I have found it to be pretty standard for most of my clients to request delayed cord clamping as part of the birth wish list. Delayed cord clamping means different things to different people. What is delayed cord clamping? If the standard practice is to clamp the cord and cut it immediately after birth, any amount of delay is delayed cord clamping. What is it that the parents are really asking for? Is any delay beneficial? Would the longer the better be the best philosophy? Is there a point where there becomes a loss of benefit and an increase in risk? Does the position of the newborn in relation to the position of the placenta affect the results? I do not aim to answer these questions for you but rather have collected some resources to help you decide for yourself.
Let us first look at the Society of Obstetricians and Gynecologists Clinical Practice Guidelines on the Active management of the third stage of labour.
"Timing of cord clamping
Clamping of the umbilical cord is a necessary part of the third stage of labour. Its timing varies widely throughout the world, early clamping being the predominant practice in Western countries.32 Physiological studies have shown that 25% to 60% of the fetal–placental circulation is found in the placental circulation.33,34 Early cord clamping in term newborns results in a decrease of 20 to 40 mL/kg of blood, which is equivalent to 30 to 35 mg of iron. A delay in clamping, causing increased neonatal blood volume, may lead to complications such as respiratory distress, neonatal jaundice, and polycythemia.
Prendiville and colleagues’ meta-analysis espousing the benefit of AMTSL8 included studies that applied early cord clamping, controlled traction, and uterotonics before delivery of the placenta. In these studies, early cord clamping was included as part of controlled traction and was not independently studied to demonstrate a benefit.
A 2004 Cochrane Review by Rabe et al.35 and a prospective study by Ibrahim et al.36 demonstrated that delaying cord clamping by 30 to 120 seconds resulted in less need for transfusion because of anemia (RR 2.01; 95% CI 1.24 to 3.27) and less intraventricular hemorrhage (RR 1.74; 95% CI 1.08 to 2.81) in nonresuscitated premature infants (< 37 weeks’ gestation).
A systematic review and meta-analysis comparing cord clamping done early (less than 1 minute after delivery of the infant) and late (at least 2 minutes after delivery) showed that late clamping conferred physiological benefit to the newborn that extended up to 6 months into infancy.37 Advantages included prevention of anemia over the first 3 months of life and enhanced iron stores (weighted mean difference 19.90; 95% CI 7.67 to 32.13) and ferritin concentration (weighted mean difference 17.89; 95% CI 16.58 to 19.21) for up to 6 months. There was no increase in respiratory distress, defined as tachypnea or grunting. Neonates were at increased risk of asymptomatic polycythemia (RR 3.82; 95% CI 1.11 to 13.21). There was no significant difference between the early and late groups in bilirubin levels and proportions of infants receiving phototherapy.
A 2008 Cochrane review included 11 RCTs that compared the effect on maternal and neonatal outcomes of cord clamping done early (up to 60 seconds after delivery) and late (beyond 60 seconds after delivery).38 The results showed no difference in the incidence of PPH but an increased incidence of neonatal jaundice requiring phototherapy, higher newborn hemoglobin levels up to 6 months of age, and higher ferritin levels at 6 months of age after late clamping. Recommendations
9. Whenever possible, delaying cord clamping by at least 60 seconds is preferred to clamping earlier in premature newborns (< 37 weeks’ gestation) since there is less intraventricular hemorrhage and less need for transfusion in those with late clamping. (I-A)
10. For term newborns, the possible increased risk of neonatal jaundice requiring phototherapy must be weighed against the physiological benefit of greater hemoglobin and iron levels up to 6 months of age conferred by delayed cord clamping."
The SOGC guidelines tell us that delaying cord clamping can increase the risk of respiratory distress, neonatal jaundice, and polycythemia (excess blood cells). One study defines delayed cord clamping as 30 to 120 seconds. The benefit described is less need for transfusion due to anemia.
Avoiding a transfusion for anemia is obviously desireable but is that the standard for which we wish to reach? I looked at the 2004 Cochrane Review referenced in the SOGC guidelines for more information and was interested to find that it suggested that more studies need to be done on the outcomes of infants left attached to the placenta without cord clamping, with a delay of 20 minutes or more and letting the umbilical cord close itself off physiologically.
"There are no reported complications of delivering preterm infants in this manner, and researchers should have no difficulty in obtaining ethical informed consent for a very large control cohort with which to compare Kinmond's method. Gravity, uterine contraction, and a time delay of 20 minutes or more may be required to provide the preterm infant with a blood volume optimal for it's survival."
Next we have Dr. Alan Greene from TICC TOCC. You can watch his Ted Talk on delayed cord clamping below.
In this video he describes the benefits of delayed cord clamping. He pleads with us to wait 90 seconds or more, until the cord stops pulsating on it's own before clamping and cutting. I really love the language he uses. Optimal cord clamping, clamping that is not delayed, it's optimal, because anything less would be early cord clamping.
There has been some suggestion that delayed cord clamping can increase the risk of newborn jaundice due to the liver having to break down excess red blood cells. I find conflicting information regarding this risk. Some studies have found a relationship while others have found no increased risk.
The randomized control trial “Effect of delayed versus early umbilical cord clamping on neonatal
outcomes and iron status at 4 months" found no increased risk for jaundice, polycythemia or postnatal respiratory problems with cord clamping of 2 - 3 minutes when compared to those with early cord clamping.
The review "Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes" did find a small additional risk of jaundice in the infants with delayed cord clamping.
It would seem the jury is out on the position of risk of jaundice with delayed cord clamping. We have to take into consideration the definition of delayed cord clamping. All of the reviews I have looked at discuss delayed cord clamping of 1-3 minutes."Jaundice requiring phototherapyThis outcome was reported in seven trials with data for 2324 infants. Significantly fewer infants in the early cord clamping group required phototherapy for jaundice than in the late cord clamping group (RR 0.62 95% CI 0.41 to 0.96, with a LCER of < 5%, I2 5%). This equates to 2.74% of infants in the early clamping group and 4.36% in the late clamping group, a risk difference of < 2% (95% CI -0.03 to 0.00) ( Analysis 1.14). In a subgroup analysis, there were no clear differences in outcomes according to use and timing of uterotonic drugs.Clinical jaundiceThe number of infants with clinical jaundice was reported in six trials with 2098 infants. The difference between early and late cord clamping for clinical jaundice did not reach statistical significance (RR 0.84 95% CI 0.66 to 1.07) ( Analysis 1.15).PolycythaemiaNo difference between the early and late cord clamping groups was detected for polycythaemia in five trials reporting this outcome (RR 0.39 95% CI 0.12 to 1.27; 1025 infants) ( Analysis 1.16)."
Another video series on delayed cord clamping, this time from Dr. Nicholas S. Fogelson. I appreciate this discussion because this doctor addresses the question "what would nature do?". Click the link to watch the series of videos.
Gloria Lemay, famous Canadian traditional birth attendant discusses extended delayed cord clamping and leaving the cord intact here.
Just as with any other decision regarding the birth of your baby, do your research using these and other resources, but most importantly be clear about what you are requesting. Delayed cord clamping means something completely different from one mother to the next and from one care provider to another. How long of a "delay" are you requesting? At least 1 minute? Until the cord stops pulsating?
SOGC Clinical Practice Guidelines
Active management of the third stage of labour: prevention and treatment of postpartum hemorrhage (Replaces #88 (April 2000))
Dr. Alan Greene TICC TOCC
Ola Andersson et al. “Effect of delayed versus early umbilical cord clamping on neonatal
outcomes and iron status at 4 months: a randomised controlled trial. British Medical
Journal 2011;343:d7157 doi.
Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes
The World Health Organization - Effect of timing of cord clampingof term infants on maternal and neonatal outcomes