Recent rapid responses

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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.

Competing interests: 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.

Candice L Downey, Junior doctor

David JR Hutchon

Leeds Teaching Hospitals Trust

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Godlee made a nice link between crying babies and cord clamping. She expressed surprise that after all the evidence that 95% of obstetricians and midwives still clamp the cord quickly. I suspect that in the vast majority of births the cord is clamped long before two minutes, with most under 30 seconds.

Of course there is inertia within the profession but there is also an undercurrent of influential individuals who do not want to change the status quo. The government is trying to increase the number of cord blood donations but successful stem cell collection is less likely to be successful after delayed cord clamping. The work of Yao et al and Farrar et al shows that there is rarely more than 50 mls residual blood in the placenta even after one minute delay in clamping. This volume is unlikely to be sufficient for successful stem cell banking. The staff at Barnet General Hospital, Northwick Park Hospital, Luton & Dunstable Hospital, Watford General Hospital, St George's Hospital and University College Hospital are likely to feel an obligation to the blood transfusion service to ensure that they are submitting a sufficient number of specimens.

The common perception is that routine early cord clamping is of little consequence to the baby. The Andersson et al study and the editorial by Patrick van Rheenen clearly shows that there is a potentially harmful effect for the baby. How many women, who consented to donate their babies blood, were informed of the risk for their baby of depleted iron stores and a higher risk of an intraventricular haemorrhage with early cord clamping as explained in The Future of Unrelated Donor Stem Cell Transplantation in the UK
http://www.nhsbt.nhs.uk/pdf/uk_stem_cell_strategic_forum_annex.pdf

It really is a world scandal because all that is needed to be done is to find a way of extracting the billions of stem cells that are left in the placenta after a physiological 3rd stage or delayed cord clamping. Is anything being done- NO - they find it too easy just to persuade most midwives and obstetricians that cord clamping makes little difference to the baby, and raise the fear that there might even be long term hazards of “leaving things to nature”. Could the perverse or at least non-sensical descriptions of physiological transition in books such as Ganong be driven by the need for large residual placental volumes?

It could be another 3 years before the NICE guideline is changed to match the advice of WHO, FIGO, ICM, and ILCOR, (Hutchon) and even then there is no guarantee that it will recommend delayed clamping. Some units, concerned about CNST may not be willing to ignore current NICE guidelines.

Common sense tells us that suddenly clamping off 40% of the cardiac output (which is what happens with immediate cord clamping) cannot be good for the heart or the remaining circulation. It is the hypovolaemia which gets the most attention because it is easy to measure but both are probably important.

Research to find a method to extract the residual stem cells from the placenta is urgently needed. No-one wants to prevent curative therapy for patients with leukaemia and other haematological malignancies. Equally no-one receiving such therapy would be comfortable if they thought a baby had risked anaemia or intraventricular haemorrhage in order to provide the blood sample.



References.

Yao Yao AC, Hirvensalo M, Lind J. Placental transfusion rate and uterine contraction. Lancet 1968;1:380-3

Farrar Farrar D, Airey R, Law G, Tuffnell D, Cattle B, Duley L. Measuring placental transfusion for term births: weighing babies with cord intact. BJOG 2011;118:70–75.

Andersson BMJ2011;343:d7157

van Rheenen BMJ2011;343:d7127

Hutchon BMJ 2010;341:c5447

Competing interests: I am a co-inventor of the BASICS trolley currently being manufactured by Inditherm, I have no financial interest in this and any profits/royalties will go to a baby charity or developing world. I organised and invited all the participants to the meeting in Worcester which initiated the development of this equipment.

David JR Hutchon, Retired Obstetrician

Memorial Hospital, Darlington, Hollyhurst Road, Darlington.

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17 December 2011

Infants usually cry in their first three months of life. Male infants cry more vigorously than females. Some cry from early evening till midnight, and others from midnight till early morning. This pattern has been observed in Yemen. They are usually active and when put on the breast they suck vigorously. We usually hear loud bowel sounds. Crying reduced when being put on their tummy. This is reassuring for parents, especially if this is their first baby. Examination of the baby reveals no abnormal findings other than mild abdominal distension, and parents need explanation & reassurance. In Yemen, breastfeeding mothers who eat a lot of gas-producing food (broad beans & peas) are more likely to have vigorously crying infants.

Competing interests: None declared

Salem Banajeh, Paediatrician

Sana'a University, Al-Sabeen Hospital

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