The great umbilical cord-cutting debate
For the layperson, a few minutes might tick by without a second thought, but those precious minutes after a baby is born could be beneficial for newborns later in life, some doctors say. When to "clamp" and or cut one of the most prominent fixtures associated with childbirth, the umbilical cord, has been at the center of an international cord-cutting clash for decades.
What started as a grass-roots movement by UK midwife Amanda Burleigh nearly a decade ago, has recently grabbed the attention of medical doctors around the world. "I wanted to find answers to why so many children, including mine, my friends' and my colleagues' appeared to have additional learning and health needs, especially the boys," said Burleigh. So she started reflecting on her own practice as a midwife.
"I began to question why we were trained to cut the umbilical cord immediately after a baby was born," said Burleigh. "I then started to explore my theory that there must be a link to a child's health based on when the cord is cut." Her curiosity grew into a movement.
Doctors say before the mid-1950s, when many babies were delivered by midwives, most cord cutting happened when the umbilical cord stopped pulsating, around five minutes after birth. Despite a growing body of medical evidence, the exact time frame when the cord should be clamped continues to be a controversial topic among the medical community.
According to the American College of Obstetrician and Gynecologists, or ACOG, generally most umbilical cord clamping happens within 15 to 20 seconds after birth. The ACOG does not endorse the practice of delayed cord clamping but rather suggests cord clamping should take place between 30 to 60 seconds after birth, since the ideal timing for cord clamping has yet to be established.
Many international health organizations, including the World Health Organization, now recommend umbilical cord clamping be performed from one to three minutes after birth.
Medical studies have suggested positive effects of delayed cord clamping after birth, including increases in iron stores, blood volume and brain development. In a study released this week in the medical journal JAMA Pediatrics, researchers in Sweden measured theeffects of delayed cord clamping on children past infancy and up to four years, a time frame few doctors have examined.
In the study, a group of 263 healthy Swedish full-term babies were randomly split into two groups. One group had their umbilical cords clamped less than 10 seconds after birth. The cords of the other group were clamped three minutes after birth. The two groups were then monitored for four years. The babies with delayed cord clamping performed modestly better on tests assessing their fine motor skills and social skills. The boys in the study displayed the most statistical improvement. The results, researchers say, showed no difference in overall IQ.
Though the results are not dramatic, researchers involved with the study said this is an important step. "It's incredible to see what a difference an extra three minutes and one-half cup of blood can have on the overall health of a child, especially four years later," said Dr. Ola Andersson, lead author of the study and a pediatrician at the department of women and children's health at Uppsala University in Sweden. "This is very promising, but larger studies are necessary," said Andersson.
At birth an estimated one-third of the baby's blood is in the placenta. Red blood cells contain hemoglobin, a protein molecule, which carries oxygen to body tissues. At birth, the smallest amount of blood could have a big impact on specific aspects of an infant's health, doctors in support of delayed cord clamping say.
Doctors in support of delayed cord clamping say there are also external drivers perpetuating the practice of early cord clamping in developed countries. Early cord clamping causes vital blood cells to remain in the placenta, which could be used and stored in stem cell banks, doctors say.
"It's not a black and white issue," said Dr. David Hutchon, retired obstetrician from the Memorial Hospital in Darlington, United Kingdom. "Though early cord clamping makes it easier to collect and bank cord blood stem cells -- since most of the blood volume remains in the placenta -- in turn, the nutrients from the cord blood are not directly delivered to the infant at birth."
In the past 55 years, early cord clamping has become more popular as the medical protocol for managing the third stage of labor. This has largely been attributed to the need to monitor the cord blood gasses to test if a baby has been starved of oxygen during labor. Lack of oxygen during labor can cause brain damage in later years for some children, doctors say.
"When it comes to labor management practices, we need to find a better way of testing for the cord blood gases as well as getting billions of stem cells out of the cord and placenta after the baby has had its physiological transition and a normal blood volume," said Hutchon. "We're getting closer to finding a solution but we're just not there yet."
Neonatologist Anup Katheria, director of the Sharp Mary Birch Neonatal Research Institute in San Diego, aims to find alternative ways in which very premature infants who need help with breathing at birth can receive delayed cord clamping without having to be removed from their mother into a separate treatment area.
"The practice of helping babies breathe while waiting to clamp the umbilical cord has been around for a long time; it makes sense for the sickest infants," said Katheria. "We're focused on producing evidence that shows the benefits. We think this could become the foundation for practice changing resuscitation techniques, transforming outcomes for the most critical of newborns nationwide."
Despite the obstacles, Amanda Burleigh said she will continue to champion for delayed cord clamping.
"I've been told I'm like the midwifery version of Erin Brockovich, which is a huge compliment," said Burleigh. "The body of medical evidence is growing in support of stopping immediate cord clamping but there is still a lot of resistance because many people just don't know about it and it's always hard to change common practice."
- Ihsan ul haq