The birth of all of my children, but especially my first child, proved to be an experience unlike any other. It’s hard to capture in words the beauty and vulnerability of bringing new life into the world. It is also difficult to be prepared for the myriad of choices mothers are presented with before, during, and directly after birth. One such decision I was particularly uninformed about was delayed cord clamping.
Cord clamping should be discussed as part of a mother’s birth plan, especially if she is giving birth in a hospital setting. For the majority of the past century, “early” or immediate cord clamping was the norm (“Does Dad want to cut the cord?”). Because of current research and evidence-based practices, many providers are turning away from that approach and practicing “delayed” cord clamping, but it is not yet not universally done. Just like everything when it comes to women’s health, the mother deserves to be an informed participant in her birth, so she can advocate for what is best for her unique birth and baby. Delayed cord clamping can make a difference for both her baby’s health and the mother’s overall birth experience.
What is delayed cord clamping?
The definition of delayed cord clamping, depending on the provider, can vary anywhere from longer than one minute following birth to whenever the cord stops pulsating and goes completely limp. Most people advocating for delayed cord clamping suggest waiting at least three to ten minutes following the birth before cutting it.
By practicing delayed cord clamping, the provider is allowing the placenta to transfuse its oxygenated, nutrient-rich blood through the cord and into the infant. After the baby is born, he can be placed either skin-to-skin on the mother’s abdomen or chest, or on her legs (below the placenta, in the case of a C-section), to allow the blood flow to continue without hindrance.
Delayed cord clamping does not mean delayed infant care. It is part of the “golden hour” which is already practiced by the majority of hospitals and birth centers. The initial non-invasive infant procedures such as drying or helping to stimulate breathing can be practiced while allowing the cord to remain unclamped. Some hospitals even have the means to perform emergency infant care, such as aspirating meconium from the lungs, while still practicing delayed cord clamping.
When did early clamping become the norm?
Before the 1950s, delayed clamping was the norm, according to Evidence Based Birth. As more and more women began to give birth in hospitals, the concept of early clamping grew in popularity, primarily due to the medical approach towards birth, especially during the third stage of labor (the birth of the placenta).
From the 1950s to the early 2000s, the “active management” approach to birth became the primary approach to the third stage of labor. In this “hands on” approach, the doctor or midwife clamps the cord before it stops pulsing, administers Pitocin to the mother via IV, and aids in the delivery of the placenta with controlled traction on the cord and counter-pressure on the woman’s stomach, over the uterus. The goal of this approach is to help prevent hemorrhage. However, recent research has demonstrated that this may not be the healthiest approach to the third stage of labor for mother or baby, especially when it comes to the timing of cord clamping.
Another reason for the active management approach is to quickly complete initial infant care procedures such as weighing the baby, warming him under the heat lamp, and administering the Vitamin K shot. Completing all of this immediately following birth allows for the hospital to continue running quickly and smoothly without neglecting these procedures.
Active vs. expectant or mixed management of the third stage of labor
In the expectant management approach, the provider does not give Pitocin, clamp the cord early, or apply controlled traction or pressure on the uterus. The mixed management approach is the current primary approach to birth in most hospitals and birth centers. It allows for delayed cord clamping plus flexibility in the other aspects of the third stage of labor depending upon the mother’s needs and desires.
Current research suggests that these expectant or mixed management approaches are healthy options for both mothers and babies with mixed management often being the best option. However, many providers are less open to practicing these methods either because of a lack of knowledge or a concern about efficiency.
How does delayed cord clamping benefit babies?
The main advantages to delayed clamping include higher birth weights, hemoglobin levels, and iron stores. Research has found that full term infants who had their cord clamped early were often at risk for iron deficiency. The improved iron levels from delayed cord clamping lasted for multiple months after the baby’s birth. Iron plays a role in developmental as well as physical health. Having the proper levels of this necessary nutrient during the critical first year of life can have a positive rippling effect throughout the rest of a person’s life.
Preterm infants may gain even more than full term infants
For preterm infants, the advantages of delayed cord clamping are even more abundant, according to the American College of Obstetricians and Gynecologists (ACOG). Preterm infants who were allowed to have delayed cord clamping demonstrated healthier circulation, higher volume of red blood cells, “a decreased need for blood transfusion, and lower incidence of necrotizing enterocolitis and intraventricular hemorrhage.”
How does a few minutes of delayed cord clamping help so much?
Cord clamping matters because of what the cord connects to: the placenta, the incredible organ the mother’s body made just for the baby. Before birth, the placenta was the baby’s source of nutrients, oxygen, and blood circulation. This doesn’t cease immediately after birth, likely because our bodies know that our babies need a little help transitioning from life in the womb to life outside of it.
According to an article in Frontiers in Pediatrics, as much as one-third of the infant’s blood remains in the placenta at the time of birth [1]. This blood is rich in stem cells, oxygen, immunoglobulins, and iron, all of which help support overall health and development as well as tissue and organ repair in the newborn. Lack of these nutrients at birth can result in delayed or inadequate cognitive, motor, and behavioral development.
According to ACOG, approximately 80ml of blood is transferred to the baby within a minute after birth and 100ml by approximately three minutes following birth. The most blood volume seems to happen within the first one to three minutes. In the case of an emergency where the cord must be clamped earlier, even waiting one minute can make a big difference.
How does delayed cord clamping benefit moms?
According to a 2013 Cochrane review, there is no proven increase in postpartum hemorrhage (PPH) with delayed cord clamping [1]. When a mom requests delayed cord clamping, she is, in many ways, requesting a more expectant management approach to the third stage of labor. This allows for the process to occur more gently and naturally.
During the birth of my first child, I was uninformed about the many options surrounding birth, especially the third stage of labor. My doctor practiced the active management approach, and I found it to be painful and aggressive. It ultimately resulted in the initial part of our “golden hour” being very disrupted and disturbed. I remember feeling like that initial bonding moment with my baby was taken from me.
At the birth of my second child, I still did not know all I know now, but I did request delayed cord clamping. Subsequently, the doctor waited for the placenta to be birthed naturally, and I was able to spend that time focusing more on the baby, which allowed for the increase in oxytocin in my system (reminder: pitocin is not the same thing as your body’s natural oxytocin!). Consider all the positive domino effects when a mother’s body is allowed to work calmly and naturally and the multitude of benefits she receives from proper bonding with her newborn.
Why doesn’t everyone practice delayed cord clamping?
Some healthcare providers worry about increased jaundice risk with delayed cord clamping. According to ACOG, current research does not support an added risk for jaundice from delayed cord clamping. Additionally, if this were to be a known risk, jaundice is easily treatable.
Another concern is the possibility of increased postpartum hemorrhage risk. The 2013 Cochrane review found that the cord often stops pulsating around the five-minute range, and that brief delay has not proven to increase the risk of hemorrhage [2].
Many providers fear a delay in resuscitation efforts, especially for preterm babies, if delayed cord clamping occurs. Most hospitals do not have the equipment necessary to proceed with resuscitation attempts while keeping the cord intact. It is worth considering, however, that before birth the placenta was performing the gas exchange process for the infant. As long as the cord is pulsating, it allows for that gas exchange and transfusion of blood through the cord. All infants, in particular preterm infants, can benefit from this oxygen and blood exchange, especially if they need resuscitation. Ultimately, in these situations, it is best to practice what your hospital or birth center is prepared for while delaying the clamping of the cord as much as possible.
What do the experts recommend?
ACOG recommends in both term and preterm infants that the clamping of the cord is delayed by at least thirty to sixty seconds. They also assert that the concern for increased risk of PPH is unwarranted.
The World Health Organization (WHO) says the cord should not be clamped earlier than is absolutely necessary. This usually means delaying the cord by three minutes. They emphasize not clamping the cord earlier than one minute, except in the case of necessary infant resuscitation that cannot be done with the cord intact.
The American College of Nurse-Midwives (ACNM) recommends delaying cord clamping by at least two to five minutes following birth. Typically, the cord stops pulsating by five minutes.
What are my options in an emergency?
Every baby, birth, and mother is unique, and therefore, requires unique care. Sometimes a baby is born extremely premature and needs immediate resuscitation. Sometimes the mother starts hemorrhaging immediately. And sometimes there are unforeseen problems that arise and cause our plans to be changed.
When it comes to delayed cord clamping, any amount of delay can be beneficial. At a third trimester prenatal appointment, speak with your provider about how comfortable they are delaying cord clamping in an emergency and what equipment they may have available to allow for delayed cord clamping while performing resuscitation.
Cord milking or cord stripping is another option. This process has not been researched as heavily as delayed cord clamping, but it could prove to be a viable alternative in extreme circumstances when delaying for thirty to sixty seconds is not possible. This process involves ten to fifteen seconds of performing a milking motion on the cord (picture squeezing the last of the toothpaste of the tube) to increase placental transfusion within a short time frame to provide those nutrients to the baby before clamping the cord.
The bottom line
Check with your provider how long the healthcare staff usually wait to clamp the cord, and be sure to include your desire for delayed cord clamping in your birth plan. Any amount of delay in cord clamping provides invaluable benefits to your baby, so even if the delay is just a minute, rest assured that your baby received a multitude of nutrients.
Additional Reading:
Should you eat and drink during labor?
Beyond the epidural: Labor pain management options
Resources:
[1] Katheria AC, Brown MK, Rich W, Arnell K. Providing a Placental Transfusion in Newborns Who Need Resuscitation. Front Pediatr. 2017 Jan 25;5:1. doi: 10.3389/fped.2017.00001. PMID: 28180126; PMCID: PMC5263890. [2] McDonald, Susan J et al. “Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes.” The Cochrane database of systematic reviews vol. 2013,7 CD004074. 11 Jul. 2013, doi:10.1002/14651858.CD004074.pub3
