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Saturday, July 02, 2011

Immediate Cord Clamping (ICC) vs.
Delayed (or “physiological”) Cord Clamping (DCC)

Dr. Nicholas S Fogelson MD · practices obstetrics & gynecology in Honolulu, Hawaii

He blogs for Academic OB/GYN

Dr. Nicholas Fogelson: immediate clamping and cutting of the umbilical cord deprives the newborn of nearly 20mL/kg of her potential blood volume. The iron in the red blood cells is essential for normal brain development. All babies need to get the majority of their placental blood. Those stem cells are very precious (as are the red blood cells), and were meant to be in the baby to lay down his immune foundation for the rest of his life. [See “Mankind’s first natural stem cell transplant” by Jose N. Tolosa, Dong-Hyuk Park, David J. Eve, Stephen K. Klasko,Cesario V. Borlongan, Paul R. Sanberg, J. Cell. Mol. Med. Vol 14, No 3, 2010 pp. 488-495.]

Preterm deliveries are an area of even greater interest, given the data to suggest impact on critical endpoints of sepsis and intraventricular hemorrhage. Three groups of researchers have independently reported that early clamped infants have a much higher incidence of cardiac murmurs during the first 14 days of life.

Immediate cord clamping is an intervention shown to have substantial physiologic impact on a term fetus in terms of iron stores, blood volume, and hemoglobin. Blood, intended to perfuse the newly functioning lungs and other vital organs, is discarded along with the placenta. Possible consequences include breathing difficulties and anemia, especially in vulnerable babies; long-term effects on brain development are also very plausible. 2

Randomized data to date suggests a measurable clinical benefit to delayed clamping (and restoration of a more physiological transition from placental to pulmonary circulation). “After crying starts, the baby received a transfusion of nearly 100 minutes of blood within one minute; this was forced by maternal uterine contraction into the baby’s venae cavae, liver, heart and lungs.” [George Malcolm Morley, MB ChB FACOG] No data has found a danger in delayed cord clamping.

Delaying/physiological cord clamping at C/S.

These babies need their own blood probably as much or more than the vaginally delivered infants.

It’s not difficult at all to delay cord clamping at cesarean. We put the baby down on the mom’s draped legs and put a sterile towel over the infant to keep it warm (face uncovered of course.) We clamp at 60-90 seconds and then hand off to the pediatricians. Anecdotally, infants that are not vigorous at delivery always seem quite vigorous at 60 seconds, even without any active resuscitation.

Given that immediate cord clamping is the intervention, I think we have the evidence required to suggest that right now we should be delaying cord clamping after term deliveries.

Jaleel et al “Delayed umbilical cord clamping at birth seems to be safe and can be expected to reduce the prevalence of anaemic newborn babies in our community.” J Pak Med Assoc. 2009 Jul;59(7):468-70.
Timing of umbilical cord clamping and neonatal
haematological status.
R. Jaleel, F. Deeba, A. Khan

Hutton et al “Delaying clamping of the umbilical cord in full-term neonates for a minimum of 2 minutes following birth is beneficial to the newborn, extending into infancy. Although there was an increase in polycythemia among infants in whom cord clamping was delayed, this condition appeared to be benign.” JAMA. 2007 Mar 21;297(11):1241-52.
Late vs early clamping of the umbilical cord in full-term neonates: systematic review and meta-analysis of controlled trials.
 Hutton EK, Hassan ES.

Levy et al “Although a tailored approach is required in the case of cord clamping, the balance of available data suggests that delayed cord clamping should be the method of choice.” J Perinat Med. 2006;34(4):293-7.
Timing of cord clamping revisited.
Levy T, Blickstein I.

J Matern Fetal Neonatal Med. 2010 Nov;23(11):1274-85.
Timing of umbilical cord clamping: new thoughts on an old discussion.
Arca G, Botet F, Palacio M, Carbonell-Estrany X.