Delaying umbilical cord clamping for two minutes cuts deaths in premature babies, studies show
BMJ 2023; 383 doi: https://doi.org/10.1136/bmj.p2680 (Published 15 November 2023) Cite this as: BMJ 2023;383:p2680
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Dear Editor,
I welcome publication of even more conclusive evidence on the increased mortality after early cord clamping at preterm birth. Clearly gestational age represents a spectrum and while the harm of early cord clamping is most readily identified in preterm babies, it will inevitably also harm term babies to a lesser extent.
It is well recognized that early clamping of the cord results in the loss of the placental transfusion and therefore always a degree of neonatal hypovolemia. Hypovolaemia at birth is sometimes the underlying cause of the failure of the term newborn to respond to positive pressure ventilation resuscitation. The late Professor Peter Dunn (1) emphasized this in his letter in 1988 as being most marked in babies with a tight nuchal cord. He pointed out that “When the umbilical cord was clamped at the moment of birth, as much as 30-40% of the normal fetal blood volume might be trapped within the placental vasculature rendering the placenta congested, tense, bulky, and more likely to be retained.” Unless this is recognized, and volume, ideally an emergency transfusion of uncross-matched O-neg blood is given, the baby is likely to die, or at best suffer significant hypoxic ischemic brain injury.
The hazard can be totally avoided by leaving the cord unclamped for as little at 30 seconds. The baby with a tight nuchal cord must be delivered with the cord intact, if necessary using the somersault manoeuvre. (2) Might a change in obstetric practice contribute to the RCOG commitment to reduce early neonatal mortality and severe neonatal brain injury by 50% by 2025?
David J R Hutchon FRCOG david.hutchon@student.shu.ac.uk
References
1. Dunn P. Arch Dis Child: 10.1136/adc.63.5.570-a on 1 May 1988 Tight nuchal cord and neonatal hypovolaemic shock
2. Mercer JS, Skovgaard RL, Peareara-Eaves J, Bowman TA. Nuchal cord management and nurse-midwifery practice. J Midwifery Womens Health. Sep Oct 2005;50(5):373-9
Competing interests: No competing interests
The BBC should not normalise practices that harm babies
Dear Editor
The nation’s favourite programme, Call The Midwife,(1) is rightly proud of close attention to detail, yet shows the ahistoric (but safe) practice of putting babies into their cots ‘back-to-back’ (2): presumably so as not to mislead viewers about a practice endorsed for decades by Dr Spock that led to thousands of Sudden Infant Deaths.(3,4) Another recent routine - of ‘early’ (or rather, unindicated) cord clamping - is shown in most episodes despite established baby harms that ensue.(5,6)
This is also historically inaccurate; clamping only after cord pulsation stopped was standard practice until 1995.(7) Sadly, although NICE recommended waiting at least a minute to allow fetal-to-neonatal cardiorespiratory transition to take place a decade ago,(8) there’s no objective evidence this has been implemented or taken seriously by the professions (no audits/ publications), medicolegal or NHS authorities – with the exception of extreme prematurity where death and brain damage are undeniable.(9,10,11) It’s hard to imagine a reasonable justification for cutting off a baby’s continuing blood supply – yet this is normalised on TV.(12) The BBC did not answer FOI questions on the grounds that if the information requested were held it would be for the purposes of “art, journalism or literature” and it was not obliged to disclose this type of information.(13). It has also defended inconsistent “highly accurate… drama”.(14,15)
Another cultural paradigm shift is required to see this separation rite as wrong, just as Anne Diamond achieved for baby sleeping position three decades before being honoured for her work.(16) We call upon the producers and BBC to issue a warning to the public who should no longer expect and accept a routine practice that endangers babies’ lives and health.
References
(1) PA Media. Call the Midwife voted best show in last 25 years by RadioTimes.com readers. The Guardian 1 August 2022 https://www.theguardian.com/tv-and-radio/2022/aug/01/call-the-midwife-vo...
(2) See, for example, the distressed mother in Call the Midwife, BBC 1 Episode 3, Series 13, transmitted 21 January 2024. https://www.whattowatch.com/features/call-the-midwife-season-13-episode-...
(3) Wikipaedia. Benjamin Spock https://en.wikipedia.org/wiki/Benjamin_Spock last accessed 30 January 2024
(4) Perkins A. Back to sleep: the doctor who helped stem a cot death epidemic https://www.theguardian.com/society/2016/aug/26/back-to-sleep-sudden-inf...
(5) McDonald SJ, Middleton P, Dowswell T, Morris PS. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database Syst Rev. 2013 Jul 11;2013(7):CD004074. doi: 10.1002/14651858.CD004074.pub3
(6) Rabe H, Gyte GM, Díaz-Rossello JL, Duley L. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database Syst Rev. 2019 Sep 17;9(9):CD003248. doi: 10.1002/14651858.CD003248.pub4
(7) Aflaifel N, Weeks A. Push, pull, squeeze, clamp: 100 years of changes in the management of the third stage of labour as described by Ten Teachers. BMJ. 2012;345:e8270
doi:10.1136/bmj.e8270
(8) Recommendation 1.10.14 in NICE guideline [NG235] Intrapartum Care. 29 September 2023 https://www.nice.org.uk/guidance/ng235/chapter/Recommendations#third-sta...
(9) British Association of Perinatal Medicine. Optimal Cord Management in Preterm Babies: A Quality Improvement Toolkit https://www.bapm.org/pages/197-optimal-cord-management-toolkit December 2020
(10) RCPCH National Neonatal Audit Programme - Data dashboard 23 August 2023 https://www.rcpch.ac.uk/resources/nnap-data-dashboard#summary-of-the-nna...
(11) Seidler AL, Libesman S, Hunter KE et al.; iCOMP Collaborators. Short, medium, and long deferral of umbilical cord clamping compared with umbilical cord milking and immediate clamping at preterm birth: a systematic review and network meta-analysis with individual participant data. Lancet. 2023 Dec 9;402(10418):2223-2234. doi: 10.1016/S0140-6736(23)02469-8
(12) Dawda G, Weeks AD, Bewley S. 'It must be right, I saw it on TV!': An observational study of third stage birth practices in popular television programmes. JRSM Open. 2023 Oct 19;14(10):20542704231205385. doi: 10.1177/20542704231205385
(13) BBC reply to Freedom of Information request reference RFI20230779 13 June 2023
(14) Shaw I. Health Screening. Warning issued over Call the Midwife and One Born Every Minute. The Sun 19 October 2023 https://www.thesun.co.uk/health/24456759/call-the-midwife-warning-clamping/
(15) Pickles K. TV shows like BBC's Call The Midwife and C4's One Born Every Minute 'are inaccurately depicting childbirth' and should come with safety warnings, say researchers 19 October 2023 https://www.dailymail.co.uk/health/article-12645119/TV-shows-like-BBCs-C...
(16) BBC. New Year Honours 2023: Anne Diamond honoured for cot death campaign 31 December 2022 https://www.bbc.co.uk/news/uk-england-oxfordshire-64134208
Competing interests: AB, HR, DH & CPJ declare no interests. SB chaired NICE CG190 Intrapartum Care 2014 that advised against routine cord clamping and was involved in the development of a Bedside Assessment Stabilisation and Immediate Cardiorespiratory Support (BASICS) trolley but gave away her intellectual property rights. All SBs declarations of interest can be found at https://www.whopaysthisdoctor.org/doctor/58/active