For our first Tea Morning we chose to look at the topic delayed cord clamping. As a subject we thought we knew a fair amount about it, but when we started digging deeper into the information, we were blown away. Here are the goods, we hope that by the end of this post, you will be asking the same question as the title of the post.
It is unclear when early cord clamping became widely used, but we suspect it came around the same time that birth became more medicalised and was moved into hospitals – 1960’s – 1970’s. Early cord clamping is practiced without any thought to its effect. Until the benefits of delayed cord clamping was illuminated, it really was not thought to have any particular positive of negative impact on neonatal and childhood outcomes.
How do we define early vs delayed clamping?
Early cord clamping is clamping and cutting before 30 second after birth, this is currently common practice in South Africa with the exception of specific practitioners implementing it for preterm infants.
Delayed cord clamping – a standard definition is elusive. Different articles define it differently, the variations are: cutting the cord from between 30 – 60 seconds after birth; no earlier that 1 minute after birth1 ; or after 5 minutes post birth; or after cessation of cord pulsation; or leaving it until after the placenta is born; or for the cord to dry out and fall off by itself.
What can we observe from nature?
We did some searching on the internet to see what we could learn from other animals. In elephants, the cord snaps in second stage and the baby has about 20 minutes worth of oxygen supply – we were overwhelmed watching a mother elly kick and desperately urge her newborn before it started breathing. In dolphins, the cord also snaps at the newborn end, allowing the calf free agility and to swim to the surface for air, supported by the mother. Talk about a sudden transition intra- to extrauterine transition!
Closer to home – in mammals like primates, horses, donkeys, cats and dogs, the mother is not in any hurry to do anything with the umbilical cord. There is a rest period following the birth and delivery of the placenta, after which the mother will sever the cord, often consuming the membranes and placenta – more about this later. Anyway, there is no rush, no emergency.
Our closer cousins, chimpanzee mothers, are said to ignore the matter entirely, and haul the placenta around with the baby until the cord dries up and drops off. Interesting.
What are the benefits of allowing babies to receive all their blood?
The normal blood volume of a full term average newborn is about 300 – 400ml (roughly 80ml -90ml/kg)2. Of this amount, there is still about 150 ml in the placenta at birth. Within the first 60 seconds after birth about 80 ml has been transfused into the baby, reaching 100 ml at about 3 minutes. So when clamping and cutting of the cord is delayed by as little as 3 minutes, a baby receives about a third of its blood.
This can add up to 50 mg/kg of body weight so total blood volume (total fluid pumping around the body) is increased.
Imagine an adult losing a third of their blood -they would have to be rushed to hospital with stage 2 haemorrhagic shock. They would require intravenous fluid and a blood transfusion.
When we cut early, we deprive a newborn of its own blood – we are technically bloodletting the baby. Here is Penny Simkin showing us what a huge percentage of blood is still due to a baby at birth:
Here is a list of the compelling benefits of delaying clamping of the cord:
Increased heamoglobin (a conjugated protein in our red blood cells that carry oxygen to the tissues of the body, and carbon dioxide from tissues to lungs) and hematocrit (the ratio of the volume of red blood cells to the total volume of blood – thanks wiki) means an increased oxygen supply – a better oxygenated baby is a more relaxed baby
Receiving all its cord blood is a baby’s first stem cell transplant3. The baby automatically receives pluripotent (capable of developing into any type of cell) stem cells, as well as maternal antibodies. Stem cells provide the potential for improved organ repair. This means that baby gets cells that have the potential to become any cell that’s needed. This is possibly used as needed during repair from damage within the first couple of years of life, with some research suggesting that this might continue up into adulthood. Consider the potential benefits of having the cell that we can store at such a high price transfused straight into our babies bodies.
A note on the storage of cord blood – banking cord blood involves immediate, very early cord clamping, to take a significant amount of blood (100ml on average), which is crucial for the baby and can be as much or more than a third of the baby’s own blood. This is taken at a stage when a newborn is most vulnerable and deprives it of these super cells. This topic should be further discussed with your care provider, because options like storing the cord instead of the first blood is also an option – in turn giving the baby the initial benefit and storing some cells
There is a lower risk for perinatal complications such as inter ventricular bleeds due to hypoxaemia. This benefit is especially pronounced in preterm infants.15
One of the major benefits is an increase in iron stores that may help prevent iron deficiency causing anaemia during the first year of life. This directly decreases the need for iron supplementation.15
The long-term importance of iron is massive.
A two-minute delay increases 27-47mg Iron – the equivalent of 6 months15 of requirement – a normal infant is about 0,2 mg per day (0-6 months) and for a toddler (6-12 months) needs about 0,55 mg per day.4 This advantage in babies’ iron stores does not affect the mother’s iron levels.15
What is iron needed for?
- Production of red blood cells – oxygen carrying capacity ensuring proper and efficient functioning of all the organs. All cellular activity is dependent on oxygen for energy production and life.2
2. Effects on neurocognitive and neurobehavioral development – iron forms an integral part of neural development (the actual physical/mechanical structures), and is essential for the actual development of neurons and their differentiation into cells with specific function as a whole in the brain, as well as the biochemical environment (the neurotransmitters) and the proper functioning of the system.
3. Formation of oligodendrocytes – they produce myelin that wrap around neurons (this process is called myelination) and help to transmit impulses. They are responsible for making white matter in the brain. White matter is responsible for speeding up the impulses between areas of grey matter where cognition and processing happens.
4. Decreased arborisation – causing decreased number and complexity of interneuronal connections. The neuronal systems laid down forms the foundation of all neural development including behaviour and cognition – including learning and remembering simple and complex tasks.5
5. Another effect of iron is on neurochemistry and especially the monoaminergic pathways – dopamine and norepinephrine pathways. These pathways are responsible for sleep cycles, control of motor functions, learning, memory and pleasure sensations. In essence it’s signal controlling of the normal functions.10-12
6. Myoglobin – iron containing oxygen storage protein in muscle cells responsible for normal muscle metabolism and function.
7. Cytochromes (one haeme group and one protein) are electron carrying systems within cells responsible for energy transfer within cells and especially within mitochondria (power houses of the cells) where energy production takes place.
8. Other key functions for the iron-containing enzymes (e.g., cytochrome P450) include the synthesis of steroid hormones and bile acids; detoxification of foreign substances in the liver.
Iron is reversibly stored within the liver as ferritin and hemosiderin whereas it is transported between different compartments in the body by the protein transferrin.
Who are the babies that are at risk for developing iron deficiency in early childhood?
- Babies who are born prematurely — more than three weeks before their due date.Low birth weight babies – less than 2500g.
- Babies who drink cow’s milk before age one.
- Breast-fed babies who aren’t given complementary foods containing iron after six months of age.
- Babies who drink formula that isn’t fortified with iron.
- Children ages 1 to 5 who drink more than 710 millilitres of cow’s milk, goat’s milk or soy milk a day
- Children who have certain health conditions, such as chronic infections.
- Children on restricted diets.
- Children ages 1 to 5 who have been exposed to lead.
What does an iron deficient child present with?
- Pale skin.
- Fatigue or weakness.
- Slow cognitive and social development.
- Difficulty maintaining body temperature.
- Increased likelihood of infections or recurrent infections.
- Unusual cravings for non-nutritive substances, such as ice, dirt or pure starch – the condition is called pica.
By delaying the clamping of the cord, we can greatly help to ease babies’ transition into extrauterine life. Babies are born from a safe, soft, dark, muted and warm place so integrated into the mother’s body. Often early cutting results in the necessity for other interventions to take place, and mostly away from the mother, which is really the place that can offer the newborn everything it needs – immediate skin-to-skin contact after birth helps a baby to regulate breathing, temperature, and heart rate, and sets the stage for optimal bonding and allows a baby to feel safe, to allow for those important bonding hormones to flow. Undisturbed bonding is led by mother and baby.
When a baby is separated from it’s mother, it is experiencing a stress, and the release of cortisol and adrenaline.14 When a newborn is left on the mother’s chest or abdomen, mom and baby are releasing a unique cocktail of hormones that facilitate bonding. Through skin contact, smell, taste, sight and sound, the two get to fall in love with each other – basically ensuring that the mothering instincts kick in to afford the baby the optimal loving and nurturing care and protection that it needs in its vulnerability. This bonding awakens in the mother a ferocity to care for her young above anything else.
This crucial bonding is also helped along by the next benefit:
Endorphins and other hormones are shared through the placenta via the umbilical cord between mother and baby.
Allowing a baby its full blood supply, ensures that it receives the full retinue of clotting factors. This, in addition to early breastfeeding (colostrum is high in Vitamin K), could be an interesting research topic with regards to the recommended Vitamin K shot or drops that most babies receive immediately after birth.
What are the drawbacks?
The main cons were thought to be an increased risk of post partum haemorrhage from the mom, in the infant the main concern was that they will be more prone to neonatal jaundice from polycythaemia (increased heamatocrit). Studies17,18 show that both these concerns were only theoretical and that in practice this was not the case. Also importantly no added benefit was shown by milking the cord or by holding the newborn below the level of the uterus as the uterine arteries have smooth muscle layers that contract to actively pump blood from the placenta to the fetus.18,19 This implies that the baby can be left on the mother’s chest directly after delivery and wait for the cord to stop pulsating.
Specific conditions in which delayed cord clamping is not recommended are for instance placental abruption, rhesus incompatibility, monochorionic twins, placenta previa and other emergent circumstances in which the care provider estimates the benefits of early clamping more than delaying it.
Here is a clip of Grand Rounds that goes into a lot of detail:
Lotus birth (umbilical cord non severance)16 – the opposite side of the spectrum.
Lotus birth is the practice of not severing the umbilical cord, and letting it dry and drop of naturally after 3 to 6 days. The baby, cord and placenta are treated as one unit – they all originate from the same cellular source and are a molecular unit.
Lotus babies are observed to be relaxed and peaceful. There is a decreased risk of infection at the naval site .
In yogic terms, the non severance of the cord is a further practice of ahimsa -non-violence in action and in thought, within one’s self and towards others, doing no harm. Another yogic principle is the sacredness of the first 40 days, and with lotus births, this time tends to be valued for this nature and treated consciously. Also, it can be viewed as a practice of letting go of all attachment, something experienced perfectly in the gentle breaking off of the cord.
After the placenta is birthed, it can be kept next to the baby in a special cloth or container, and covered with herbal powder and sea salt to help it dry.
Placentophagy – ingesting your baby’s placenta
This is common practice in some Asian cultures. In some mammals, the mother ingests some of the amniotic fluid, as well as the afterbirth. It has been found that this boosts endogenous opioid production to alleviate pain and stimulate maternal behaviours.
Increasingly, new mothers have been consuming the placenta, either dehydrated and encapsulated or raw, and this is reported to help stop post partum haemorrhage, increase strength, relieve post partum depression, helps the production of breast milk, and speeds up the mother’s recovery.
The placenta contains various vitamins and protein, as well as corticotropin-releasing hormone, CRH, known to reduce stress.
Some schools of thought promote cooking or steaming it prior to encapsulation. These tablets are then consumed over the first couple of weeks to months.
In closing we are now even more convinced that delaying the clamping and cutting of the cord should be the norm in all the different settings where women choose to birth their babies and for vaginal as well as for surgical births.
Like Alan Green and Robin Lim, we are calling for a revolution based on evidence that will change the world – one birth at a time. Watch their inspiring calls to action:
Robin Lim’s latest book is called Placenta: The Forgotten Chakra, we are in the process of reading it, and would recommend it if you feel drawn to learn more.
- Optimal timing of cord clamping for the prevention of iron deficiency anaemia in infants: World Health Organisation.
- Tolosa JN, Park DH, Eve DJ, Klasko SK, Borlongan CV, Sanberg PR. Mankind’s first natural stem cell transplant. J Cell Mol Med. 2010 Mar;14(3): 488-95. doi: 10.1111/j.1582-4934.2010.01029.x. Epub 2010 Feb 5.
- Food and Nutrition Board: Institute of Medicine. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, manganese, Molybdenum, Nickel, Silicon, Vanadium and Zinc. Washington DC: National Academy Press, 2001.
- Losoff B, Beard J, Connor J, Barbara F, Georgieff M, Schallert T. Long-lasting neural and behavioral effects of iron deficiency in infancy. Nutr Rev. 2006;64:S34–43.
- Rao R, Tkac I, Townsend EL, Ennis K, Gruetter R, Georgieff MK. Perinatal iron deficiency predisposes the developing rat hippocampus to greater injury from mild to moderate hypoxia-ischemia. J Cereb Blood Flow Metab. 2007;27:872.
- Ward KL, Tkac I, Jing Y, Felt B, Beard J, Connor J, Schallert T, Georgieff MK, Rao R. Gestational and lactational iron deficiency alters the developing striatal metabolome and associated behaviors in young rats. J Nutr. 2007;137:1043–9.
- Rao R, Tkac I, Townsend EL, Gruetter R, Georgieff MK. Perinatal iron deficiency alters the neurochemical profile of the developing rat hippocampus. J Nutr. 2003;133:3215–21.
- Beard JL, Wiesinger JA, Connor JR. Pre- and postweaning iron deficiency alters myelination in Sprague-Dawley rats. Dev Neurosci. 2003;25:308–15.
- Burhans MS, Dailey C, Beard Z, Wiesinger J, Murray-Kolb L, Jones BC, Beard JL. Iron deficiency: differential effects on monoamine transporters. Nutr Neurosci. 2005;8:31–8.
- Beard J, Erikson KM, Jones BC. Neonatal iron deficiency results in irreversible changes in dopamine function in rats. J Nutr. 2003;133:1174–9.
- Wiesinger JA, Buwen JP, Cifelli CJ, Unger EL, Jones BC, Beard JL. Down-regulation of dopamine transporter by iron chelation in vitro is mediated by altered trafficking, not synthesis. J Neurochem. 2007;100:167–79.
- Who is at risk for iron deficiency anaemia? http://www.nhlbi.nih.gov/health/health-topics/topics/ida/atrisk
- Moore ER, Anderson GC, Bergman N, Dowswell T. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2012 May 16;5:CD003519. doi: 10.1002/14651858.CD003519.pub3.
- Chaparro CM, Neufeld LM, Tena Alavez G, Eguia-Líz Cedillo R, Dewey KG. Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomised controlled trial. Lancet. 2006 Jun 17;367(9527):1997-2004.
- Usher,R.,Shephard,M.,andLind,J. The blood volume of the newborn infant and placental transfusion. Acta paediat. 52: 497-512. 1963.
- AliceC. Yao, Mahmud Moinian, John Lind. Distibution of blood between infant and placenta after birth. Lancet. Volume 294 No 7626. p871–873, 25 October 1969.
- AliceC. Yao 1 , John Lind. Effect of gravity on placental transfusion. Lancet. Volume 294, No 7619. p505–508, 6 September 1969.