Cry it out (CIO): 10 reasons why it is not for us

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There are suggestions that the practice of early cord clamping may have far-reaching detrimental effects on the infant, such as autism, infant anemia, childhood mental disorders and hypoxic ischemic brain damage.  

“Immediate clamping of the umbilical cord can reduce the red blood cells an infant receives at birth by more than 50%, resulting in potential short-term and long-term neonatal problems.” So concluded Judith Mercer, CNM and colleagues in a study reported in the fall of 2001 in the Journal of Midwifery and Women’s Health (Mercer, 2001). “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” (Mercer, 2002).

A quick look at Varney’s midwifery textbook says that the timing of cord clamping is “controversial;” Williams’ obstetrics textbook notes that delayed clamping results in shifting an average of 80 ml. of blood from the placenta to the baby, increasing the iron stores and reducing the frequency of iron deficiency anemia later in infancy. Nonetheless, despite no evidence for the benefits of early cord clamping and overwhelming evidence that delayed clamping is beneficial, almost all obstetricians and many midwives just cannot wait to clamp and cut that cord. In a survey by Mercer of the habits of nurse-midwives, she found that about a quarter clamped before 1 minute after birth; slightly over a third clamped from1 to 3 minutes; and a third clamped after pulsations cease (Mercer, 2000). The clamps and scissors are readied ahead of time and, as soon as the baby is out, before there is time to assess how he is doing or to hand him up to the arms of his waiting mother, the big, fat, living, pulsing cord is clamped in two places and severed between, often spraying blood from the force of the pulsations. In the interests of being family-friendly, the scissors are frequently handed to the dazed and wide-eyed father, who hasn’t had time to take stock of the momentous event that has just occurred, nor to have a good look at his baby. “Here, dad, you want to cut the cord?”

Why this hurry? There seems to be a fear that something just terrible will happen if the baby is not separated immediately from his lifeblood, from the placental oxygen and nutrients that have nourished him for nine months. Or is it just a rush to get on with things, to get this case finished up and move on to the next one? Recently, an additional rationale for early clamping of the cord has been promoted – collecting that precious cord blood to be saved, either for use in this baby’s later life, for another individual, or for research. By clamping umbilical cord blood at an early stage, researchers obtain “a greater number of CD34+ cells” (Pafumi et al.). But wait a minute!  Those CD34+ cells belong to this infant! When they are “harvested” for another purpose, there is a great possibility that this infant is being robbed of substances that he needs for normal growth and development. It makes intrinsic sense that, during the incredible transition from intrauterine to extrauterine life, while he is trying to take his first breaths and fill his lungs with air, the baby can benefit from the additional oxygen coming from the still-attached placenta.

There are suggestions that the practice of early cord clamping may have far-reaching detrimental effects on the infant, such as autism, infant anemia, childhood mental disorders and hypoxic ischemic brain damage. These hypotheses do not seem far-fetched, considering that the infant is being deprived of half of his blood supply.

In her study, Mercer reviewed cord clamping studies from 1980 to 2001. According to her results, “five hundred thirty-one term infants in the nine identified randomized and non-randomized studies experienced late clamping, ranging from 3 minutes to cessation of pulsations, without symptoms of polycythemia or significant hyperbilirubinemia. Higher red blood cell flow to vital organs in the first week was noted, and term infants had less anemia at 2 months and increased duration of early breastfeeding. In seven randomized trials of preterm infants, benefits associated with delayed clamping in these infants included higher hematocrit and hemoglobin levels, blood pressure, and blood volume, with better cardiopulmonary adaptation and fewer days of oxygen and ventilation and fewer transfusions needed. For both term and preterm infants, few, if any, risks were associated with delayed cord clamping.” Mercer noted that longitudinal studies are needed to confirm the benefits of delayed cord clamping.

In one study of preterm infants in Louisiana, delayed cord clamping significantly reduced the requirement for blood and albumin transfusion. It also increased the initial hematocrit, red blood cell count, hemoglobin levels, and mean blood pressure (Ibrahim et al.). In another study of very premature babies delivered by cesarean section in Germany, cord clamping was delayed for 45 seconds. The researchers concluded that this practice “is feasible and safe in preterm infants below 33 weeks of gestation. It is possible to perform the procedure at caesarean section deliveries and it should be performed whenever possible. It reduces the need for packed red cell transfusions during the first 6 weeks of life” (Rabe et al.). Finally, in another study of babies born to anemic mothers in India, a randomized controlled trial, the risk for anemia at three months of age was almost eight times higher in the early compared to the delayed clamping group (Gupta et al.).

Waiting until the cord has stopped pulsing is such a simple thing. It requires no additional skills, knowledge, protocols, or investment in equipment or supplies. It has no social, political or economic ramifications; no one is opposing it. Only infrequently is a cord so short that the baby cannot be placed on his mother’s breast with the cord intact, and in those instances a simple explanation about the importance of waiting will reassure the mother. If all of us – midwives, physicians, nurses, doulas, families, and childbearing women – remember the importance of this simple act, and gently remind one another to wait before clamping the cord, we can optimize the chances for our babies to make a successful transition to extrauterine life, minimize newborn anemia, and perhaps prevent significant problems in later life.

References

Gupta R, Ramji S. Effect of delayed cord clamping on iron stores in infants born to anemic mothers: a randomized controlled trial. Indian Pediatr 2002 Feb;39(2):130-5

Ibrahim HM, Krouskop RW, Lewis DF, Dhanireddy R. Placental transfusion: umbilical cord clamping and preterm infants. J Perinatol 2000 Sep;20(6):351-4

Mercer JS.Current best evidence: a review of the literature on umbilical cord clamping. J Midwifery Womens Health 2001 Nov-Dec;46(6):402-14

Mercer JS, Skovgaard RL. Neonatal transitional physiology: a new paradigm. J Perinat Neonatal Nurs. 2002 Mar;15(4):56-75. Review.

Mercer JS, Nelson CC, Skovgaard RL. Umbilical cord clamping: beliefs and practices of American nurse-midwives. J Midwifery Womens Health 2000 Jan-Feb;45(1):58-66

Pafumi C, Milone G, Maggi I, Russo A, Farina M, Pernicone G, Bandiera S, Giardina P, Mangiafico L, Mancari R, Calogero AE, Cianci A. Early clamping of umbilical cord blood and foetal CD34 enrichment. Acta Med Austriaca 2001;28(5):141-4 

Rabe H, Wacker A, Hulskamp G, Hornig-Franz I, Schulze-Everding A, Harms E, Cirkel U, Louwen F, Witteler R, Schneider HP. A randomised controlled trial of delayed cord clamping in very low birth weight preterm infants. Eur J Pediatr 2000 Oct;159(10):775-7

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ACOG Issues Revision of Labor Induction Guidelines
Washington, DC — Revised guidelines on when and how to induce labor in pregnant women were issued today by The American College of Obstetricians and Gynecologists (ACOG). The guidelines provide physicians with guidance regarding which induction methods may be most appropriate under particular circumstances, as well as the safety requirements, and risks and benefits of the different methods. ACOG’s Practice Bulletin “Induction of Labor” is published in the August 2009 issue of Obstetrics & Gynecology.

The rate of labor induction in the US has more than doubled since 1990. In 2006, more than 22% (roughly 1 out of every 5) of all pregnant women had their labor induced. The goal of labor induction is to artificially stimulate uterine contractions so that pregnant women can deliver vaginally. As with all procedures, the risks must be weighed against the benefits to the woman and the fetus.

“There are certain health conditions, in either the woman or the fetus, where the benefit of inducing labor is clear-cut,” says Susan Ramin, MD, from the University of Texas Medical School in Houston who helped lead the development of ACOG’s Practice Bulletin. “And, there are some nonmedical situations in which induction also may be prudent, for instance, in rural areas where the distance to the hospital is just too great to risk waiting for spontaneous labor to happen at home.” In circumstances like these, the ACOG recommendations say the gestational age of the fetus should be determined to be at least 39 weeks or that fetal lung maturity must be established before induction.

Cervical ripening is the first component to labor induction. If the cervix is not sufficiently dilated, then drugs or mechanical cervical dilators should be used to ripen the cervix before labor is induced. Once the cervix is dilated, labor can be induced with oxytocin, membrane stripping, rupture of the amniotic membrane, or nipple stimulation. Misoprostol, a medication for peptic ulcers, is a commonly used off-label drug that both ripens the cervix and induces labor. The ACOG guidelines indicate that inducing labor with misoprostol should be avoided in women who have had even one prior cesarean delivery due to the possibility of uterine rupture (which can be catastrophic).

According to ACOG, there are a number of health conditions that may warrant inducing labor but physicians should take into account maternal and infant conditions, cervical status, gestational age, and other factors. Some examples in which labor induction is indicated include (but are not limited to) gestational or chronic hypertension, preeclampsia, eclampsia, diabetes, premature rupture of membranes, severe fetal growth restriction, and postterm pregnancy.

“There are certain situations where labor induction is contraindicated,” says Dr. Ramin. These situations include (but are not limited to) transverse fetal position, umbilical cord prolapse, active genital herpes infection, placenta previa, and women who have had a previous myomectomy (fibroid removal) from the inside of the uterus, according to ACOG.

“A physician capable of performing a cesarean should be readily available any time induction is used in the event that the induction isn’t successful in producing a vaginal delivery,” notes Dr. Ramin. Although rare, there are potential complications with some methods of labor induction. “These guidelines will help physicians utilize the most appropriate method depending on the unique characteristics of the pregnant woman and her fetus.”

Practice Bulletin #107, “Induction of Labor,” is published in the August 2009 issue of Obstetrics & Gynecology.