How Long To Delay Cord Clamping
The decision to delay umbilical cord clamping (i.e., to let it remain unclamped) has been a controversial subject for many years and continues to be so today. The arguments against delaying cord clamping include those that believe early clamping reduces blood loss by compressing the umbilicus, causing constriction of the vessels at their origin, which increases resistance to flow through them. There are also concerns about delayed clamping regarding hypothermia. These arguments have been countered with evidence from studies showing no increase in blood loss if there is proper compression of the umbilicus during routine neonatal care.
Delaying cord clamping may also be beneficial because the baby receives an adequate supply of oxygenated blood from both placenta and mother’s circulation. The amount of time between birth and clamping affects not only the volume of blood lost but also the incidence of fetal distress and low 5-minute Apgar scores. In addition, delaying clamping helps to reduce postpartum hemorrhage and prevents retained placentas.
However, as noted above, delaying cord clamping can result in hypothermia. Hypothermia occurs most often in premature infants who require radiant warmers. Delayed clamping should be avoided in these babies until they reach 36 weeks’ gestational age. This recommendation was based on research conducted in preterm infants whose mothers were exposed to cold air while waiting for doctors to clamp the cord. The researchers found that delayed cord clamping resulted in hypothermic episodes in 15% of the study group compared to 0% among control subjects given immediate cord clamping.
A recent randomized controlled trial of delayed versus immediate umbilical cord clamping showed no decrease in perinatal outcomes when delayed clamping was used. However, the authors did see an increased risk of placental abruption and lower 1-minute Apgar score in women who underwent delayed clamping. The American College of Obstetricians and Gynecologists recommends that physicians perform routine delayed cord clamping for any infant born weighing less than 4 pounds. For infants weighing 4 to 6 pounds, the practice remains controversial.
On the other hand, some obstetricians recommend immediate clamping of all newborns regardless of weight or gestational age. If this option is chosen, however, medical staff must ensure that the infant is placed immediately in skin-to-skin contact. Skin-to-skin contact allows the baby to receive warmth and comfort from his parent without being exposed to room temperature. It is believed that allowing the baby to stay in close proximity to its mother for several minutes promotes bonding between parents and child. Studies have shown that children who experience skin-to-skin contact soon after birth develop better emotional adjustment than do children who are separated from their mothers within 30 minutes.
As previously mentioned, delayed cord clamping is recommended for very small premature infants. Premature infants are typically considered “high-risk” patients. High-risk status means that the infant is at greater risk for complications. A major complication associated with delayed cord clamping is intraventricular hemorrhage (IVH). IVH results from bleeding into the fluid surrounding the brain. Bleeding near the base of the brain causes swelling, which then presses on the delicate brain tissue. If left untreated, the condition can lead to severe mental retardation.
In order to prevent clotting, the cerebrospinal fluid around the brain needs to contain enough dissolved proteins called gamma-globulins. Gamma globulins help to keep platelets together and allow them to stick to each other. When the umbilical cord is clamped, the pressure caused by tightening pulls apart the ends of the arteries and cuts off the blood supply to the baby, thus depriving the baby of gamma-globulins. Without sufficient gamma-globulin levels, the baby will suffer from low platelet count and poor clotting ability. Low platelet counts make the developing brain vulnerable to bleeding. The best way to avoid this problem is to maintain open arterial ducts. Arterial ducts connect the baby’s heart directly to the placenta, bypassing the umbilical vein. This procedure decreases the chance of IVH by increasing the concentration of gamma-globulins in the baby’s cerebral spinal fluid.
Another factor that determines whether or not delayed cord clamping is appropriate is the size of the infant. Infants under 2 pounds weigh too little to benefit from delayed clamping. Babies over 8 pounds are usually large enough to survive without the aid of mechanical ventilation support, such as continuous positive airway pressure (CPAP), thereby making delayed clamping unnecessary. However, larger babies are sometimes kept intubated because of breathing difficulties. During intubation, the lungs are compressed by suction created by the ventilator bellows. Intramuscular injection of steroids is another method of preventing lung collapse. Steroids improve alveolar stability, which translates into improved gas exchange.
An alternative to delaying clamping is intermittent cord clamping, where the cord is loosened every 3 to 10 minutes to allow fetal movements. Intermittent clamping has been shown to reduce the length of labor by up to 25%, the need for oxytocin augmentation, and delivery rate.
There are various methods for performing delayed cord clamping. One technique involves keeping the baby wrapped tightly in a blanket next to the mother’s chest wall. Another approach is known as Kangaroo Care, which is a strategy designed to promote optimal growth and development in premature infants. The goal of Kangaroo Care is to provide high quality health care and stimulate maternal-infant interaction. With Kangaroo Care, the infant spends much of the day in close contact with the caregiver/mother, who provides warmth, nutrition, and protection.
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