The third stage of labour - FYI
Like all other independent midwives, my clients are excellent candidates for a physiological third stage as the general norm is such that they have remained low-risk during labour and there has been no emergency or medically initiated cascade of intervention. This approach does not entail any action whatsoever (clamping and giving an oxytocic injection) and simply allows the placenta to come out on its own. I've always endeavoured to share information about the highly beneficial, hands-off approach. The less fiddling the better.
I'm including an article I wrote on the subject of Delayed Cord Clamping (DCC) as defined by a ''delay of clamping by 60 seconds or more'' -RCOG (2016). Its jargon heavy and not overly accessible for those without a medical background, so please go to ''Links'' for more woman-friendly information. You can return here if your interest has been ignited and you want to know more.
Delayed cord clamping - Elizabeth Ord-Hume
This article will discuss the increasing body of evidence that favourably indicates the practice of delayed cord clamping (DCC), a method of cord management that has increased since I last practiced in the NHS. Given the latitude of this topic, this study will give priority to specific areas of relevance only, as opposed to attempting to address the full scope of the subject matter. The research findings of a selection of studies will be disseminated in furtherance of the medical rationale underpinning the statement by the Royal College of Midwives (2014) that DCC, as opposed to early cord clamping (ECC) is “overall beneficial to the baby”. Following a brief retrospective look at the history of cord clamping and initial definitions of “early” and “delayed”, the requisite framework of the cultural norms and barriers influencing cord management will be examined in prelude to the investigation of referenced research data that signify the advantages of DCC on neonatal physiology. Furthermore, concerns regarding whether ECC actually disadvantages a baby’s healthy development will be posited and the question as to whether ECC is essentially an iatrogenic practice will be critically evaluated within the context of medical ethics and informed consent. To conclude, recommendations for future practice will be suggested.
Since the mid-1960s the standard obstetric practice dictating cord management has incorporated the widespread view that clamping and cutting immediately at birth constitutes best practice. Previously the umbilical cord was not interfered with, resulting in the full complement of fetal blood being transfused to the baby, an amount equal to 30 – 40% of a baby’s total blood volume (Hutton, 2007). Sloan (2013) reports that medics and scientists such as Aristotle and Hippocrates are recorded to have written positively of the practice and cites the first mention of ECC as circa 1600s, which later in 1801 was declared by physician Erasmus Darwin (Charles’ grandfather) as “a very injurious thing” that left babies “much weaker than [they] ought to be.” Given the mounting evidence in favour of DCC, we are now seeing a gradual movement towards the return of a non-interventionist approach towards cord management.
However, in researching DCC, one is confronted with a controversial issue, i.e. the absence of a universally accepted definition of the word “delayed”. Van Rheenen et al (2006) refer to the continuing debate regarding the interpretation of terms such as “early” and “delayed” as a contributory factor towards the lack of agreement among research clinicians involved in informing current practice. The RCM (2012) who are in support of DCC have yet to announce specific guidelines regarding the timing of clamping. Similarly, NICE (2007) refer to DCC, but only in relation to the physiological management of the third stage. The guidelines fail to provide a suggested length of delay and cite DCC as part of a package that may include the routine use of uterotonic drugs. To avoid confusion the following definitions, as presented by McDonald and Middleton (2008) will be used as unifying criteria specifically for the purposes of discussing selected research findings: ECC- defined as clamping of the cord between birth and one minute after birth and DCC- defined as clamping of the cord after one minute of birth, or upon cessation of the cord pulse.
The general view among the multidisciplinary clinical team is that for the first time in decades cord management is essentially at a point of change. Yet, thwarting the potential movement towards an immediate shift in practice are persistent cultural barriers, despite mounting evidence from randomised controlled trials. Jelin et al’s (2013) study sought to determine how reflective of the cumulative body of literature obstetricians’ attitudes and beliefs indeed are regarding DCC. The conclusions to a rigorous questionnaire-based study suggest that obstetricians’ opinions fall short of being consistent with evidence accumulated from multiple randomised controlled trials. This is a serious concern given that the vast majority of midwives are employed by the NHS and work in obstetric-led units, a setting where the author suggests midwives commonly experience a diminished sense of professional autonomy, where they are more likely to concede to, rather than challenge specious practices such as routine ECC.
Multifarious barriers that render the practice of DCC slow to be incorporated into midwifery and obstetric practice are cited by Hutchon (2012) and include: “1) Cord blood gases, 2) resuscitation, 3) nuchal cord, 4) cord blood banking and 5) the need for neonatal blood grouping in rhesus negative mothers”.
Hutchon addresses each barrier with clinical rationale, the first being the collection of cord bloods to measure blood gases. Hutchon argues that cord gases are primarily for medico-legal and audit purposes and are of no benefit to the individual baby. In addition to this, she explains that during physiological transition from fetal to infant circulation, the values given in blood gas results will in every case conflict with the neonate’s blood gas levels once independent respirations have commenced and therefore offer insubstantial information for clinical prognosis. Gallagher (2011) also addresses the medico-legal issue by pointing out that because DCC results in significantly different measured values of cord blood acid-base, it is important to document the time at which the cord was clamped given how DCC reduces pH and increases base deficit values in umbilical arterial blood samples.
Hutchon, along with an increasing number of lead clinicians (Dunn 1984; Hutchon and Thakur 2008; Mercer and Bewley 2009), assert that the second barrier “resuscitation”. contrary to standard belief, is directly benefitted by DCC and states that the burden of evidence indicates that maintaining placental circulation while allowing the transfusion of a greater percentage of blood in these babies, is actually more likely to facilitate recovery and neonatal adaptation than add compromise. Subsequently, Gallagher (2011) has incorporated DCC into the Newborn Network guidelines for neonatal resuscitation in which is stated, “The first minute after birth is mainly occupied by assessment and stimulation of the infant and hence they will not be compromised by a slightly delayed transfer to the resuscitaire”.
The Resuscitation Council (2010) guidelines promote DCC for term babies for at least one minute, or until the cessation of the cord pulsation and for preterm babies in good condition at birth, a delay of up to three minutes. The RC have by their own admission limited data on the advantages and disadvantages of delayed cord clamping in the non-vigorous infant and concur with Hutchon that there is insufficient evidence to define an appropriate time to clamp the cord in babies requiring resuscitation. They state, “This may be because time is the wrong defining parameter and perhaps the cord should not be clamped until the baby has started breathing.”
The third barrier to DCC identified by Hutchon is that of the “nuchal chord”. Nuchal chords occur at more than a third of labours and as Emerson (2013) advises, should be left untouched. However Mercer et al. (2006) indicate that it remains standard practice to feel for a nuchal chord, yet such handling can stimulate the umbilical arteries to vasoconstrict, thereby reducing fetal oxygen. Moreover, clamping and cutting nuchal cords can lead to cerebral palsy, states Chow (1999). Mercer et al advise that the best procedure indicated for a nuchal chord is to facilitate the baby to be born using the somersault manoeuvre.
As deduced by Hutchon, the fourth potential barrier to midwives and doctors offering DCC concerns “stem cell collection”. Diaz-Rossello (2006) indicates that residual placental blood volume is of prime importance and that DCC will result in suboptimal volumes and be insufficient for banking. Hutchon responds by stating that public banks will “need to consider other methods to harvest the billions of stem cells left in the placenta if the life-saving use of the cells is to continue”. Fogelson (2011) points out that the transplantation of stem cells occurs in nearly all mammals via the cord at the time of birth and that the only mammal that actively prevents this natural transplantation is the human. He emphasises the point that due to there being a fixed number of fetal stem cells available to the baby, if we “rob” the baby of 40% of its blood volume, we also rob the baby of a substantial portion of stem cells. He stresses that a reverse argument for harvesting and storing these cells must ask the question why we would deprive a baby of its own stem cells in the first place, given how within the full complement of blood volume exist stem cells that carry the potential to become any kind of biological cell. Accordingly, in the instance of ischemic injury, a human being with all its stem cells would be at a greater advantage to deal with such a trauma than one with reduced numbers of stem cell. Tolesa et al (2010) echo this stance by positing that “a delay in cord clamping may increase the stem cell population in the baby, promoting an innate stem cell therapy that can promote acute benefits in the case of neonatal disease, as well as long term benefits in age-related diseases’’.
Of all the barriers listed by Hutchon, the argument against DCC on grounds of the fifth barrier (the collection of cord bloods to determine the baby’s blood group), is the one that has least credence. An anonymous haematology laboratory technician located within one London Trust hospital states that the minimum amount of cord blood required to perform a Kleihauer test is just 2 mls. At the majority of births it is not a challenge to collect this amount while simultaneously allowing for a DCC.
The physiological affects of DCC have been demonstrated in numerous studies including the study conducted by Mercer et al (2006) which examined the outcomes of 72 mother infant pairs born at <32 weeks gestation, whereby 36 neonates were trialled for DCC and the other half received ECC. Both groups of neonates were evaluated for bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH) and late onset sepsis (LOS). Clinical significance was demonstrated by the following: in the DCC group, no neonatal deaths occurred, however in the ECC group, 8 deaths occurred. Additionally, among the DCC neonates, only 14% of neonates developed Grade 1 IVH. Grade 1 IVH has less clinical impact than IVHs of a higher grade and by contrast, in the ECC group the numbers for IVH was more than twice than those receiving DCC, with 36% being diagnosed with IVH, the majority of which were of the more clinically significant Grade 2 variety. Furthermore, LOS was also reduced from 22% among the ECC group to 1% among DCC group. Since mortality, IVH and LOS can be reduced amongst this class of highly vulnerable neonates using DCC, an obvious conclusion is for the practice of DCC to be incorporated into the general management of pre-term neonates.
Iron appears to be the key factor in driving these improved outcomes. Andersson et al’s (2011) RCT focussed primarily on the iron status of 400 full-term babies grouped equally to receive either ECC or DCC, after low risk pregnancy. The strength of this study is that the babies were followed up at 4 months for further iron studies. Initial results indicated no significant differences in haemoglobin concentration between the groups, however the DCC group had a 45% higher mean ferritin concentration, a reduced prevalence of iron deficiency and a reduced prevalence of neonatal anaemia at 4 months of age. Secondary outcomes gave no significant differences between groups in postnatal respiratory symptoms, polycythaemia, or hyperbilirubinaemia requiring phototherapy. Furthermore, a larger study with perhaps even greater significance is that of McDonald and Middleton (2008) which studied the prevalence of infant anaemia among a sample group of 2989 babies. The results correlated with findings of Andersson et al’s RCT, however important were the follow-up haematological profiles conducted at 6 months which provided conclusive evidence that the benefits of DCC continue as the infant matures.
Fogelson (2011) proposes that from the perspective of evolution, mammals evolved to the natural equivalent of DCC, therefore an intervention that phlebotomises a baby of up to 40% of its blood volume, carry the potential to increase poorer outcomes in human health must be regarded within the definition of iatrogenesis. When navigating a line of practice that poses preventable harm, Hutchon (2012) supplies the view that ethical considerations with respect to professional legal duty must underpin any information given to parents by midwives in order to safeguard informed consent.
To conclude, given the overwhelming evidence to support DCC, it seems necessary to ask that a rational approach be taken to ascertain whether robust evidence exists to justify the continuation of ECC within the scope of contemporary midwifery practice. As midwives, our duty is to demonstrate theoretical expertise in relevant physiology and possess first-hand experience in its practice. Any barriers that may impede this process are best identified as areas requiring educational and supervisory interventions. In the interim between DCC being a minority practice and it becoming an integrated aspect of intrapartum care, the pragmatic and methodical philosophy of midwifery indicates the peer review process could be an appropriate intervention. Open peer discussions, together with the application of appraisal instruments such as questionnaires, could assist midwives to identify deficits in their theoretical understanding of DCC and consequently equip them to move forwards. Meanwhile, it is advisable to continue researching this physiological process and ensure that all clinicians are equipped with a reflexive understanding of current evidence.
References
RCM (2013). RCM supports delayed cord clamping. Retrieved April, 23, 2014, fromhttp://www.rcm.org.uk/college/about/media-centre/press-releases/rcm-supports-delayed-cord-clamping-11-07-13/.
Hutton, E. (2007). Late vs. early clamping of the umbilical cord in full-term neonates. JAMA, 297(11),1241-1252.
Sloan, M. (2009). A brief history: In Birth day: a pediatrician explores the science, the history and the wonder of childbirth. (pp. 63-75). New York: Ballentine Books.
Van Rheenen, P.F., Gruschke, S. & Brabin, B.J. (2006). Delayed umbilical cord clamping for reducing anaemia in low birthweight infants. BMJ. 333(7575), 954-958.
NICE. (2007). Intrapartum care: care of healthy women and their babies during childbirth. Retrieved April, 23, 2014, from www.nice.org.uk/nicemedia/pdf/CG55FullGuideline.pdf
McDonald, S.J. & Middleton, P. (2008). Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Obstetrics and Gynecology, 112(1), 177-178.
Jelin, A., Kuppermann, M., Erickson, K., Clyman, R. & Schulkin, J. (2012) Obstetricians' attitudes and beliefs regarding umbilical cord clamping. Journal of Maternal, Fetal, Neonatal Medicine, 25(S2), 1-115.
Hutchon, D. J. R. (2012). Immediate or early cord clamping vs delayed clamping. Journal of Obstetrics and Gynaecology, 32(8), 724-9.
Dunn, P.M. (1984). Reservations about the methods of assessing at birth the predictive value of intrapartum fetal monitoring including premature interruption of the feto-placental circulation. In Rolfe, P.(Ed.), Fetal physiological measurements. Report of the 2nd International Conference, (pp.130-175). Oxford: Butterworths Press.
Hutchon, D.J. R. & Thakur, I. (2008). Resuscitate with the placental circulation intact. Archives of Disease in Childhood, 93(5), 451.
Mercer, J. & Bewley, S. (2009). Could early cord clamping harm neonatal stabilisation? Lancet, 9687 (374), 377-378.
Gallagher, N. (2011). Delayed Cord Clamping Grand Rounds Parts 1-4. Retrieved April, 24, 2014, from http://www.youtube.com/watch?v=cX-zD8jKne0
The Resuscitation Council (2010). Newborn Life Support. Retrieved April, 23, 2014, from http://www.resus.org.uk/pages/nls.pdf
Emerson, K. (2012). Cord around the neck – what parents & practitioners should know. Retrieved April, 24, 2014, from (http://cord-clamping.com/2011/11/04/cord-around-the-neck-what-parents-practitioners-should-know/.
Mercer, J.S., Vohr, B. R., McGrath, M. M., Padbury, J. F., Wallach, M.& Oh, W. (2006). Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial. Pediatrics, 117(4), 1235-42.
Chow, D. (1999). Cutting of the nuchal cord before birth. Retrieved April, 23, 2014, from http://cord-clamping.com/2012/05/10/on-trialcutting-of-the-nuchal-cord/
Diaz-Rossello, J.L. (2006). International perspectives: cord clamping for stem cell donation: medical facts and ethics. Neoreviews, 7(11), 557-63.
Tolosa, J. N., Park, D. H., Eve, D. J., Klasco, S. K., Borlongan, C. V. & Sanberg, P. R. (2010). Mankind's first natural stem cell transplant, Journal of Cellular Molecular Medicine. 14(3), 488-95.
Kirkham, M. (2007) Cutting the cord. Retrieved April, 23, 2014, from http://www.theguardian.com/society/2007/may/24/health.comment
Emerson, K. (2010) Cord around the neck – what parents & practitioners should know. Retrieved April, 23, 2014, from http://midwifethinking.com/2010/07/29/nuchal-cords/.
Todorich, B., Juana, M., Pasquini, C.,Corina, I., Garcia, J., Pablo, M. & Connor, J. R. (2008). Glia. Volume 57(5), 467–478.
Andersson, O., Hellstrom-Westas, L., Andersson, D. & Domellof, M. (2011). Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. BMJ. (343), 7157-61.
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Like all other independent midwives, my clients are excellent candidates for a physiological third stage as the general norm is such that they have remained low-risk during labour and there has been no emergency or medically initiated cascade of intervention. This approach does not entail any action whatsoever (clamping and giving an oxytocic injection) and simply allows the placenta to come out on its own. I've always endeavoured to share information about the highly beneficial, hands-off approach. The less fiddling the better.
I'm including an article I wrote on the subject of Delayed Cord Clamping (DCC) as defined by a ''delay of clamping by 60 seconds or more'' -RCOG (2016). Its jargon heavy and not overly accessible for those without a medical background, so please go to ''Links'' for more woman-friendly information. You can return here if your interest has been ignited and you want to know more.
Delayed cord clamping - Elizabeth Ord-Hume
This article will discuss the increasing body of evidence that favourably indicates the practice of delayed cord clamping (DCC), a method of cord management that has increased since I last practiced in the NHS. Given the latitude of this topic, this study will give priority to specific areas of relevance only, as opposed to attempting to address the full scope of the subject matter. The research findings of a selection of studies will be disseminated in furtherance of the medical rationale underpinning the statement by the Royal College of Midwives (2014) that DCC, as opposed to early cord clamping (ECC) is “overall beneficial to the baby”. Following a brief retrospective look at the history of cord clamping and initial definitions of “early” and “delayed”, the requisite framework of the cultural norms and barriers influencing cord management will be examined in prelude to the investigation of referenced research data that signify the advantages of DCC on neonatal physiology. Furthermore, concerns regarding whether ECC actually disadvantages a baby’s healthy development will be posited and the question as to whether ECC is essentially an iatrogenic practice will be critically evaluated within the context of medical ethics and informed consent. To conclude, recommendations for future practice will be suggested.
Since the mid-1960s the standard obstetric practice dictating cord management has incorporated the widespread view that clamping and cutting immediately at birth constitutes best practice. Previously the umbilical cord was not interfered with, resulting in the full complement of fetal blood being transfused to the baby, an amount equal to 30 – 40% of a baby’s total blood volume (Hutton, 2007). Sloan (2013) reports that medics and scientists such as Aristotle and Hippocrates are recorded to have written positively of the practice and cites the first mention of ECC as circa 1600s, which later in 1801 was declared by physician Erasmus Darwin (Charles’ grandfather) as “a very injurious thing” that left babies “much weaker than [they] ought to be.” Given the mounting evidence in favour of DCC, we are now seeing a gradual movement towards the return of a non-interventionist approach towards cord management.
However, in researching DCC, one is confronted with a controversial issue, i.e. the absence of a universally accepted definition of the word “delayed”. Van Rheenen et al (2006) refer to the continuing debate regarding the interpretation of terms such as “early” and “delayed” as a contributory factor towards the lack of agreement among research clinicians involved in informing current practice. The RCM (2012) who are in support of DCC have yet to announce specific guidelines regarding the timing of clamping. Similarly, NICE (2007) refer to DCC, but only in relation to the physiological management of the third stage. The guidelines fail to provide a suggested length of delay and cite DCC as part of a package that may include the routine use of uterotonic drugs. To avoid confusion the following definitions, as presented by McDonald and Middleton (2008) will be used as unifying criteria specifically for the purposes of discussing selected research findings: ECC- defined as clamping of the cord between birth and one minute after birth and DCC- defined as clamping of the cord after one minute of birth, or upon cessation of the cord pulse.
The general view among the multidisciplinary clinical team is that for the first time in decades cord management is essentially at a point of change. Yet, thwarting the potential movement towards an immediate shift in practice are persistent cultural barriers, despite mounting evidence from randomised controlled trials. Jelin et al’s (2013) study sought to determine how reflective of the cumulative body of literature obstetricians’ attitudes and beliefs indeed are regarding DCC. The conclusions to a rigorous questionnaire-based study suggest that obstetricians’ opinions fall short of being consistent with evidence accumulated from multiple randomised controlled trials. This is a serious concern given that the vast majority of midwives are employed by the NHS and work in obstetric-led units, a setting where the author suggests midwives commonly experience a diminished sense of professional autonomy, where they are more likely to concede to, rather than challenge specious practices such as routine ECC.
Multifarious barriers that render the practice of DCC slow to be incorporated into midwifery and obstetric practice are cited by Hutchon (2012) and include: “1) Cord blood gases, 2) resuscitation, 3) nuchal cord, 4) cord blood banking and 5) the need for neonatal blood grouping in rhesus negative mothers”.
Hutchon addresses each barrier with clinical rationale, the first being the collection of cord bloods to measure blood gases. Hutchon argues that cord gases are primarily for medico-legal and audit purposes and are of no benefit to the individual baby. In addition to this, she explains that during physiological transition from fetal to infant circulation, the values given in blood gas results will in every case conflict with the neonate’s blood gas levels once independent respirations have commenced and therefore offer insubstantial information for clinical prognosis. Gallagher (2011) also addresses the medico-legal issue by pointing out that because DCC results in significantly different measured values of cord blood acid-base, it is important to document the time at which the cord was clamped given how DCC reduces pH and increases base deficit values in umbilical arterial blood samples.
Hutchon, along with an increasing number of lead clinicians (Dunn 1984; Hutchon and Thakur 2008; Mercer and Bewley 2009), assert that the second barrier “resuscitation”. contrary to standard belief, is directly benefitted by DCC and states that the burden of evidence indicates that maintaining placental circulation while allowing the transfusion of a greater percentage of blood in these babies, is actually more likely to facilitate recovery and neonatal adaptation than add compromise. Subsequently, Gallagher (2011) has incorporated DCC into the Newborn Network guidelines for neonatal resuscitation in which is stated, “The first minute after birth is mainly occupied by assessment and stimulation of the infant and hence they will not be compromised by a slightly delayed transfer to the resuscitaire”.
The Resuscitation Council (2010) guidelines promote DCC for term babies for at least one minute, or until the cessation of the cord pulsation and for preterm babies in good condition at birth, a delay of up to three minutes. The RC have by their own admission limited data on the advantages and disadvantages of delayed cord clamping in the non-vigorous infant and concur with Hutchon that there is insufficient evidence to define an appropriate time to clamp the cord in babies requiring resuscitation. They state, “This may be because time is the wrong defining parameter and perhaps the cord should not be clamped until the baby has started breathing.”
The third barrier to DCC identified by Hutchon is that of the “nuchal chord”. Nuchal chords occur at more than a third of labours and as Emerson (2013) advises, should be left untouched. However Mercer et al. (2006) indicate that it remains standard practice to feel for a nuchal chord, yet such handling can stimulate the umbilical arteries to vasoconstrict, thereby reducing fetal oxygen. Moreover, clamping and cutting nuchal cords can lead to cerebral palsy, states Chow (1999). Mercer et al advise that the best procedure indicated for a nuchal chord is to facilitate the baby to be born using the somersault manoeuvre.
As deduced by Hutchon, the fourth potential barrier to midwives and doctors offering DCC concerns “stem cell collection”. Diaz-Rossello (2006) indicates that residual placental blood volume is of prime importance and that DCC will result in suboptimal volumes and be insufficient for banking. Hutchon responds by stating that public banks will “need to consider other methods to harvest the billions of stem cells left in the placenta if the life-saving use of the cells is to continue”. Fogelson (2011) points out that the transplantation of stem cells occurs in nearly all mammals via the cord at the time of birth and that the only mammal that actively prevents this natural transplantation is the human. He emphasises the point that due to there being a fixed number of fetal stem cells available to the baby, if we “rob” the baby of 40% of its blood volume, we also rob the baby of a substantial portion of stem cells. He stresses that a reverse argument for harvesting and storing these cells must ask the question why we would deprive a baby of its own stem cells in the first place, given how within the full complement of blood volume exist stem cells that carry the potential to become any kind of biological cell. Accordingly, in the instance of ischemic injury, a human being with all its stem cells would be at a greater advantage to deal with such a trauma than one with reduced numbers of stem cell. Tolesa et al (2010) echo this stance by positing that “a delay in cord clamping may increase the stem cell population in the baby, promoting an innate stem cell therapy that can promote acute benefits in the case of neonatal disease, as well as long term benefits in age-related diseases’’.
Of all the barriers listed by Hutchon, the argument against DCC on grounds of the fifth barrier (the collection of cord bloods to determine the baby’s blood group), is the one that has least credence. An anonymous haematology laboratory technician located within one London Trust hospital states that the minimum amount of cord blood required to perform a Kleihauer test is just 2 mls. At the majority of births it is not a challenge to collect this amount while simultaneously allowing for a DCC.
The physiological affects of DCC have been demonstrated in numerous studies including the study conducted by Mercer et al (2006) which examined the outcomes of 72 mother infant pairs born at <32 weeks gestation, whereby 36 neonates were trialled for DCC and the other half received ECC. Both groups of neonates were evaluated for bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH) and late onset sepsis (LOS). Clinical significance was demonstrated by the following: in the DCC group, no neonatal deaths occurred, however in the ECC group, 8 deaths occurred. Additionally, among the DCC neonates, only 14% of neonates developed Grade 1 IVH. Grade 1 IVH has less clinical impact than IVHs of a higher grade and by contrast, in the ECC group the numbers for IVH was more than twice than those receiving DCC, with 36% being diagnosed with IVH, the majority of which were of the more clinically significant Grade 2 variety. Furthermore, LOS was also reduced from 22% among the ECC group to 1% among DCC group. Since mortality, IVH and LOS can be reduced amongst this class of highly vulnerable neonates using DCC, an obvious conclusion is for the practice of DCC to be incorporated into the general management of pre-term neonates.
Iron appears to be the key factor in driving these improved outcomes. Andersson et al’s (2011) RCT focussed primarily on the iron status of 400 full-term babies grouped equally to receive either ECC or DCC, after low risk pregnancy. The strength of this study is that the babies were followed up at 4 months for further iron studies. Initial results indicated no significant differences in haemoglobin concentration between the groups, however the DCC group had a 45% higher mean ferritin concentration, a reduced prevalence of iron deficiency and a reduced prevalence of neonatal anaemia at 4 months of age. Secondary outcomes gave no significant differences between groups in postnatal respiratory symptoms, polycythaemia, or hyperbilirubinaemia requiring phototherapy. Furthermore, a larger study with perhaps even greater significance is that of McDonald and Middleton (2008) which studied the prevalence of infant anaemia among a sample group of 2989 babies. The results correlated with findings of Andersson et al’s RCT, however important were the follow-up haematological profiles conducted at 6 months which provided conclusive evidence that the benefits of DCC continue as the infant matures.
Fogelson (2011) proposes that from the perspective of evolution, mammals evolved to the natural equivalent of DCC, therefore an intervention that phlebotomises a baby of up to 40% of its blood volume, carry the potential to increase poorer outcomes in human health must be regarded within the definition of iatrogenesis. When navigating a line of practice that poses preventable harm, Hutchon (2012) supplies the view that ethical considerations with respect to professional legal duty must underpin any information given to parents by midwives in order to safeguard informed consent.
To conclude, given the overwhelming evidence to support DCC, it seems necessary to ask that a rational approach be taken to ascertain whether robust evidence exists to justify the continuation of ECC within the scope of contemporary midwifery practice. As midwives, our duty is to demonstrate theoretical expertise in relevant physiology and possess first-hand experience in its practice. Any barriers that may impede this process are best identified as areas requiring educational and supervisory interventions. In the interim between DCC being a minority practice and it becoming an integrated aspect of intrapartum care, the pragmatic and methodical philosophy of midwifery indicates the peer review process could be an appropriate intervention. Open peer discussions, together with the application of appraisal instruments such as questionnaires, could assist midwives to identify deficits in their theoretical understanding of DCC and consequently equip them to move forwards. Meanwhile, it is advisable to continue researching this physiological process and ensure that all clinicians are equipped with a reflexive understanding of current evidence.
References
RCM (2013). RCM supports delayed cord clamping. Retrieved April, 23, 2014, fromhttp://www.rcm.org.uk/college/about/media-centre/press-releases/rcm-supports-delayed-cord-clamping-11-07-13/.
Hutton, E. (2007). Late vs. early clamping of the umbilical cord in full-term neonates. JAMA, 297(11),1241-1252.
Sloan, M. (2009). A brief history: In Birth day: a pediatrician explores the science, the history and the wonder of childbirth. (pp. 63-75). New York: Ballentine Books.
Van Rheenen, P.F., Gruschke, S. & Brabin, B.J. (2006). Delayed umbilical cord clamping for reducing anaemia in low birthweight infants. BMJ. 333(7575), 954-958.
NICE. (2007). Intrapartum care: care of healthy women and their babies during childbirth. Retrieved April, 23, 2014, from www.nice.org.uk/nicemedia/pdf/CG55FullGuideline.pdf
McDonald, S.J. & Middleton, P. (2008). Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Obstetrics and Gynecology, 112(1), 177-178.
Jelin, A., Kuppermann, M., Erickson, K., Clyman, R. & Schulkin, J. (2012) Obstetricians' attitudes and beliefs regarding umbilical cord clamping. Journal of Maternal, Fetal, Neonatal Medicine, 25(S2), 1-115.
Hutchon, D. J. R. (2012). Immediate or early cord clamping vs delayed clamping. Journal of Obstetrics and Gynaecology, 32(8), 724-9.
Dunn, P.M. (1984). Reservations about the methods of assessing at birth the predictive value of intrapartum fetal monitoring including premature interruption of the feto-placental circulation. In Rolfe, P.(Ed.), Fetal physiological measurements. Report of the 2nd International Conference, (pp.130-175). Oxford: Butterworths Press.
Hutchon, D.J. R. & Thakur, I. (2008). Resuscitate with the placental circulation intact. Archives of Disease in Childhood, 93(5), 451.
Mercer, J. & Bewley, S. (2009). Could early cord clamping harm neonatal stabilisation? Lancet, 9687 (374), 377-378.
Gallagher, N. (2011). Delayed Cord Clamping Grand Rounds Parts 1-4. Retrieved April, 24, 2014, from http://www.youtube.com/watch?v=cX-zD8jKne0
The Resuscitation Council (2010). Newborn Life Support. Retrieved April, 23, 2014, from http://www.resus.org.uk/pages/nls.pdf
Emerson, K. (2012). Cord around the neck – what parents & practitioners should know. Retrieved April, 24, 2014, from (http://cord-clamping.com/2011/11/04/cord-around-the-neck-what-parents-practitioners-should-know/.
Mercer, J.S., Vohr, B. R., McGrath, M. M., Padbury, J. F., Wallach, M.& Oh, W. (2006). Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial. Pediatrics, 117(4), 1235-42.
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