Chinmayo Forro, CDM

    When it comes to new research aimed at saving people’s life, none elicits more conflicting opinions than the stem cell controversy. More specifically, the use of umbilical cord blood has generated numerous heated debates: to cut or not to cut and when to cut? Conflicting information has added pressure on pregnant couples: who is right? Doctors favor cutting the cord within seconds of the baby’s birth, whereas midwives have always delayed cord clamping until it stops pulsating - an average of fifteen minutes - and some even advocate to wait a couple of hours after the delivery of the placenta. Cord blood banks have been growing like mushrooms in the past twenty years and advocate freezing the cord blood for possible later use. Some cultures even practice Lotus Birth – leaving the placenta attached to the baby until the cord falls off days later - as a meaningful spiritual practice. Thus, if we want to improve the health of future generations we absolutely must start at the beginning of life and seriously investigate the risks/benefits of early vs. delayed cord clamping.

    So let’s first look at what proponents of immediate cord clamping have to say, since theirs is the most accepted practice today. French doctor Francois Mauriceau, a leading obstetrician in 17th century Europe, was the first to insist that the cord be cut immediately following the baby’s delivery. Although this was not an evidence-based decision it has become the gospel of truth in today’s obstetrics, which argues that polycythemia (too many red blood cells) and hyperbilirubinemia (clinical jaundice) could endanger the newborn’s health if the cord is left uncut for more than a few seconds after birth. Does research agree with this argument?

    First, according to Dr. H. Rabe (2008), Neonatologist at Brighton and Sussex Hospitals, U.K., "the procedure of a delayed cord clamping time of at least 30 seconds is safe to use and does not compromise the preterm infant in the initial post-partum adaptation phase." Furthermore, in an article published in Pediatrics (2006), Drs. Barclay and Murata present randomized trials and conclude that early cord clamping “…might deprive the newborn of some benefits such as an increase in iron storage…Iron deficiency early in life may have pronounced central nervous system effects such as cognitive impairment.” And that is not all: in the same article, they argue in favor of delayed cord clamping because “…the increase of hematopoietic stem cells transfused to the newborn might play a role on different blood disorders and immune conditions.” In addition, Dr. Andrew Week (2007), Senior Lecturer in Obstetrics at the University of Liverpool, has research of his own which supports Barclay and Murata’s argument:

Clamping and cutting the umbilical cord should be delayed for three minutes after the birth, particularly for pre-term infants…as the umbilical cord sends oxygen-rich blood to the lungs until breathing establishes…As long as the cord is unclamped, the average transfusion to the newborn is equivalent to 21% of the neonate’s final blood volume and three quarters of the transfusion occurs in the first minute after birth…There is now considerable evidence that early cord clamping does not benefit mothers or babies and may even be harmful…Both the World Health Organization (WHO) and the International Federation of Gynecology and Obstetrics (FIGO) have dropped the practice [of early cord clamping] from their guidelines.

    Well, some doctors will argue, what will you do when presented with a nuchal cord (cord wrapped around the baby’s neck)? Cutting the cord then is especially detrimental to the fetus, as CNM’s Mercer et al (2005) have observed from their research: “Cutting the umbilical cord before birth is an intervention that has been associated with hypovolemia, anemia, shock, hypoxic-ischemic encephalopathy and cerebral palsy.” Mercer continues by suggesting the use of the Somersault maneuver (holding the infant’s head flexed and guiding it upward so that the baby does a somersault) to deliver these infants. And what about babies who suffer from hypoxia (oxygen deprivation) and need resuscitation, the skeptic will ask? Mercer has an answer for them, too:

Air pressure does not keep lungs open, because lungs have only atmospheric pressure. It is the hydrostatic exoskeleton generated by the capillary network that maintains alveolar expansion and prevents the alveoli from closing or collapsing on expiration…Adequate blood flow to the lung clears the lung fluid during the initial breaths because higher colloidal osmotic pressure of the blood in the capillaries draws the fluid from the alveoli (p.375)

    Having established the importance of delayed cord clamping, how do we determine when to cut? As we have seen from the research mentioned above, the recommended time is at least three minutes after the birth of the baby. So why do most midwives wait until the cord stops pulsating, which averages fifteen minutes after birth? Common sense! If nature keeps it pulsating for so long there must be a reason, so why interfere with it? Also, midwives know that immediate cord clamping prolongs the delivery of the placenta and increases maternal blood loss. Yes, physiological jaundice sometimes occurs, but this is a natural process not to be mistaken with clinical jaundice, which has been associated with medications in labor.

    Midwife and obstetrics researcher Anne Frye (1998) goes a step further by recommending not to cut the cord until it stops pulsating at the base of the umbilicus: “…typically, it takes one and half to three hours for pulsing at the umbilical base to completely disappear.” She adds:

Even after the placenta is born, equilibration continues by slight adjustments that occur via reflex action of the intra-abdominal portions of the vessels, eliminating the development of excessive central nervous pressure and thus allowing the baby’s system to gradually integrate the additional blood volume…Allowing physiologic equilibration to take place as it naturally occurs is the most gentle option as far as normal neonatal transition is concerned.(p.496)

    In light of what we have learned from all this research, why on earth would doctors still want to cut the cord within seconds? Old habits are hard to die. Meanwhile, cord blood banks are pushing hard to store cord blood as a rich source of stem cells to treat more than 70 diseases. This is a multimillion dollar industry - Cryocell, established in 1989, has over 160,000 clients; Viacord, established in 1993, has over 110,000 clients; and Cord Blood Registry Inc., established in 1995, has over 200,000 clients - Here is how it works: as soon as the baby is born the cord is cut and cord blood must be collected within ten minutes; before delivery of the placenta, the mother’s blood must be collected as well, and everything is picked up immediately by a courier who sends it to the blood bank. The shipment must arrive within 24 hours in order to be processed and frozen. Having done this procedure for couples who paid the cord blood bank thousands of dollars I can testify that this process disrupts early bonding between mother and child and distracts the care provider who, instead of looking out for them, must focus on mixing the blood with a prepared Heparin syringe, place labels on all vials, and fill in the paperwork before the courier shows up.

    What if, by cutting the cord too early, we created the exact conditions that stem cell research is trying to fix? And what if we just gave Mother Nature a chance, left the cord intact at least until it stops pulsating, and started gathering data on these newborns? As health care providers, “first do no harm” means little if we can’t acknowledge with humility that, yes, perhaps we got it wrong; we should be willing to learn from our mistakes and do our best to provide the next generation with what is its birthright: a cord full of rich blood.

This newborn is only minutes old and still attached to the umbilical cord when he starts nursing in his mother's arms.

References

Barclay, L., Murata, P. Delayed cord clamping at birth may reduce neonatal anemia.
Pediatrics, 2006: 117,779-786. Retrieved February 13, 2009 from
www.medscape.com/viewarticle/530352

Frye, A. Holistic Midwifery 1998; 497-498. Portland: Labrys Press Publication.

Mercer, J., Skovgaard, R., Peareara-Eaves, J., Bowman, T. Nuchal cord management and nurse-midwifery practice. Journal of Midwifery and Women’s Heath 2005: 373-379. Copyrights 2005 by the American College of Nurse Midwives.

Rabe, H., Reynolls, G., Diaz-Rossello, J. A systematic review and meta-analysis of a brief delay in clamping the umbilical cord of preterm infants. Neonatology (2008) Vol.93 No2. Retrieved March 7, 2009 from
www.content.krager.com/produkteb/produkte.asp?typ=fulltex&file=000108764

Week, A. (2007) - BMJ – British Medical Journal. Umbilical cord clamping should be delayed. Science Daily. Retrieved February 13, 2009 from
www.sciencedaily.com/releases/2007/08/0708161/93328.htm