Fiona Godlee has neatly summarized the decades of research into the timing of umbilical cord clamping. She is not the first to have called for a change in practice in recent years. (Mercer, Hutchon 2008, Weeks, Hutchon 2010). Nevertheless, surveys of third stage practice in modern maternity units illustrate the prevailing popularity of early cord clamping (Downey, Ononeze, Mercer 2000). This has been attributed to the influence of tradition, lack of knowledge and gaps in the research. These gaps have been exploited by both sides of the argument.
The NHS Blood and Transplant’s recent report into the UK Stem Cell Strategic Forum for The Future of Unrelated Donor Stem Cell Transplantation in the UK has been cited above. It implies an association between cord blood banking and delayed cord clamping. This seems to contradict the previous statement that cord blood banking is performed in adherence to ‘standard UK birthing protocols.’ Both NICE guidelines and common practice advocate early cord clamping.
The paragraph continues: ‘advantages of delayed cord clamping are improved iron stores and a lower risk of an intraventricular haemorrhage.’ Whilst delaying clamping has indeed been shown to improve iron status in term infants (Andersson), its protection against intraventricular haemorrhage has only been proven in premature neonates (Mercer 2006), a group unlikely to be suitable candidates for cord blood donation. The data could potentially be extrapolated to term infants: it is hypothesised that early interruption of the placental circulation causes a rapid rise in peripheral resistance, which could potentially result in haemorrhage within vulnerable brains (Barrett). Nevertheless, the evidence for delaying clamping is more compelling in premature babies. It is misleading to maternity practitioners and irresponsible to patients to extrapolate findings from outside the relevant subject group, in this case, preterm infants for cord blood banking.
Until the available evidence is specific and comprehensive, its translation into medical practice should be carefully considered. Delayed cord clamping was considered the non-intervention in the 1989 edition of ECPC (Chalmers), echoing the opinion of Archie Cochrane. It was only later that delayed cord clamping became considered as the experimental intervention. Delayed cord-clamped infants are less likely to require resuscitation and respiratory support, and preterm neonates may also obtain protection against respiratory distress syndrome, intraventricular haemorrhage and sepsis (Rabe, Mercer 2006). If cord blood banking is to become as widespread as is hoped by the NHSBT, its implementation should be accompanied by clearer information on the impact of the timing of cord clamping. This, in addition to the current revision of NICE third stage guidelines, will necessitate a thorough review of the evidence base.
Andersson O, Hellström-Westas L, Andersson D, Domellöf M. Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. British Medical Journal 2011;343:d7157
Barrett KE, Barman SM, Boitano S, Brooks HL. Ganong’s Review of Medical Physiology, 23rd Edition. Lange Basic Science 2010, 584
Chalmers I, Enkin MW, Keirse C (eds). Effective care in pregnancy and childbirth (Volumes 1 and 2). Oxford University Press, 1989
Downey C, Bewley S. Childbirth Practitioners' Attitudes to Third Stage Management. British Journal of Midwifery 2010;18(9):576-582
Hutchon DJR. A view on why immediate cord clamping must cease in routine obstetric delivery. The Obstetrician & Gynaecologist 2008:10(2):112–116
Hutchon DJR. Why do obstetricians and midwives still rush to clamp the cord? British Medical Journal 2010;341:c5447
Mercer, J.S., Nelson, C.C., Skovgaard, R.L. (2000). Umbilical cord clamping: beliefs and practices of American nurse-midwives. Journal of Midwifery & Women's Health 45(1), 58-66.
Mercer JS, Vohr BR, McGrath MM, Padbury JF, Wallach M, Oh W. Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial. Pediatrics 2006;117(4):1235-1242
Ononeze, A.B., Hutchon, D.J. (2009). Attitude of obstetricians towards delayed cord clamping: a questionnaire-based study. Journal of Obstetrics and Gynaecology 29(3), 223-224.
Rabe H, Reynolds G, Diaz-Rossello J. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database of Systematic Reviews 2004, Issue 4. Re-published online with edits: 21 January 2009 in Issue 1, 2009
Weeks, A. (2007). Umbilical cord clamping after birth. British Medical Journal 335, 312-313.
DJR Hutchon is a co-inventor of the BASICS trolley currently being manufactured by Inditherm. He has no financial interest in this and any profits/royalties will go to a baby charity or developing world. He organised and invited all the participants to the meeting in Worcester which initiated the development of this equipment.