Why do obstetricians and midwives still rush to clamp the cord?
BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c5447 (Published 11 November 2010) Cite this as: BMJ 2010;341:c5447
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David JR is wondering why obstetricians and midwives still rush to
clamp/cut the cord, without having the support of the medical and
scientific literature.1 In order to offer interpretations we should not
look at cord cutting in isolation, but in the huge framework of neonatal
beliefs and rituals that have been transmitted from generation to
generation on the five continents for thousands of years. The primary
effect of all of them (e.g. the colostrum is harmful) is to separate
mother and newborn babies and to delay the initiation of breastfeeding. In
other words it is to neutralise the maternal protective aggressive
instinct. According to recent scientific advances a newborn baby needs its
mother: nobody knew that when I was a medical student around 1950. The
lesson is that we cannot overcome overnight thousands of years of cultural
conditioning.
Learning to delay this ritual intervention until the time when the
cord is thin, dry, and exsanguine would have spectacular health effects we
do not think of in developed countries. For example it would be theoretically an effective way to eradicate neonatal tetanus.2
1 Hutchon D J R. Why do obstetricians and midwives still
rush to clamp the cord? BMJ 2010; 341:c5447 doi: 10.1136/bmj.c5447
(Published 10 November 2010)
2 Odent M. Neonatal tetanus. The Lancet 2008; 371:385-386
DOI:10.1016/S0140-6736(08)60198-1
Competing interests: No competing interests
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More evidence needed to inform practice
The Royal College of Obstetricians and Gynaecologists' Scientific
Advisory Committee did not advise that there is 'no evidence that the
timing of cord clamping affected postpartum bleeding', rather it said
there is 'no statistically significant difference' for postpartum
haemorrhage or severe postpartum haemorrhage, and therefore the optimal
timing for cord clamping is 'unclear' (1). Lack of evidence of an effect
is not the same as evidence of lack of effect.
We agree that immediate cord clamping should have been rigorously
evaluated decades ago. We disagree that the current evidence supports 'a
rush to change'. Trials of immediate versus deferred cord clamping for
both term and preterm births (2,3) have not reported data for all
important outcomes, have been underpowered for serious adverse effects,
and lack adequate long-term follow-up of the women or children. This is
particularly important for very preterm infants, for whom the risk of
disability is greatest.
The conflicting recommendations about timing of cord clamping are
because the evidence on substantive clinical outcomes remains unclear.
For example, although the World Health Organisation has removed the need
for immediate cord clamping as part of active management of the third
stage of labour, this is described as 'weak recommendation, low quality
evidence' (4). It is unlikely that we will have consistency in
recommendations for practice until we have strong high quality evidence on
which to base them. There is a need for further randomised trials to
resolve the uncertainties. Opinion leaders and influential organisations
(1,4,5) have an important role in encouraging such trials.
1. RCOG Scientific Advisory Committee. Clamping of the umbilical cord
and placental transfusion: Royal College of Obstetricians and
Gynaecologists, 2009.
2. Rabe H, Reynolds G, Diaz-Rossello J. A systematic review and meta-
analysis of a brief delay in clamping the umbilical cord of preterm
infants. Neonatology 2008;93:138-44.
3. McDonald SJ, Middleton P. Effect of timing of umbilical cord
clamping of term infants on maternal and neonatal outcomes. Cochrane
Database Syst Rev 2008:CD004074.
4. WHO Recommendations for the Prevention of Postpartum Hemorrhage:
World Health Organisation. Department of Making Pregnancy Safer, 2007.
5. Perlman JM, Wyllie J, Kattwinkel J, Atkins DL, Chameides L,
Goldsmith JP, et al. Part 11: Neonatal Resuscitation: 2010 International
Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care Science With Treatment Recommendations. Circulation 2010;122:S516-538
Competing interests: All the authors are either co-applicants or collaborators on a programme of work which includes developing strategies for providing initial care with the cord intact and a pilot RCT of timing of cord clamping for preterm births. Lelia Duley contributed to developing the RCOG Scientific Advisory Committee opinion paper on clamping of the umbilical cord. Derek Tuffnell was a member of the Guideline Development Group for the NICE Intrapartum Care Guideline. William Tarnow-Mordi is Principal Investigator of the Australian Placental Transfusion Study (ACTRN12610000633088)