Stumped by the Cord: delayed cord clamping, dry umbilical care

I find it truly fascinating that–after thousands of years of delivering babies (ok, maybe only about 60 years of doing so with relative success)–we still can’t agree about what to do with an umbilical cord. There’s a lot of dissent out there. And frankly, I feel like we’ve been doing this one wrong all along.

The umbilical cord and placenta are where my involvement begins; everything prior to this is clearly the turf of my OB/GYN colleagues. There are a few points of contention surrounding this topic, the most hotly-debated of which is what to do with the placenta. But while I think that a placenta does a fantastic job of providing nutrition to a developing fetus, I care very little about what you do with it once the cord is cut. (Just don’t invite me over if you serve it for dinner.) The other two areas where there is a bit of disagreement involve the cord itself: when to clamp it, and what to do next.

A [very superficial] intro to perinatal transitional circulation

The umbilical cord contains three blood vessels that carry blood from the baby to the placenta and back. There is a fascinating transition that occurs immediately after birth, during which the infant’s circulation switches from getting oxygenated blood from the placenta to using his own lungs. Part of this transition is that, as the blood flow is shifted to the lungs, the umbilical arteries contract until the blood flow to the placenta stops. After about 2-3 minutes, this transition has progressed to the point where there is no more blood flow through the cord.

What is delayed cord clamping?

The optimal timing of cord-clamping is an area of ongoing research. Traditionally, when babies are delivered, the cord is clamped within a few seconds, then cut to release the baby, leaving what we call an umbilical “stump.” Essentially, the idea of delayed cord clamping is that waiting to clamp the cord until the blood has stopped flowing (usually between 1 and 3 minutes), allows a more physiologic transition, and also allows the blood inside the cord to flow back into the baby instead of remaining inside the cord.

You would think that for a baby who is limp and blue, in need of some serious resuscitation, the answer would be clear–clamp it, cut it, and get to work. But that doesn’t seem to be the case at all. OB/GYNs and neonatologists have performed a tremendous amount of research that demonstrates clear benefits in delayed cord clamping in premature infants–even those that require resuscitation. You just put the table close enough to the mother that you can work with the cord still attached.

Benefits of delayed cord clamping

For premature infants, these benefits include improved blood pressures and a lower risk of severe complications like brain bleeds and life-threatening bowel injury. Additionally, the infants start out with a 20%-30% higher blood volume, improving the infant’s iron stores and reducing the need for transfusions, which have plenty of complications. (And to be fair, this isn’t really “bonus” blood; they made it for themselves, not for a cord blood bank). The evidence is pretty convincing.

For term infants, the evidence is a little less clear–likely only because there haven’t been as many studies. The few that have been done in term infants seem to show similar results. Additionally, a recent study showed improvement in developmental outcomes in 4-6 year-old children who had delayed cord clamping. This was attributed to improved iron stores, which are known to improve brain function. Perhaps we could accomplish the same thing with iron supplementation–but why would we, when we can simply allow an infant to transition prior to clamping the cord?

Potential risks of delayed cord clamping

The only real downside to delayed cord clamping that I’ve been able to find is a slightly increased risk of hyperbilirubinemia, or jaundice–a condition that I’ll discuss in a later post. The basic idea here is that bilirubin comes from the breakdown of red blood cells, so the more blood, the more bilirubin. We care because there is a potential that, at very high levels, bilirubin can cause severe neurological problems. This is something we routinely monitor for, and it’s usually simple to treat–you might even say we over-treat it…but more on that later. But strangely, there’s conflicting evidence about whether infants that have delayed cord clamping are truly at higher risk. Some studies say yes, some say no. Either way, the increased risk is small, if present at all.

There is another concern called polycythemia, which is Latin for “too many blood cells.” Rarely, this condition can cause some severe complications–but while infants who have delayed cord clamping are at higher risk for having higher concentrations of red blood cells, there haven’t been any recorded complications in these cases. In these cases, it seems to be just an abnormal lab value that probably doesn’t have any significance (and probably shouldn’t be considered abnormal).

So, when should we clamp?

Now that I think about it, “delayed cord clamping” isn’t really a great term. Maybe we should just call it “cord clamping,” since that’s the way it’s supposed to work. It’s not the delay, but the practice of immediate clamping that is the intervention; we should have demanded evidence that it was superior prior to implementing the practice. Instead of looking for more and more evidence that delayed cord clamping is better, we should be asking why we started doing it immediately in the first place. I haven’t been able to find any great reasons, and it seems to have been mostly a matter of convenience. It’s not the first time we’ve gotten something wrong, or that people have failed to challenge a traditional practice.

We clamped; now what?

But at some point, whether it’s early or late, it’s time to cut the cord–which leave us with the question of what to do next. And how to care for an umbilical stump is a question that has left the medical community…well, stumped. The big concern is infection of the umbilical stump, or omphalitis. This infection is particularly concerning because of its proximity to the three umbilical blood vessels and the potential to introduce bacteria to the bloodstream. The majority of infectious disease experts agree that giving bacteria a free ride to anywhere in your body is less than ideal–especially for babies with wimpy immune systems.

Over the years, we’ve tried a lot of different things–alcohol, triple dye, antibiotic ointments, betadine, and chlorhexadine (among various other interventions). Sometimes these are applied only once; sometimes they are used until the cord separates in about 1-2 weeks. There have been several studies that examined the effectiveness of these various interventions, and there’s compelling evidence that applying chlorhexadine can reduce the risk of omphalitis and death–if you happen to live in rural Bangladesh, Nepal, or Pakistan. Otherwise (if “home” is a country with a Starbucks), it doesn’t seem to make much of a difference.

Yep–it seems like the available evidence would suggest that all of our interventions are just as good as doing nothing. Nothing, that is, aside from keeping the cord clean and dry. And living in a developed nation. And using a sterile instrument to cut the cord, instead of rusty scissors or a sharp rock, which would place your child at risk for neonatal tetanus as well. Many hospitals still use some form of antiseptic, which isn’t necessarily bad; it’s just not necessary. But I’m a bit of a minimalist (if you haven’t figured that out already), so if it’s just as safe not to do something, why bother?


I’d love to hear your thoughts–leave them below or on my Facebook page. Thanks for reading and sharing–I couldn’t do it without you. Be sure to follow me for future posts (another great newborn post coming up later this week).

-Chad

As always, your comments are welcomed (even if you happen to disagree). I'll get back to you as soon as I can. Please try to keep it civil--I reserve the right to delete comments that are offensive or off-topic.

4 thoughts on “Stumped by the Cord: delayed cord clamping, dry umbilical care

  1. Not that I know much about it, but per board studying, for completeness sake…Delayed cord clamping can lead to polycythemia which can lead to hypoglycemia and hyperviscosity syndrome as well as hyperbili

    • “J”- thanks for your anonymous comment–even though I know who you are and hope you’re loving the new home 😉

      That’s certainly the textbook (and board exam) answer, but after reading over a dozen articles and 3 systematic reviews, I find no evidence of symptomatic polycythemia, and conflicting evidence of hyperbili requiring phototherapy (in one study it went from about 1.5% to 3.5%, but others show no difference or even improvement). Here’s the best summary I found:

      “As for polycythaemia, usually defined as venous haematocrit above 65%, and increased blood viscosity, Hutton and Hassan did find significantly
      higher rates of polycythaemia associated with DCC, although they commented that no infant in any of the included studies in their review had been
      symptomatic. In the Cochrane report, the risk ratio of polycythemia by ECC compared to DCC was estimated to 0.39 (95%CI 0.12 to 1.27).

      In our study, no case of polycythemia was noted in either group, suggesting that neonatal polycythemia may be more of a problem in risk groups associated with high intrauterine haematocrit such as maternal diabetes and intrauterine growth restriction.

      There are conflicting results, also in meta-analyses, regarding the risks for hyperbilirubinaemia after DCC. In a meta-analysis from 2007, Hutton and
      Hassan concluded that DCC was not associated with a higher mean of bilirubin, or a higher risk for, clinical jaundice (8 studies) or use of phototherapy (3 studies), in contrast to results published in another meta-analysis, by van Rheenen et al three years earlier, demonstrating a higher risk of hyperbilirubinaemia after DCC (4 studies). Also the Cochrane analysis from 2008 suggested that DCC was associated with increased risk for jaundice requiring phototherapy (5 studies) but not for clinical jaundice (5 studies)…In the present study, we did not find any indications of neither higher bilirubin, nor of proportion of infants having hyperbilirubinaemia or use of phototherapy in the DCC group.”

      -Andersson O, Hellström-Westas L, Andersson D, Domellöf M. 2011. Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. British Medical Journal 343:7157.

      The decision to start the practice of immediate cord clamping was not based on evidence; it just seemed like a good idea, and nobody bothered to challenge it. In reality, immediate clamping should be viewed as the intervention that needs to be proven to be safe–not the other way around. DCC allows infants to keep the blood they made (which seems both fair and beneficial), and it allows them to transition physiologically as the lungs gradually take over the role of oxygenation. From the data out there, it certainly doesn’t seem that our fears of symptomatic polycythemia/severe hyperbilirubinemia justify an unproven and arbitrary intervention.

  2. As a former maternity nurse, when I was in my training back in the early 1970’s, the older nurses said that the immediate cord clamping started when they were using twilight sleep. Babies tended to need help breathing quite often, due to the amount of meds their mom were given. So they would want to whisk them off the infant warmer. After twilight sleep when out of style, they just kept doing it.

    • I’ll admit, I just Googled “twilight sleep.” And I kind of understand why they would do that. Like I said, it makes sense that if a baby isn’t breathing, you’d want to get him across the room and start bagging. But if you push the warmer closer, you can do it with the cord attached. And it seems to be the infants at highest risk for complications that actually benefit most. It’s those little decisions that nobody bothers to question that become “the way we’ve always done it.”

      Thanks for reading and your comments!
      -Chad

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