a stalk) obscuring her nasopharyngeal airway that
moved away, when PPV was applied. Imagine the outcome of the baby, had the cord
been cut during those precious seconds when we struggled to assess and treat her
apnea. After surgical removal of the teratoma she went home and is doing great with
no adverse or long term effects that could have occurred from a lack of oxygen during
her resuscitation, had her cord been cut immediately upon delivery.
Lynette M. Elizalde-Robinson,BS,LM,CPM,CCEd
NRP & ACLS Certified
President, Louisiana Midwives Association
o
Nicholas Fogelson
December 3, 2009 at 4:06 pm | #11
Reply | Quote
What’s interesting about your story is that if that baby had be prenatally
diagnosed with that lesion, the likely plan would have been an EXIT
procedure. With EXIT (Ex Utero Intrapartum Treatment) the baby is delivered
by cesarean only far enough to operate on the lesion that needs repairing, with
the baby continuing to be on maternal circulation until the procedure is
complete. Prior to this procedure, defects that completely occluded the fetal
airway were often fatal. With this procedure, these defects can be repaired
before the baby ever needs to take its first breath. This procedure is not
commonplace, but is available in a number of tertiary centers in the country.
11.
marianne
December 3, 2009 at 1:51 pm | #12
Reply | Quote
There is a way to achieve this during a surgical birth or a preterm birth. A table similar
to an over the bed table is placed close to mom, over her belly. Baby can be placed on
it and recusitation measures done without cutting the cord. It can also be done during a
Cesarean birth. I’ve seen it happen. Unless the cord is very short there is not a
problem…
12.
Judith Mercer
December 3, 2009 at 2:13 pm | #13
Reply | Quote
Thank you for acknowledging our research. Very nice post. My colleague, Deb
Erickson-Owens, and I are just beginning to put together a proposal for a large RCT
on placental transfusion in term infants. No study on term infants has been completed
in the US and it is high time that it be done. Will keep you posted on our progress.
Again, it is always so nice to have one’s work acknowledged! Keep up the good work.
o
Nicholas Fogelson
December 3, 2009 at 4:00 pm | #14
Reply | Quote
I practice in a center where a great deal of our medicaid population are iron
deficient. Delayed clamping is likely to help those infants, and perhaps all term
infants as well.
13.
Lynette M Elizalde-Robinson
December 3, 2009 at 5:15 pm | #15
Reply | Quote
Thank you, Nicholas, for the information on the EXIT procedure. This was a very
healthy pregnancy, with no indication or suspect for the growth. First and second
trimester US were unremarkable, as lab work and H&P showed no discernible alerts to
prime investigation of this congenital malformation. Even the NICU Neonatologists
admitted they had never seen anything like this before, and since my client never
presented with problems during her prenatal care, and her labor was uneventful with
no fetal distress during the entire time, I had no reason to believe she was incapable of
a SNVD without complications. As a Licensed Midwife, my scope of practice is low-
risk, in collaborative association with my OB/GYN. As this seems to be an extremely
rare situation, can you point me in the direction of research info, and materials that
will best inform me of early diagnosis and prevention procedures that I may pass on to
my collaborating physician.
o
Nicholas Fogelson
December 3, 2009 at 5:52 pm | #16
Reply | Quote
This case points out one of the differences between the care provided in
tertiary centers versus midwife care. All in all, both parties can provide
excellent care, but each has their strengths and weaknesses. I am wondering if
your second trimester ultrasound was read by a Maternal Fetal Medicine
physician. If this patient had been cared for in my center, she would have had
an anatomy ultrasound read by an MFM, and very likely this lesion would
have been antenatally diagnosed, and precautions might have been taken.
Ultimately, one has to decide ones threshold for missing rare defects. One
extreme (which I follow) is to have a high risk obstetrician scan every
pregnancy in the mid second trimester. A middle ground is to have a routine
ultrasound done by a tech which is read by a radiologist or general OB/GYN.
The minimalist path is to not get an ultrasound at all unless there is some real
reason (generally not done by OBs. Some FPs and lay midwifes have this
philosophy.)
In this day in age, we have the capability to diagnose >98% of congenital
defects antenatally. I practice in a setting where all my patients can get MFM
ultrasounds, so I do that. When MFMs do routine scans, they typically still do
what would be considered a Level II ultrasound, which includes screening for
just about any defect that can be detected on ultrasound. This is different from
the Level I ultrasound that most generalist OB/GYNs and radiologists can
provide, which screens only for certain heart defects, CNS defects, spina
bifida, and certain urinary tract and GI abnormalities. Something like what you
mentioned would probably be missed with a level I scan. When an MFM gets a
referral for a routine scan, they are using the same equipment, and more
importantly the same brain, as they would use to do a level I, so basically you
are getting the level II for the price of a level I (which is all insurance is going
to pay for unless there is good reason for a level II). MFMs are able to find
these kinds of rare lesion more often than other practitioners because they
spend years of training looking at abnormal fetuses, and usually have seen at
least a few of any known lesion. Generalist OB/GYNs and radiologists usually
get most of their experience looking at normal fetuses, since they work with a
much lower risk population, and thus they are not as good at finding subtle
defects.
So my answer to your question is that you probably can’t expect to find these
lesions antenatally unless you are going to refer every patient get their anatomy
scan with an MFM. Even then there is a chance it could been missed.
Of course if your screening scan was done by an MFM, then there really was
nothing else that could have been done.
14.
Lynette M Elizalde-Robinson
December 4, 2009 at 2:56 am | #17
Reply | Quote
It was a 20 week anatomical, which I routinely schedule at an imaging center and is
read by a radiologist if there are no prior indications for it to be done by the MFM
specialist. It was missed. The OB and I also work in collaborative association with an
MFM, but, he sees clients referred by us for abnormal quad screens, gestational
diabetes,and diagnosing w/follow-up, etc. Besides my practice at the Birth Center,
both the OB and MFM specialist have the highest Medicaid population practices in the
area (I also work two days a week in the OB office seeing patients). I believe you have
suggested that I rethink my sono protocols and utilize the services of our MFM for
every 20 week anatomical as opposed to the imaging center. If a client risks out of my
care, she then moves back up to the OB/GYN generalist, who determines if she is high
risk and should be followed by the MFM. I will address this discussion at our next
meeting. Thank you for the advice and the valuable information you have shared. I
will continue to follow all information posted here, you’ve been most helpful.
o
Nicholas Fogelson
December 4, 2009 at 4:55 am | #18
Reply | Quote
I’m not necessarily saying that you should start getting all MFM scans. I’m
saying that this is what would be necessary to find these rare kinds of lesions.
This is not to say that MFMs never miss lesions, but they do miss fewer, in my
opinion.
All MFM anatomy scanning is something that is common and standard in
tertiary centers, and in some communities. In some communities, however, it is
not practical. Sometimes there is limited MFM access and they are busy
enough doing targeted scans and consultations that they do not have time for
doing routine scanning.
It is important to clarify that what you are doing is the standard of care. ACOG
recommends a level I ultrasound for anatomy screening, and you are providing
that. One just has to accept that finding very rare and subtle birth defects is not
part of a level I (screening) ultrasound. Having MFMs perform your level ones
gets you a better detection rate, at the same cost. If its available, its great. If
not, that’s fine.
This is also just my opinion. And to dispell any thoughts out there of turfism,
I’m not an MFM. I’m a generalist OB/GYN, and am quite sure that I cannot
find subtle lesions as well as an MFM who looks at them all day.

Angela England
December 4, 2009 at 8:10 am | #19
Quote
This is what we do as well. While I prefer a homebirth for my personal
birthings I do like to have the peace-of-mind from an Ultrasound. We
always have a full diagnostic/anatomical ultrasound with all our
pregnancies before settling on a home birth. It was interesting to
hear the difference in levels of specialization in this discussion. I called
and our local hospital refers out to an MFM so it’s not readily available
for mothers at the hospital either. The downside of rural living. *wry
grin*
15.
Roland Baiza MD
December 4, 2009 at 7:37 am | #20
Reply | Quote
You are correct there is a benefit but primarily for preterm infants and for approx 4560 sec delay. Not until stops pulsating. Also for term there is a risk see below. Balance
is everything not to long or to short.. about 60 sec is best at term.
(Dr Baiza posted entire posting of 2007 Cochrane Review, this was edited out for
brevity and replaced with conclusion and a link to the PubMed Page for the cited
article)
McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term
infants on maternal and neonatal outcomes. Cochrane Database Syst Rev. 2008 Apr
16;(2):CD004074.
Conclusion
“… In this review delaying clamping of the cord for at least two to three minutes
seems not to increase the risk of postpartum haemorrhage. In addition, late cord
clamping can be advantageous for the infant by improving iron status which may be of
clinical value particularly in infants where access to good nutrition is poor, although
delaying clamping increases the risk of jaundice requiring phototherapy.”
16.
sarah
December 4, 2009 at 2:44 pm | #21
Reply | Quote
I have what might be a strange question. I am a (canadian) family doc who delivers
term, med-low risk babies at a community hospital. I would be happy to delay cord
clamping (although my reading also agrees that it’s more beneficial for preterm babies
and/or in communities with low iron levels, neither of which are our babies).
But…what exactly do you *do* with the baby while you are hanging out for that 1-2
minutes? with a spontaneously crying baby, I usually clamp & then put up onto
mom’s belly, drying & doing basic resus there. With delayed cord clamping, do you
just kind of hang out with baby at level of perineum? this seems like an awkward time
to start making conversation…”it’s a girl! yay! just…hanging out! okay…still a girl!
gee, a minute is really a long time eh!”. Do you get the same beneficial effect if baby
is non-clamped but elevated to mom’s belly?
With a silent baby, I usually clamp & then move baby to a bedside warmer where
mom can watch but we are a bit more controlled for resus. I understand the theory that
delaying stimulation/drying/freeflow O2 is ok for a flatter baby, because they are
getting mom’s circulation, but that seems even more awkward use of time as you all
stare at this silent, floppy baby, waiting for the 60 seconds to pass. what on earth do
you talk about for THAT minute?
This all may sound silly, but it is a real consideration for me…would appreciate any
insight from those of you further along than me.
o
Angela England
December 4, 2009 at 3:50 pm | #22
Reply | Quote
Speaking only from personal experience – at all three of my births the baby
was placed on my stomach or chest depending on length of the cord and the
warmed blanket/towel placed over both of us to prevent chilling. Since I don’t
bath the baby immediately that wasn’t an issue. My second born actually
nursed right away. And by right away I mean within two minutes – greedy
little girl. She had a very long cord compared to the other two obviously. Lol!
Really the parents will be so busy exclaiming over their new arrival the time
will fly. My health care provider always suctioned during this time as well and
usually the baby cried right away or within a minute depending.
Just lay the baby on the stomach and let the mom hold him!!
you for it.
She’ll thank
o
Ulrike
December 5, 2009 at 10:01 am | #23
Reply | Quote
A baby with a short cord can still be placed on mom’s tummy and covered to
prevent chilling. Babies with average to long cords can be placed at the breast
and allowed to nurse if they desire.
Skin to skin contact is beneficial for baby’s health (facilitating the transfer of
healthy, “probiotic” bacteria from Mom to Babe, and regulating baby’s body
temperature and breathing), as well as being a bonding experience for Mom
and Baby. Nipple stimulation from nursing helps to contract the uterus,
decreasing bleeding and expelling the placenta. For squeamish parents, you
could wrap the baby in a receiving blanket before passing her along to Mom to
hold, but it’s really not necessary. Mom’s going to want a quick shower
afterward anyway.
17.
Nicholas Fogelson
December 4, 2009 at 3:34 pm | #24
Reply | Quote
I’m sure other commenters have opinions on this. I would just hold the baby for a bit
and wash him/her off at perineum level then put it on mom’s belly. I’m not sure about
whether or not it matters where the baby is being held. Most do it at perineum level
but on the belly might be just as good. Certainly for the oxygenation part it wouldn’t
matter, as gravity is helping in one direction and hurting in the other, so there should
be no net effect on blood flow through the cord..
I agree that this is much more of an issue for the pretermer. As Dr Mercer said there
has yet to be a large randomized trial for term babies in the US, so there will be more
data on this in the future.
As to what to talk about? Guess I’ve never had a problem with that. People say I talk
too much not too little.
18.
Ingrid Jakobsen
December 4, 2009 at 5:20 pm | #25
Reply | Quote
Thanks for this article, it’s really great to see an OB/GYN acknowledge that “delayed”
cord clamping is the standard that immediate cord clamping has to prove itself better
than.
I’d like to note that the Cochrane analysis does not find any *benefit* to immediate
cord clamping, so I think the “but delayed cord clamping only demonstrably helps
premature births” argument is misplaced. Additionally, there is a Cochrane analysis
(http://www.cochrane.org/reviews/en/ab004665.html) suggesting (limited evidence so
far) that placental cord drainage is beneficial.
This looks to me very much like a second intervention to compensate for the first
intervention (immediate cord clamping). Why ever not just let that blood “drain” into
the baby? I am not a physician or a midwife, just a biologist with too much time to
waste on PubMed.
19.
Nicholas Fogelson
December 4, 2009 at 5:31 pm | #26
Reply | Quote
Interesting that draining the cord speeds time to placental detachment. This makes
teliologic sense, as drainage of the cord blood into fetus would also signal that it is
time for the placenta to detach, or to be less anthropomorphic about it, allows collapse
of the fetal side of the spiral vessels promoting separation.
The only real concern for delayed clamping at term, as pointed out by a few folks, is
that there is a slight increase in neonatal jaundice. Some studies have found this to be
clinically significant, others have not. In my mind, we have to ask ourselves if we are
honestly going to intentionally drain some blood from the fetal system to prevent this
problem. Seems strange to me, but I’d welcome the opinion of some pediatricians or
neonatologists. It is possible that I(we) are minimizing the impact of these few extra
incidents of neonatal jaundice.
20.
Amy Romano
December 5, 2009 at 12:18 am | #27
Reply | Quote
To answer the question of where to put the baby and what to talk about, I always place
the baby right in the mother’s arms and I agree with Angela that it’s possible with all
but the shortest cords. In fact, I’ve never encountered a cord too short for the mother
to hold her own baby. I do all assessments with the baby skin-to-skin. I also avoid
suctioning in all but the goopiest babies (I’d say my bulb suction rate is well below
5%). If Dr. Fogelson is up for another challenge from the midwife camp, I’d suggest
taking on suctioning and/or skin-to-skin next. In the former, you’ll find no evidence of
benefit and some troubling surrogate outcomes (pulse ox disruptions), plus many
things unmeasured (e.g., effect on feeding). In the latter, well, you’d probably be hard
pressed to find anything I care more deeply about, and there’s a ton of literature to
support it. See this. Physiologic cord closure facilitates skin-to-skin contact and also
may reduce the need (or perceived need, because I really don’t think there is a need in
the vast majority of cases) for suctioning, because it pulls fluid out of the alveoli.
As for jaundice requiring phototherapy, most of the data supporting an excess in
delayed cord clamping comes from an unpublished trial that was included in the
Cochrane review because it was the PhD thesis of one of the reviewers. From the
information included in the Cochrane, it seems like it was reasonably conducted, but
we can’t critically assess it without the paper available. Another systematic review
published a year prior in JAMA did not find an association between timing of cord
clamping and jaundice, and unlike the Cochrane reviewers, these reviewers reported
bilirubin levels, which also did not differ significantly.
21.
Henci Goer
December 5, 2009 at 6:41 am | #28
Reply | Quote
Nicholas Fogelson :Interesting that draining the cord speeds time to placental
detachment. This makes teliologic sense, as drainage of the cord blood into
fetus would also signal that it is time for the placenta to detach, or to be less
anthropomorphic about it, allows collapse of the fetal side of the spiral vessels
promoting separation.
The only real concern for delayed clamping at term, as pointed out by a few
folks, is that there is a slight increase in neonatal jaundice. Some studies have
found this to be clinically significant, others have not. In my mind, we have to
ask ourselves if we are honestly going to intentionally drain some blood from
the fetal system to prevent this problem. Seems strange to me, but I’d welcome
the opinion of some pediatricians or neonatologists. It is possible that I(we) are
minimizing the impact of these few extra incidents of neonatal jaundice.
I think the finding of excess cases of jaundice is an example of an “iatrogenic norm.”
Because early cord clamping has been routine for decades, the normal range for
bilirubin was almost certainly established in babies who were deprived of a substantial
proportion of their blood volume. Some proportion of babies allowed to capture all
their blood volume would then read “high” because the curve was shifted lower than it
should be. A more familiar example of this is infant growth charts, which, until fairly
recently, were based on white, formula fed infants and led to an all too frequent
diagnosis of poor weight gain when applied to breastfed babies. Iatrogenic norms are
but one of the problems that arise when trying to conduct research within the context
of a highly interventive system, the effects of which are rendered invisible by their
universality.
o
Nicholas Fogelson
December 5, 2009 at 6:56 am | #29
Reply | Quote
An interesting theory and comment. There may very well be truth to that. I
believe the indication for putting a baby under the lights at a certain bilirubin
level is based on outcomes research though. Not being my field I am not
certain though, perhaps a pediatrician can weight in on this.
22.
Linda
December 5, 2009 at 7:33 am | #30
Reply | Quote
Thanks for posting this. I am 32 weeks pregnant and have been doing research into
this. I’ve talked to some people about it and I was told by one person that if you delay
cord clamping and the placenta detaches too early that the baby could lose blood back
into the placenta. Is there any truth to that?
Thanks so much
o
Nicholas Fogelson
December 5, 2009 at 8:05 am | #31
Reply | Quote
>> I’ve talked to some people about it and I was told by one person that if you
delay cord clamping and the placenta detaches too early that the baby could
lose blood back into the placenta.
I don’t think this is a substantial concern. The placenta doesn’t detach right
away unless its abrupted, in which case delayed cord clamping probably would
be the right thing.
23.
Linda johnson
December 5, 2009 at 7:48 am | #32
Reply | Quote
Thank you for publishing this review and I especially appreciate the comment that
evidence presented by midwives is frequently ignored due to prejudice.
In most of medicine, and especially obstetrics, what is “right” depends on the
perspectives and belief systems of the people involved. However, what is done should
always include the short and long term physical and emotional effects that any action
will have on the newborn and the family. Too often, another course of action that is
just as correct, is dismissed because it was put forth by the midwife or the wellinformed parents.
ignorance should never be a reason to ignore the dictum: “First, do no harm.”
24.
Linda johnson
December 5, 2009 at 8:02 am | #33
Reply | Quote
Sarah (the Canadian family doc) as for resuscitation, I am a midwife and an NRP
instructor. In 12 years I have only found the need to clamp a cord to move the baby for
resuscitation on 2 occasions. It can be accomplished with the baby in mom’s arms or
on her abdomen for all but the most critical cases, i.e. those requiring chest
compressions. Having the baby in mom’s arms automatically provides warmth and a
familiar auditory presence. If we believe that newborns have an emotional presence at
birth, then removing them from a familiar environment would increase catecholamine
release and make the adjustment to extrauterine life more difficult.
Usually there isn’t much for the midwife or doctor to say once the infant is born. The
parents’ focus will have totally become the baby in mom’s arms.
25.
Shay
December 5, 2009 at 2:38 pm | #34
Reply | Quote
If the general public just gives up and decide to not fight for something like delayed
cord clamping ~ because “we are too far away from seeing this happen as
mainstream,” then change will not occur. It is the individuals, families, classes, etc…
along with studies who create change in the first place. It’s all about supply and
demand, and sadly about money. So if the majority ask and keep pushing, eventually
change will occur.
o
Nicholas Fogelson
December 6, 2009 at 4:57 am | #35
Reply | Quote
Honestly I think this needs to happen from the MD side. A few MDs need to
talk it up at some major meetings and get a few real thought leaders behind
them. A few editorials in major journals later this will all change. That is how
change happens in medical practice, and it is what will be required here.
26.
Sharon Muza, New Moon Birth
December 6, 2009 at 9:06 am | #36
Reply | Quote
Henci Goer :
Nicholas Fogelson :Interesting that draining the cord speeds time to
placental detachment. This makes teliologic sense, as drainage of the
cord blood into fetus would also signal that it is time for the placenta to
detach, or to be less anthropomorphic about it, allows collapse of the
fetal side of the spiral vessels promoting separation.
The only real concern for delayed clamping at term, as pointed out by a
few folks, is that there is a slight increase in neonatal jaundice. Some
studies have found this to be clinically significant, others have not. In
my mind, we have to ask ourselves if we are honestly going to
intentionally drain some blood from the fetal system to prevent this
problem. Seems strange to me, but I’d welcome the opinion of some
pediatricians or neonatologists. It is possible that I(we) are minimizing
the impact of these few extra incidents of neonatal jaundice.
I think the finding of excess cases of jaundice is an example of an “iatrogenic
norm.” Because early cord clamping has been routine for decades, the normal
range for bilirubin was almost certainly established in babies who were
deprived of a substantial proportion of their blood volume. Some proportion of
babies allowed to capture all their blood volume would then read “high”
because the curve was shifted lower than it should be. A more familiar
example of this is infant growth charts, which, until fairly recently, were based
on white, formula fed infants and led to an all too frequent diagnosis of poor
weight gain when applied to breastfed babies. Iatrogenic norms are but one of
the problems that arise when trying to conduct research within the context of a
highly interventive system, the effects of which are rendered invisible by their
universality.
Thanks for this comment, Henci, I consider this along the lines of the current infant
growth charts in use, based on growth rates for formula fed babies in the ’70’s. Just
like it might be high time for the growth charts to be re-evaluted, so might it be time
for the charts used to determine normal bilirubin be reassessed?
27.
Gail Hart
December 6, 2009 at 9:29 am | #37
Reply | Quote
The large body of research over 5 decades shows beefits from delayed clamping of the
umbilical cord, but there are conflicting reports of potential rise in rates of jaundice.
I believe the conflict in these reports is a result of the variations in conduct of third
stage.
The practice of delayed cord-clamping does not mix well with oxytocics given as part
of “active third stage management”.
Under normal physiologic conditions, the uterus remains in quiet tone for a few
minutes while the baby receives the “correct” amount of blood remaining in the
placental circulation.
If oxytocics are given with delivery, the early uterine contractions may result in an
over-infusion of blood to the baby, polycythemia, and elevated risk of jaundice.
In my region, the understanding of the association of increased risk of jaundice with
the practice of “pitocin with the shoulders” was the major reason for the abandonment
of this routine in the 1980s.
I think a wise policy is to allow normal third-stage umbilical transfusion by clamping
after the cord goes flat under most circumstances. But when pitocin is used then the
cord should be clamped within 30 seconds.
Midwives and doctors who follow this policy report rare incidences of neonatal
jaundice, and extremaly rare need for phototherapy.
regarding ‘what to do with the baby while waiting”… Let MOM deal with the baby!
In almost all cases, the cord is long enough to allow the baby to be held on mom’s
abdomen (and in her arms). There is no need to keep the baby at the level of the
intoitus: in fact, this is not physiological. It is normal instinctive behavior for mothers
to want to hold their babies at birth; in evolutionary terms, this means mothers hold
babies while the cord is still intact!
The maternal abdomen may be considered to be close enough to the level of the
placenta that gravity is not likely to impact either under-infusion or over-infusion,
unless the woman has given birth while standing (and this is unusual in our culture)
(On a personal note: I’ve been a midwife for almost 40 years and can attest that babies
do extremely well with a policy of delayed cord-clamping! I think they transition to
extra-uterine life more easily, and breathe more quickly and deeply with a lower
incidence of “gunky lungs” or TTN. And their intact cord allows them an additional
life-line in the rare instance when they require assistance.
Immediate cord-clamping is a very new development in human history. The routine
evolved as a method to reduce the neonatal load of maternal medication when births
were conducted under general anesthetic.
Those days are LONG past, but this old routine still remains!
We;re having a heck of a time getting rid of the silly thing!
see: JAMA. 2007 Mar 21;297(11):1241-52.
Late vs early clamping of the umbilical cord in full-term neonates: systematic review
and meta-analysis of controlled trials.
Hutton EK, Hassan ES.
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.
PMID: 17374818
(note nearly a 1000 babies in late-clamping study)
also check out PMID: 16567393
PMID: 15510946
PMID: 18624002 — describes additional benefit of increased alveoli perfusion and
recommends a minimum of 3 minutes delay
PMID: 11783688
28.
Sigismond (Michel Hervé Navoiseau-Bertaux)
December 6, 2009 at 11:05 pm | #38
Reply | Quote
One important remark: please stop speaking about “delayed” or “late” clamping. It’s
high time to pass on to the concept of NATURAL CLAMPING (induced by natural
process, hormones and so on…).
On the other hand “premature” or “early” clamping are adequate.
Sigismond, author of “Placenta, clitoris, foreskin, same fight against violence!”
http://circabolition.multiply.com/journal/item/345/Placenta_clitoris_foreskin_same_fi
ght_against_violence
o
Nicholas Fogelson
December 7, 2009 at 9:16 am | #39
Reply | Quote
PoTAEto PoTAto.
29.
Tsedef Hadar
December 7, 2009 at 6:14 am | #40
Reply | Quote
I am a birth educator and doula in Israel, the hospitals here clamp pretty quick but I
have been working with a midwife who does homebirths and she clamps hours after
and I have seen the difference in the way the baby accepts his/her new environment, a
nonviolent procedure, disconnecting when it’s time like saying hello to the new and
being ready to say goodbye to the old, it also makes sense and I am not a nurse or a
doctor that the blood that still is pulsating in the cord from the placenta is meant for
that new life every ml of it. I hope this changes soon, LISTEN TO THOSE LITTLE
HUMANS AND THE MOTHER”S REQUEST TO HAVE IT CLAMPED
LATER!!!!NATURE IS PERFECT WHEN IT”S LEFT ALONE!!!
30.
Tsedef Hadar
December 7, 2009 at 6:25 am | #41
Reply | Quote
I Just wanted to add, the less interferring at birth and being there with all the
technology “just in case” would make a whole lot of difference for the mother and
baby whom should be born into a loving caring and supportive society! Unfortunately
man believs he created nature so he has the right to meddle with it, Does it really
suprise you that there are so many angry sorry and unhappy people running this world
afterall violence was the key of entering this world, and forgetting how much we have
to learn and study nature itself and maybe realise when to use the knowledge needed
to save a life and not before.
31.
Tsedef Hadar
December 7, 2009 at 6:28 am | #42
Reply | Quote
Thanks for writing about your research, I forgot to say that, it helps for all of us that
believs that clamping should be delayed!
o
Nicholas Fogelson
December 7, 2009 at 9:19 am | #43
Reply | Quote
Not my research – just a review of what is already out there. I don’t want to
take credit for others’ work here.
32.
Nicholas Fogelson
December 7, 2009 at 9:18 am | #44
Reply | Quote
I appreciate all your comments. While I appreciate the different ways of supporting
this issue, what _I_ care about is the DATA that supports the practice. I don’t feel
terrible about the conceptual nature of allopathic medicine. I just want to do, and think
others should do, what the data supports.
33.
Yehudit
December 7, 2009 at 11:21 am | #45
Reply | Quote
Honestly I think this needs to happen from the MD side. A few MDs need to talk it up
at some major meetings and get a few real thought leaders behind them. A few
editorials in major journals later this will all change. That is how change happens in
medical practice, and it is what will be required here.
++++++++++
Change in obstetric and midwifery practice is so much more complex than this. For
example, the research evidence (not all RCTs, but solid scientific investigations on the
physiology involved) for spontaneous and directed pushing (and particularly coached
breath holding, valsalva etc…) has been available for decades. And yet it is hard to
shift practice. It is not just a question of being in the right or having the editorials in
the right place.
The history of changing fashions for episiotomy is instructive in this respect – the
science was the same, the access to the science was same, but practice changed at a
very different pace on different sides of the atlantic.
34.
Nicholas Fogelson
December 7, 2009 at 6:31 pm | #46
Reply | Quote
Honestly, I don’t think it is much more complex than this. System wide pattern
changes, in my experience, often stem from one or two prominent articles that “go
viral” throughout the community. The WHI is a great example. David Grimes article
“Magnesium: It’s Time To Quit” also had a dramatic impact in a short period of time,
despite the fact that it brought no new data to the field. The large trial on magnesium
neuroprotection spun it back in the other direction a few years later.
Like any group of people, OBs respond to a respected leader that directs change. Right
now, there is no respected leader pushing for delayed/physiologic cord clamping. If
there were, we would see a big change. An ACOG committee opinion article would
have a large impact as well.
35.
Rachel
December 7, 2009 at 7:46 pm | #47
Reply | Quote
I work for a large company that owns many hospitals across the state I live in. They
work hard to look at the research out there and implement what it suggests. As of
recently, they are working with their OBs to start clamping the cord later. The research
you mentioned has also been brought up as examples as to why we should do this. So,
the word is getting out that is would be good practice.
36.
Yehudit
December 7, 2009 at 8:38 pm | #48
Reply | Quote
That’s kind of a circular argument though (i.e. Research done -> Article published ->
Practice changes, ergo article must have been influential/writer was respected). There
are scores of counter-examples. It’s also easier to amend the obstetric formulary (like
dropping magnesium sulfate for tocolysis, especially when there are other tocolytics
still in the formulary) then make changes that impact the culture of birth. Cordclamping practice is related to skin-to-skin (promotion or otherwise), third stage
management – and a lot of people resist it because they are concerned about not being
able to ‘control’ the situation (witness discussion above about where to put baby
etc….)
Why are women still encouraged to give birth in supine positions despite the evidence
that this is not the optimum position? Induction for suspected macrosomia?
Routine/universal use of cEFM? Restriction of oral fluids/eating in labour? Who
would be the ‘respected leaders’ who could take up these issues and make an impact?
o
Nicholas Fogelson
December 8, 2009 at 7:33 am | #49
Reply | Quote
I guess my point is that things change in big bursts, not slowly over time.
Often times a key article or editorial is the impetus for that change. Just as
easily it could be some other stimulus. I believe strongly in the idea of “The
Tipping Point”, as described by Malcolm Gladwell, which describes how a few
small stimuli lead to systemwide change.
As to who? Could be me, could be you, could be anybody. It would just take
some concerted effort by that individual, or group of individuals, to initiate that
cascade of change. Not to say that anyone could definitely make it happen, but
that it won’t happen without a concerted effort. This blog post and its resultant
discussion has already had some effect (see two comments up)
37.
Yehudit
December 9, 2009 at 7:39 am | #50
Reply | Quote
I guess my point is that things change in big bursts, not slowly over time.
++++++++
I totally agree. I just don’t entirely recognise your description of change in medical
practice (particularly obstetric practice!) being entirely an internal affair. My
perspective may be different because I’m outside the US context, but the experience in
the UK has been one in which pressure for change from the service users has been
pretty important over the past 2-3 decades.
38.
Yehudit
December 9, 2009 at 7:50 am | #51
Reply | Quote
I don’t know if you’ve come across this book?
http://www.amazon.com/Episiotomy-Challenging-Interventions-IanGraham/dp/0632041455
You might enjoy it.
39.
Jeffrey Ahmed
December 11, 2009 at 1:27 am | #52
Reply | Quote
Great article, but extremely odd that you feel the need to reference creationist theory
in a scientific review of evidence!
o
Nicholas Fogelson
December 11, 2009 at 7:06 am | #53
Reply | Quote
Just trying to be respectful of all views….you can imagine where I stand on
that one.
40.
Beth
December 11, 2009 at 7:47 pm | #54
Reply | Quote
Not mine to control, but you would be an excellent addition to the science-based
medicine blog. Much better than the dreck about OB being written over there right
now.
41.
Danae Steele, M.D. (MFM)
January 19, 2010 at 1:18 pm | #55
Reply | Quote
I just this morning presented to the Ob-Gyn committee at my hospital about the
benefits of delayed cord clamping for premature babies. I’ve been doing delayed
clamping term (and “termish”) babies (and putting them directly on the mother’s
belly) for years, but have still been immediately clamping preterm babies so they
could be moved to a warmer for evaluation and resuscitation. I was really surprised to
come across all these articles about reduced rates of IVH (as well as other benefits)
and my immediate reaction was that we have NO excuse not to be doing this for our
preterm babies. I was expecting some opposition from our neos, but there was not one
peep. People were very supportive. And one of the nurses in admin had printed your
blog and gave it to me, which I found SO encouraging! I am not the only Ob-Gyn who
thinks we need to get the word out on this! Thank you!
o
Nicholas Fogelson
January 19, 2010 at 8:51 pm | #56
Reply | Quote
I’m happy that your department is starting to look at this, and that my blog was
able to play a part in that! Thanks for looking, and please come back!
Remarkably this blog post has been a catalyst for change in a number of
places, which is more than I ever expected. I will be speaking at the REACHE
conference in Seattle, WA in April about delayed cord clamping and other
topics, also due to this blog post.
Thanks for reading!
42.
Danae Steele, M.D. (MFM)
January 20, 2010 at 2:34 am | #57
Reply | Quote
Where are you located? I’m in Green Bay, WI. My co-fellow in MFM fellowship was
Vincenzo Berghella (chair of MFM at Jefferson in Phila, and pretty well-published
guy, and well-connected), and I’ve asked him to think about what he can do to get the
word out about this and he is all over it. He is also working on a free on-line
compendium of evidence-based recommendations for pregnancy and perinatal care.
43.
Nicholas Fogelson
January 20, 2010 at 4:19 pm | #58
Reply | Quote
Columbia, SC presently, previously in Honolulu, HI and Charleston, SC before that.
44.
Claudia
January 23, 2010 at 5:22 am | #59
Reply | Quote
I agree in the delayed cord clamping, eventhough cord blood banking is also a great
opportunity for future cell therapies. Eventhough collection of vol of blood is directly
related to the amount of cells (CD 34 cells), each cell counts because the numbers are
usually low. Science today is only moving forward with technologies on the
proliferation of those cells, as well as the use of the cord tissue (Wharton Jelly) as
another source of stem cells (mesenchymal).
My question reading your references is what have seen so far is in preterm which I
agree provide much needed blood flow for further vital functions. Are there any
studies related to delayed cord blood in normal term babies and its benefits?
o
Nicholas Fogelson
January 23, 2010 at 5:51 am | #60
Reply | Quote
You make a great point, which I think came up in the comment thread before.
Delayed clamping does preclude cord blood collection for future use. Clearly if
you are going to save cord blood for banking, you would want to clamp right
away. As you mentioned, the efficacy of a banked unit of cord blood is directly
related to the volume of cord blood collected.
As preterm babies are less likely to have enough cord blood to make a good
donor unit, and they have the most to gain from delayed clamping, it makes
sense to me that delayed clamping should be the standard.
There is data with term infants that shows a decreased incidence of iron
deficiency anemia in babies born to iron deficient mothers. There is not yet a
large randomized trial of of immediate vs delayed clamping in term infants,
though one is either underway or in design now.
I noticed that you represent a company that does private cord blood banking,
and as such you clearly have a financial interest in preserving immediate
clamping as a standard in term babies. I am a huge supporter of public cord
blood banking, based on a strong track record of success. I do not recommend
private banking to my patients, based on the incredibly high cost per unit used,
which in randomly donating families is in the hundreds of millions of dollars
per unit. That is of course based on current technology, and most likely in the
future the use of privately banked stem cells will increase, so that cost per unit
used will fall as that happens. But based on current use the value private cord
blood banking is selling is science fiction, not science fact. If my patients are
willing to spend the money based on the vanishingly small likelihood that they
will use the cord blood, or the potential that future use will increase, I’m happy
to collect it, but I do try to temper the claims of the various storage companies
with the evidence so far.
At my last position, we were able to collect blood for public storage, which we
did quite often. As we were in Hawaii, we actually did a great service for the
public system as we added a lot of units that were ethnically dissimilar to the
overall banked population, and as such did a lot of good for the southeast asian
and pacific islander population around the world.
It is my hope that public cord blood banking becomes the standard around the
country. When that happens, we will be able to have a very good discussion
about the merits of delayed cord blood clamping vs immediate clamping for
public donation of cord stem cells, as they will be mutually exclusive options.
This is a good topic for a future blog post. If I do one I’d certainly appreciate
the side of the private cord blood banks in the comment thread!
Thanks for your comments!
45.
Claudia
January 23, 2010 at 7:13 am | #61
Reply | Quote
Dear
I agree with you, we collect donations also, unfortunetly the cost of processing (we
process with AXP and Bioarchive system same as all Public Cord Blood Banks such
as NY Cord Blood Bank, MD Anderson , Duke, Utah and others), testing (related with
the volumen of cords to process) and not much funds makes the public practice of
collection difficult. Cord Blood Banking is an essential practice that should be the
standard of care, covered by health insurance, for the benefit of your loved ones and
the general public. With new cell therapies available every day these cells could be an
extra opportunity for several diseases.
Like Monoclonal Antibodies became a very useful tool in many therapies (as humoral
response) so does the cellular response and the ability of the body to repair itself.
Check clinicaltrials.gov search box cord blood stem cells to see what the future may
look like.
We believe in mixed banks private and public therefore we decided to go for the latest
technology and invest on it as the only private bank doing it.
We give the choice and try to accomodate donations as well as private banking.
I agree costs should go down, hopefully all providers and the awarness will make this
an affordable choice.
Thanks for your feedback !!!
46.
Tsedef Hadar
January 26, 2010 at 6:22 pm | #62
Reply | Quote
I was wondering if cord clamping has anything to do with all the coctails and different
drugs a mother might recieve during labor? Are there more drugs going to the
newborn if the cord is cut later or has that already passed through so cord clamping
early really doesn’t have any impact on if the baby will be drugged more or not. I
would be interested to know> Thanks
o
Nicholas Fogelson
January 28, 2010 at 6:22 am | #63
Reply | Quote
I think the baby will get whatever narcotics the mother gets in pretty short
order, so I don’t think it matters much. That being said, I don’t think that
maternal narcotics are particularly harmful to neonates. Throughout my career,
I’ve never seen a baby substantially depressed from maternal narcotic
exposure, despite thousands of women who have gotten narcotics either
parenterally (IV) or in an epidural.
47.
LH
February 3, 2010 at 10:44 am | #64
Reply | Quote
Sorry about that, apparently my arrows were interpreted as html and some things got
lost… what I meant to post:
**NewMoonBirth: I have also, always said, (as a strong believer in evolution) that if
the cord was meant to detach right away after birth, it would, all on it’s own!
Nicholas Fogelson: We should not assume that what is natural is necessarily the best
way. [...] You could easily say “If we were meant to survive a placenta previa, we
would have higher hemoglobins in pregnancy!”**
The analogy doesn’t work to support your assertion, given that in one case we’re
talking about normality and in the other abnormality. Of course it makes sense to
intervene when something goes wrong. It does not follow that the normal
physiological process needs to be “improved” by obstetric management.
**Nicholas Fogelson: While I appreciate the different ways of supporting this issue,
what _I_ care about is the DATA that supports the practice. I don’t feel terrible about
the conceptual nature of allopathic medicine. I just want to do, and think others should
do, what the data supports.**
Studies don’t get done and data don’t get gathered until people look at a situation
critically and observe a logical discrepancy. Reason first.
**That being said, I don’t think that maternal narcotics are particularly harmful to
neonates. Throughout my career, I’ve never seen a baby substantially depressed from
maternal narcotic exposure,**
Perhaps there are other harms besides being “substantially depressed” that you aren’t
privy to, not spending significant time with the mother and baby post-birth and (I’m
guessing) not being terribly familiar with a completely undisturbed process and
therefore truly normal mother-baby behavior.
o
Nicholas Fogelson
February 3, 2010 at 11:40 am | #65
Reply | Quote
Thanks for the comment. We probably have some fundamental differences in
thought about things, but that’s ok. That being said, our thoughts are probably
closer than you think.
When it comes to the narcotics in labor, I don’t agree. Babies born to mothers
that have some narcotics in labor are not harmed from it. Mothers clearly
benefit from the pain relief, if that is their desire. I strongly believe that pain
relief in labor is the right of women. If women choose not to have that that is
fine, but I will not withold it based on metaphysical ideas of “natural” or
“normal” labor. Natural and normal labor is painful, and some(most) mothers
would like to avoid that. Probably in your selected clientele that is not true, but
believe me in my patients it is very true. Given a complete lack of evidence to
suggest any significant harm in giving mothers narcotics in labor, it would
irresponsible of me to withold that based on some theoretical idea about baby
bonding, activity, or whatever.
“..and therefore truly normal mother-baby behavior”
Again, normalcy is not what I am going for. Best outcomes is what I am going
for. Normalcy/naturalism is the best way in some cases, but in some cases it is
not. We use what data we have, followed by what logic we can muster, to
figure out when it is time for normal and when it is time for not normal.
Differing preconceptions about intervetion/naturalism/physician roles etc.. may
change where we fall on these individual issues, but ultimately each patient
and caretaker have to make those decisions individually.
Thanks for the comment!
1. December 4, 2009 at 1:13 pm | #1
Delayed Cord Clamping — an OB’s take « Woman to Woman Childbirth Education
2. December 5, 2009 at 11:37 am | #2
Grassroots Network: Delayed Cord Clamping « Midwives, Doulas, Homebirth, OH
MY!
3. December 6, 2009 at 3:10 am | #3
Academic OB argues for delayed cord clamping at Gentle Birth Doula Services
4. December 9, 2009 at 7:33 am | #4
Late vs Early Clamping of the Umbilical Cord in Newborn Babies « Birth Bliss
5. December 10, 2009 at 7:55 pm | #5
Gloria Lemay » Good news on pulsing umbilical cords
6. December 20, 2009 at 2:59 pm | #6
Link | Article: Delayed Cord Clamping Should Be Standard Practice in Obstetrics
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