Delayed cord clamping: much ado about nothing

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Ahhh, the power of the press release.

How else to explain the fanfare with with the latest Cochrane Review on delayed cord clamping was greeted despite the fact that it showed almost no benefit?

To see what I mean, I’ve created the following chart listing all the benefits of delayed cord clamping.

Benefits of delayed cord clamping

As you can see, the authors looked at a variety of possible benefits of delayed cord clamping and found almost nothing … except slightly higher iron stores (a laboratory value), one that has no clinical effect and probably has no clinical significance.

So why did mainstream media outlets like the New York Times wax rhapsodic on the front page?

But a new analysis has found that delaying clamping for at least a minute after birth, which allows more time for blood to move from the placenta, significantly improves iron stores and hemoglobin levels in newborns …

Um, not exactly. Obviously babies subject to delayed cord clamping had higher hemoglobin levels in the first few days after birth; they got more blood. But that doesn’t mean that higher hemoglobin levels are beneficial and, indeed, the higher hemoglobin levels did not translate to better Apgar scores, less respiratory distress, fewer NICU admissions, or greater breastfeeding success.

Moreover, it did not translate to lower levels of anemia at 3-6 months. Babies in both groups had the same hemoglobin level and hematocrit at that point, suggesting that the initial transfusion of blood from the cord was unnecessary and the baby had to destroy those blood cells to get to a normal hematocrit.

Not surprisingly, babies who had to destroy blood cells ended up with higher iron stores, but there is no evidence that they benefited from this in any way. Indeed, it would be helpful to look at longer term outcomes to determine if the higher iron eventually disappeared, suggesting no advantage to having higher measures of iron stores. The authors actually acknowledge that the apparent difference in iron stores may not be real, and may reflect disparities in the way that iron stores were measure in the individual studies that make up the meta-analysis.

To understand exactly why there are no real benefits to delayed cord clamping, lets do a thought experiment. Let’s pretend that we gave half of newborns a blood transfusion in the immediate aftermath of birth to test the hypothesis that an immediate blood transfusion benefits normal babies. If we measure the same things that the Cochrane investigators measured, we would get exactly the same results. The only “benefit” would be slightly higher iron levels, and even that isn’t guaranteed since the authors are not sure that result is real.

Would we conclude that routine newborn transfusions offered enough benefits to recommend them? Of course we wouldn’t, since it offers no clinical benefits at all.

The exact same thing can be said about delayed cord clamping.

So what’s this paper really about? This paper is about midwives and natural childbirth advocates dissing obstetricians. Indeed the paper was written by midwives who are desperate to find yet another reason to criticize obstetricians. Delayed cord clamping is just a reaction to the fact that obstetricians have traditionally clamped the cord early. As the chart clearly shows (no chart was included in the study since it would have graphically displayed the lack of benefit), there is no clinical benefit to delayed cord clamping and only a difference in laboratory values at 3-6 months that has no bearing on health and may not be really anyway.

Fortunately, delayed cord clamping appears to have no harms, so there’s no reason that we can see (at the moment) not to do it if parents request it. By that reasoning, we could give every newborn a blood transfusion if their parents request it.

So why is everyone jumping up and down about this study?

That’s the power of the press release … and a paper written to maximize clinically irrelevant effects and minimize the absence of clinical benefit.

  • Angela Lygren

    This is a lie. Unless you wait until the cord has stopped pulsing, it has not finished its work, and your are robbing babies bodies of blood that is an integral step in normal neonatal physiologic transition. How do you sleep at night writing a blog that promotes so much violence towards pregnant/birthing moms and their newborn babies!?? And who do you think you are performing these violent interventions and shaming hard working midwives that are trying to give women a fair chance at birth!? PROBS VOTING FOR TRUMP TOO!

    • Nick Sanders

      Violent?

      • Angela Lygren

        I know it sounds like overkill, but I do find that cutting off someones warm air and blood supply with cold metal objects to be pretty violent. But I was also referring to all the other violent interventions like the overuse of forceps and episiotomies WITHOUT PERMISSION, giving moms routine pitocin without permission, and take babies by cesarean at a rate of 1:3. Just the whole culture of medicalizing low risk birth is so violent.

        • Montserrat Blanco

          Well, yes, I guess that if you take the 1:3 CS as violence you consider far worse to perform surgery on a adult woman than choking a newborn baby, as most CS are performed for anomalies in fetal monitoring showing the baby is not tolerating labour well and is oxygen deprived. If you consider that then yes, it is more violent.

          Fórceps without permission and episiotomies without permission? That is bad practice, if you know of any case I suggest you file a lawsuit. Dr. Amy has offered her help for a lawsuit for precisely an episiotomy without consent.

        • Sarah

          It does sound like overkill, yes. You finding cord clamping performed before you would ideally prefer it to be performed to be violent says more about you than anything else.
          I agree, of course, about violent interventions, but one hopes you would also be as concerned and vocal about other forms of violence towards birthing women such as epidural denial and forced rooming in.

        • Nick Sanders

          Citation please on the umbilical cord providing air after birth. And throw in another that “cold metal objects” make a difference to something that has no nerve endings. After that, I’d like some data on how commonly forceps and episiotomies are used without permission in non-emergency situations. And some more data on pitocin use without permission, specifically by doctors and CNMs, because we already know CPMs sneak it without even telling the mother. Lastly, what, specifically, is wrong with the c-section rate? And I want a basis on evidence, not feelings.

    • corblimeybot

      Ha, you definitely don’t follow Dr. Amy at all if you think she’s voting for Trump. Oh man. If you only knew how idiotic your whole comment sounds, but especially that part.

      By the way, you gonna to whip our your citations for all this nonsense? No, right?

      • Angela Lygren

        You are right, I don’t follow her, her lies and arrogance (which led me to my poor political joke) make me utterly to angry but being a birth worker I can’t help that these articles surface in my searches. Also – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3423128/ and Williams Obststrics will both tell you that the neonate can receive 92 cubic meters, which is over 3 oz of blood if clamping is delayed just 60 seconds. This can be the make or break difference for a preterm baby.

        • Angela Lygren

          It’s also worth noting that the table at the beginning of the article is made up, as she admits, and the first item, APGAR scores is irrelevant in ascertaining benefits from early and late cord clamping because APGAR scoring was intended to be evaluated AFTER cord cutting. Virginia Apgar was an advocate of early cord clamping and designed this scoring system based on her belief system, as anyone would.

          • Azuran

            hum…..if you want to evaluate the effect of delayed cord clamping, then you kinda have to look at the health of the babies AFTER the cord was clamped and compare the outcome with various cord clamping time. Hence, APGAR scores would be totally appropriate.

        • Poogles

          It goes without saying that more blood will end up in the baby’s body with delayed cord clamping that is done properly; what we would like to see citations for is whether that blood actually improves the baby’s health outcomes.

        • Nick Sanders

          I would indeed say that 92 cubic meters is somewhere above 3 ounces…

          • Charybdis

            It is 3110890.0885696 fluid ounces. I believe this is above the venous capacity of an adult, much less a baby.

          • An Actual Attorney

            I missed that. While I may have felt like I was carrying 92 m^3 of fluid when pregnant, I’m pretty sure that I was not.

        • corblimeybot

          I don’t get it. If you don’t follow her, then how are you making so many confident statements about what you think she’s like, and what she espouses?

  • Informed Mom-To-Be

    Wow, this article is quite disturbing.

    It’s really not that surprising that the difference between a one-to-three minute delay and immediate clamping was relatively small, especially considering the limited number of outcomes that the study focused upon. There was not enough difference in the two groups (nor enough measured outcomes) for one to expect much more. How about a study about delaying clamping until the cessation of cord pulsing (ie. after the placenta stops transferring blood to the baby on its own), or lotus birth (non-severance of the cord, allowing it to dry up and fall off on its own, which happens over a few days)? The fact that they found any benefits at all in that short 1-3 minute interval is significant, but truly ‘delayed cord clamping’ as described in the study is still a medical intervention with the natural birth process, just as immediate cord clamping is. It is only a slightly less extreme intervention than that which is standard practice in Western obstetrics.

    Further reading on the subject will reveal that there are more substances in cord blood than simply red blood cells (the focus of both the study and this article), including stem cells and cancer fighting killer-T cells (which cord blood banks take from the newborn and then sell back to the parents if the baby develops cancer later). Also, if left undisturbed, the placenta continues to supply oxygen to the newborn while its lungs begin to function independently, the deprivation of which can cause brain cell death and brain damage. Why are babies that take a few extra moments to breathe immediately separated from their nine-month supplier of oxygen (the placenta) while it is still functioning, in order to be given external oxygen? The extra blood pumped from the placenta to the baby after birth increases circulation into the lungs (which is suppressed while in the womb) and encourages breathing to get started on its own. Is that not a medical outcome as valid as red blood cell count? There are many other considerations that were not mentioned in either the original study cited or this article.

    Finally, I feel impelled to point out that the author of this article is highly abrasive in tone–disrespectful of both her reader and of the legitimacy of a scientific inquiry being used to inform medical practice. Like the original study, this article does not consider enough factors of placental and umbilical cord function in order to determine the full scope of ‘benefit’ offered by a delayed or non-interventionist approach.

    I highly recommend reading further articles from several perspectives on the subject before taking this woman’s derisive paper as holy writ or making the decision about how you will manage any births over which you have any control.

    • Young CC Prof

      “If left undisturbed, the placenta continues to supply oxygen to the newborn while its lungs begin to function.”

      Pity the placenta can’t remain undisturbed–it usually starts detaching from the uterus the moment the baby is out, occasionally earlier (see placental abruption.) It can’t generate oxygen out of nothing, any more than a SCUBA mask with no tank.

      Also, the fetal-to-newborn circulation change is pretty dramatic–and final. Drawing oxygen from the lungs means not drawing it from the umbilical artery any more.

      The cord stops pulsing very soon after birth, one to three minutes is plenty long enough. Placentas aren’t magic, they’re a tool that works for nine months (if you’re lucky) and then dies.

    • Roadstergal

      “Also, if left undisturbed, the placenta continues to supply oxygen to the newborn”

      Alas, the placenta gets its oxygen from mom, so once it’s no longer enmeshed with her, it’s just a slab of meat.

      “cancer fighting killer-T cells (which cord blood banks take from the newborn and then sell back to the parents if the baby develops cancer later)”

      I don’t know if you’ve noticed, but babies and children have a huge hurking thymus (it gets smaller as you age) that does little else but churn out T-cells 24/7 (through mixing and matching and randomly mutating DNA – OMGerd, GMOs are everywhere!). A healthy kid is not lacking in T and B cells; we make a massive excess of them, which are culled through various types of selection to make a generally adequate repertoire.

      Even if your inane postulate were true – OMG, cut that cord immediately, you’ll get all of those self-reactive T-cells that could give you T1D or MS or IBD in there! :p

      Banking cells can be useful in some cancers because cord blood is a good source of HSC (not mature T-cells) for transplant. So why would you dump them into a healthy term infant, who has plenty of them, instead of banking them? (Donation to a public bank is generally preferred to private banking, BTW.)

  • Captain Obvious
  • Jane

    why doctor are you suggesting doing procedures such as blood transfusions & hormone replacement can be likened to the natural process of birth and how it works physiologically? why the need to DO something??

  • Dan

    I’ve browsed this site a few times over the past several months as we get ready to deliver our first baby. Although I am no fan of the sophomoric, insulting way in which Dr. Tuteur’s expresses her opinion, there usually seems to be some logic behind it–which is why I was extremely puzzled while reading this particular article. At first I couldn’t understand why she is so adamant about discrediting the notion that there could be some benefit to NOT clamping a newborn’s umbilical cord immediately. At the very least, there is certainly no harm to be done by choosing the slightly more natural procedure of waiting a couple minutes to clamp the cord.

    Then I read this sentence…”This paper is about midwives and natural childbirth advocates dissing obstetricians. Indeed the paper was written by midwives who are desperate to find yet another reason to criticize obstetricians.”
    It’s obvious this article (and the vast majority she writes) is from an extremely defensive and insecure perspective. Is it really that hard to believe that maybe the “routine” that most ob’s have been practicing recently might not be ideal? Does it hurt their ego that much?
    I’ve asked several doctors for their opinion on the subject, with varying responses. However, I ALWAYS get the impression that the ones who discourage it or minimize the potential benefits have no real familiarity with the relevant studies or are of a similar defensive, closed-minded disposition. The ones supportive of the idea are clearly convinced by the data they’ve seen, and I’ve even had a couple tell me they believe immediate cord clamping SHOULD be the exception, rather than the rule.
    The extent to which you are convinced by the studies is up to you. As a soon-to-be father I may not be “educated” by Dr. Tuteur’s definition, but I have read and heard enough that we have decided to opt out of immediate cord clamping (assuming there are no complications). If there is even a slim chance it might help my child get a healthier start, why not? There is no reason not to.
    Do plenty of research, get several professional opinions, and make the decision you feel is best for you and your family. Most of all, don’t be bullied and insulted into a decision.

    • Amy Tuteur, MD

      Is there something you don’t understand about the chart? Why are you ingoring the evidence and talking about me?

      • Dan

        Your “chart” as you call it, is an oversimplification of your assessment of the data. That being said, my wife and I have decided that higher birth weight, blood volume, hemoglobin levels, and iron stores are enough potential “benefit” for our newborn. As I mentioned, the degree to which these outcomes are “beneficial” is certainly debatable. But one thing is abundantly clear–there is ZERO benefit to clamping the cord early. If you have some convincing evidence to the contrary I am open to it.
        Why was I talking about you? I was simply making a direct observation of the context in which this article was written. You are clearly bitter, defensive, and insecure and I guess I think it’s important for expecting mothers to realize that if they come across this site looking for objective information.

        • Tim

          There is benefit to clamping the cord early if they are in a rush to resuscitate the infant or otherwise perform some kind of emergency medicine on it. The point is to get the notion out of expectant mothers heads that its SUPER IMPORTANT to clamp it late, so that if this happens, they don’t feel it’s the end of the world and that they have somehow disadvantaged their baby.

          And before you think “that’s silly, why would any woman place that much importance on it” , stop. As someone who had to help his wife deal with depression over having to stop breastfeeding because of the medical realities of a baby with congestive heart failure and their caloric needs, if someone has become focused on something being super important for her newborn to have, and is already in the throes of postpartum hormonal shifts, it can push her over the line into misery over an overall, inconsequential act.

          • Dan

            Tim, I agree wholeheartedly. Nothing in my post suggests that I believe delaying cord clamping should trump emergency care that may be required. I stated that as long as there are no complications we choose not to have the cord clamped early.

          • Tim

            But Dr Amy isn’t trying to make this out like a safety issue where people are putting lives at risk by delayed cord clamping. She just is saying the studies done so far don’t appear to make it that big a deal – so she is stressing that people shouldn’t make it out to be that big a deal (and my aforementioned reason is a really good reason to not make it a big deal) – we delayed also, I just don’t want to see anyone broken hearted over not being able to.

          • Dan

            If the article didn’t come across as downright desperate to discredit the findings I would agree. There is certainly no reason to feel regret if you are unable to prevent early clamping. However, it seems borderline irresponsible to be so adamantly trying to dissuade women from considering the potential benefits.

          • Karen in SC

            It may due to the fact that the NCB side is adamantly trying to persuade expectant families that there is an incredible, not to be missed, key to it all, benefit.

            In fact, with DCC there is a potential for newborn jaundice, which is treatable, but may throw new parents for a loop.

          • Dan

            I guess my bigger issue is that I don’t have a “side”. I never realized there were such extremist views on both the “NCB side” and the “don’t-ever-question-the-institutional-status-quo side”.

          • Lizzie Dee

            That is a very false dichotomy though. I detest even the moderate end of NCB, but that doesn’t mean I automatically think everything that happens in hospitals is just peachy. Nor does it mean that I expect people to believe my view is right. My view, close to Dr. Amy’s, is that the benefits of NCB (which I fail to appreciate) are not worth the risk, small as it may be. I am more extreme in my view than Dr. A, because I am one of the low risk mothers who ended up with catastrophe – in a hospital, victim of “It isn’t an illness you know.” I am not defective, I didn’t fail to trust my body – it just ran out of luck in an undertaking that isn’t full of certainties.

          • Dan

            It may be a false dichotomy but you wouldn’t know it if you’re trying to find objective information on something like timing of cord clamping. That’s obvious in Amy’s statement that I referenced about her assumptions on the purpose of this review–to “diss obstetricians”. Anything that goes against the routine they’ve become accustomed to must be an attack on their competence evidently.
            I look at it this way–let’s assume that OBs had not adopted the default of clamping the cord immmediately over the last 50-75 years. With no preconceived notion about what the status quo should be, if each expecting mother was clearly and objectively explained the benefits/results/outcomes of not clamping the cord immediately, what do you think their truly free-willed decision would be?
            As a soon-to-be first time parent, the whole “NCB” platform is a fairly new concept to me. It just seems utterly sad that anything that might make delivery a little more natural, and perhaps beneficial–like not immediately clamping the cord for no reason–is met with such vitriol by people like Amy.

          • Lizzie Dee

            I just don’t see anything remotely resembling vitriol in being unimpressed by the evidence so far. And in a normal, unproblematic birth, how instant is instant anyway? By the time dad or whoever has figured out what to do, I would think a minute or so may have passed anyway.

            What I will still have a problem with is the easy collocation of “natural” and “beneficial”. Birth is natural, all right. The things that happened to me were quite natural, and naturally led to a daughter with brain damage. A bit less natural and more rapid unnatural intervention might have saved her from that.

            I do wish you well with your commitment to a natural birth and your desire to give your child the best possible start. That is admirable, and natural too – and of course achievable for the majority. But to assume that those who fpr one reason or another have come across the negative aspects of natural are all bitter and vitriolic is just a teensy bit smug. Cord clamping is unlikely to be a big deal very often – but the attitude that turns it into a big deal IS a problem.

          • Dan

            You may be right Lizzie, perhaps “defensiveness” would have been a better choice than “vitriol” in this instance.
            I admit I am very confused with the way people use the term “natural” here. My wife is delivering in a hospital, with an epidural, we’re opting for the Vitamin K shot, eye drops, circumcision–most of the things “NCB-ers” are against. Immediate cord clamping for no reason is just something I can’t wrap my head around. Why would I not want my newborn to have “more natural” blood volume, hemoglobin levels, and iron stores? As I stated before, the extent to which these outcomes are “beneficial” is certainly debatable, and warrants more research but my initial question stands–if expecting mothers were objectively informed about the two options and allowed to make their decision without feeling coerced by the hospital/ob’s routine, which do you think the majority would choose?

          • Lizzie Dee

            The word I would probably choose is irritation – and a degree of exasperation which is what I tend to feel when people leap on something like this.

            However, to answer your question, sane and open minded people who are not experts might well do as you do and decide “Why not?” I don’t have a problem with that, because I don’t think it matters very much.

            Clearly, you have not yet had time to realise just how loaded a word “natural” is in this context. I wouldn’t have engaged at all if you had not implied that NCB was at one extreme, and posters here, and Dr. Amy, were extreme in the opposite direction. Really not the case. No-one here would regard your plans as anything other than perfectly reasonable. They are anathema to NCB.

          • Rachel L

            It’s pretty instant. I was only just holding my son when I heard my husband remind the midwife I didn’t want the cord clamped. It isn’t the dad who clamps the cord, it’s the midwife. If my husband hadn’t been watching carefully it would have been clamped within maybe 10 seconds.

            I also wonder if DCC may have been one of the reasons my third stage was so quick and easy. No pain at all. I did have the injection, so I realise that certainly would have helped. But I’ve spoken to other mothers who had quite a long third stage despite having the syntocinon.

            It’s all very interesting. I’d like to see studies on this – should have a look and see if there are any.

          • araikwao

            Dan, I would recommend taking a look at the Science-Based Medicine blog, Harriet Hall did an article which also mentioned DCC. I got schooled by them, as I commented with the above blog post in mind, but it was pointed out by a researcher (screen name “angora rabbit”) that anemia is still a common problem in the developed world, and given that iron deficiency does have a negative and ?non-reversible impact on infant neurodevelopment, DCC is actually a good public health measure where practical.

          • Dan

            Wow, thanks araikwao. I did find that article and the subsequent posts that reference much more than the oversimplified and biased conclusion that Amy provides here.

          • Rachel L

            Yes, this was my understanding, Araikwao, that anemia and/or iron deficiency can have developmental consequences. I read numerous studies on this topic before giving birth (two years before this Cochrane Review). In the time since then, DCC has become a lot more common. I was iron deficient during pregnancy, so it was important to me to have DCC to give my child a better chance at normal levels.

            Iron deficiency is not uncommon in pregnant women, and it stands to reason to take that into consideration. I don’t have any studies or evidence to back this up, but to me it is a logical next step, that if the mother is iron deficient, the baby could be at a greater risk. Is that right?

            Further to that, it’s not unusual for children to be pretty fussy eaters, so who is to say I would be able to get meat into my child once he started solids? 😉
            (As it turned out, meat is all the rage, it’s vegies we have issues with!)

            So I wouldn’t be too quick to dismiss the iron levels reasoning, it was my main reason for choosing delayed clamping. We delayed by about one minute and that was sufficient. When my midwife did the blood sample (standard thing at my hospital), she had to really squeeze the cord to get any blood out for the sample! There was practically nothing there.

            The other concern I had – and Dr Amy may be able to offer more information here, as it’s not something I’m well aware of – was about breathing issues. If baby doesn’t breathe immediately, the standard seems to be to immediately cut the cord and commence resuscitation, is that right? But those favouring DCC have said that as long as the baby is attached to the cord, they are still receiving oxygenated blood through the placenta.

            If this is true, what is the risk of cutting the cord? If the child is indeed receiving oxygen through the cord, it seems to me (as a lay person) that you would want to keep that going until you were certain that breathing was established. Not just a breath or two, but really breathing well without issues. So that was my other reason for requesting delayed clamping. As I understand it, lack of oxygen to the brain can cause permanent disability, so it seemed wise to have the “back up” of the placenta during those first few minutes.

            I would be interested to hear if Dr Amy, or any other readers have resuscitated a baby while still attached to the cord. Does this give them a better chance? Is it possible to do resuscitation on the bed, assuming you have portable equipment? Is this the standard anywhere?

          • Lizzie Dee

            Of course people should consider the benefits. But how are you going to reach any conclusion about what they are if you don’t listen to people who might know what they are talking about? Science isn’t black and white and definite all that often. Doctor 1 says it is a big plus, Doctor 2 says it isn.t, and Doctor 3 say it may or may not be. I have considered the benefits, read some of the research and reached no very firm conclusion except that some of the claims seem a little…unlikely.

        • Amy Tuteur, MD

          Sorry, Dan. I’m not here to reinforce your smugness and pat you on your head for your “educated” decision. I realize that makes you sad and angry, but I can’t help the fact that the scientific evidence shows no clinical benefit for delayed cord clamping in term infants no matter how much wish it did.

          What exactly were you hoping to accomplish by parachuting in to boast of your decision and insult me?

          • Dan

            Did I give the impression I need any reinforecement? Sorry, I thought this was a comment board where readers shared their opinions on the topic–my mistake.
            And I apologize if I insulted you, I thought I was just stating the obvious.

        • Karen in SC

          Hello Dan. I’d like to invite you to read lots of other posts here. We have a great group of regulars and guess what? Dr. Amy is a real person, and her writing varies a lot.

          You are always welcome to check out her sources, and compare with what you have found. You might find valuable information here on other topics. The main goal is providing facts so people can make informed decisions.

          • Dan

            Thanks Karen, I’ve read plenty of other articles here, and as I stated in my initial post, I usually see the logic behind Dr. Tuteur’s opinions, just not on this topic. And unfortunately I’m not a fan of the immature way in which she ridicules and insults anyone and anything that contradicts her thinking. Furthermore, I’ve seen several instances where commenters cite errors or omissions but those are conveniently never addressed.

          • theNormalDistribution

            I don’t find Dr. Amy’s tone immature in the least. Derisive, certainly. But her derision is always secondary to facts. There’s nothing immature about expressing disdain where it is warranted.

            I have never seen Amy ignore a valid criticism or neglect to acknowledge and correct an error. Please do share with us the ‘several instances’ you have observed Amy skirting the truth.

          • Dan

            Sorry, I can’t be bothered to go back and comb through the comments on articles I’ve read over the past several months. But my goal was not to attack Dr. Tuteur, it was simply to share my opinion on this particular article and its context.

          • theNormalDistribution

            I see. So you have time to make claims about what Dr. Amy has or has not done, but you don’t have time to back them up with evidence.

            It seems to me that the difference between you and Dr. Amy is that she doesn’t make truth claims without providing evidence (or having it readily available) to back them up.

            FYI, Dan – no one on this blog is interested in conjecture.

          • Karen in SC

            ND, I wish Dan would visit BabyCenter or Mothering to see the women there offering medical advice and/or cheering each other on to take risks.

            *you don’t need antibiotics for GBS, put garlic in your vagina
            *you can have a breech home birth, it’s just a variation of normal
            *you can labor for hours and hours, even days, the baby isn’t a library book
            (those are all NCB lies that have led to babies dying)

            Those are the things Dr. Amy rails against. If this issue is little less cut and dried, so what? She presented a study that showed little to no benefit, slight chance of harm. If she added her opinion, it’s her blog after all.

          • dan

            Karen you may very well be right about what goes on at those sites in regard to those issues. I just have no idea how that is relevant to this topic.

          • dan

            Since you brought up “conjecture” much of this article is just that.

            Here’s some readily available evidence: “Obviously babies subject to delayed cord clamping had higher hemoglobin levels in the first few days after birth; they got more blood. But that doesn’t mean that higher hemoglobin levels are beneficial…”

            She acknowledges the data but then swiftly makes the leap that higher blood volume, hemoglobin levels, and iron stores cannot possibly be beneficial. Are they? I’m not sure, but I don’t have any preconceived notions that prevent me from considering the possibility.

            And I’m sure there are many differences between Dr. Amy and me. I’m ok with that.

    • lakestella

      Dan and Dr. Tuteur,
      Currently in the Twin Cities, where I work, delayed cord clamping IS becoming the standard of care. My hospital is one of the last to adopt it as standard care but we are moving in that direction. I have done a lot of research on this topic in order to provide education to both providers and staff. Interestingly, Dr. Tuteur makes no mention whatsoever of the PROVEN benefits of delayed cord clamping for preterm babies. The evidence is overwhelmingly in favor of it. The preterm babies are much more stable hemodynamically. Better blood pressure and perfusion so less need for a fluid resusitation or BP support medication. Less need for a blood transfusion. Less NEC, a life threatening condition in preterm infants. MOST IMPORTANTLY, about a 50% reduction in intraventricular hemorrhage which is obviously a serious problem in preterm babies. There can be no debate on the usefulness of delayed cord clamping in preterm babies. Term infants? The benefits are not as clear. An iron store that lasts about a year seems to be the biggest benefit. Is that important? Well, about 10% of year old babies have iron deficient anemia in this country. A built in year’s supply of iron may help that 10% and it certainly won’t hurt. A slightly increased need for phototherapy to treat jaundice in term babies was found in some studies but not others. Dr. Tuteur keeps referring to delayed cord clamping as equivalent to giving a baby a blood transfusion at birth. Um,not exactly doctor. The blood left in the placenta after delivery with immediate cord clamping represents about 30% of the babies blood volume that gets thrown in the trash. That is the babies’ blood, not an adult stranger’s. It is rich in stem cells. How can that be a bad thing? Human’s are the only mammels, other than dolphins, that practice immediate umbilical cord severance. All other mammels get the benefit of the blood left in the placenta. I think the doctor should look at this issue another way, that immediate cord clamping represents phylobotomy of the newborn. In this day and age of evidence based medicine, where is the evidence that immediate cord clamping is a good thing for a newborn? Just because you have always done things a certain way, as in immediate cord clamping, doesn’t mean it is the best practice. At this point, the onus is on the providers to justify with evidence that immediate cord clamping is the best practice. And coming from the neonatology side of the issue, NO ONE is advocating for delaying resusitation of a newborn in need of resusitation. However, one must remember that unless there is a placental abruption, delayed cord clamping actually can be viewed as the first step in resusitation as the placenta is still fully functional in gas exchange.And the good doctor’s pot-shot at the midwives? All I will say is that fortunately in my community, the OB’s, FP docs and midwives have chosen to work together as colleagues and not adversaries for the benefit of our clients.

      • Amy Tuteur, MD

        I’m old enough to remember when hormone replacement therapy became standard of care at hospitals. There was not strong data to support it, but people figured, “it’s estrogen and progesterone, what could be bad?’

        It turned out to be a big mistake, which isn’t surprising when you make policy based on weak data.

        • lakestella

          No mention by Dr Tuteur of the studies about the proven benefits of delayed cord clamping in preterm babies. Not weak data doctor. And also, no citation of any studies showing the benefits of immediate cord clamping by Dr Tuteur. If such studies exist I would love to have your references. I am serious about that. I come from the world of neonatology. Certainly not a field of medicine that is huge into all things “natural”, that isn’t my bias at all. But does it make sense to leave all that blood in the placenta, return to the NICU and one of the first things you do for the baby to bolster BP is to give a saline bolus? Does it make sense to ignore the data saying that there is a statistically significant decreased risk for an IVH or NEC or exposing the baby to a blood transfusion from an adult stranger? What you are suggesting is to ignore data, reject common sense and continue on with tradition with no data to back that tradition up.

          • Captain Obvious

            I have certainly read Dr Amy post about the benefits of DCC to preterm babies over the years. So, because you haven’t read all of her posts, you come on here and say she doesn’t know about it. She is talking about term babies. The benefits are trivial to term babies and you said so yourself. Funny, you actually criticized Dr Amy, but you believe what she posts! Go back and read some of these threads. DCC has been shown to help pretermers and maybe a little for term infants.
            So let me get this straight, in utero the baby, the umbilical cord, and the placenta has baby’s blood flowing through them. A volume sufficient for each vascular space to be full. But at birth you wish to jam the blood from the cord and placenta into the already nearly full baby because it is the baby’s blood by god. Well maybe nature made more than enough blood available in case some gets sequestered or lost. Jamming all the blood from the baby, cord, and placenta might lead to polycythemia, hyperbilirubinemia, jaundice, and kernicterus. There certainly are cases of it in the literature.
            Polycythemia
            is an abnormally high concentration of red blood cells.

            This disorder may result from postmaturity (see see Problems in Newborns: Postmaturity), diabetes in the mother, or a low oxygen level in the fetal blood.
            A high concentration of red blood cells makes the blood thick (hyperviscosity) and may slow blood flow through small blood vessels.
            Most affected newborns do not have symptoms but occasionally have a ruddy or dusky color, are sluggish (lethargic), feed poorly, and very rarely may have seizures.
            The diagnosis is inferred from a test that measures the content of red blood cells in the blood.
            Usually no treatment is needed except to maintain normal hydration.
            When the newborn has symptoms, treatment with a partial exchange transfusion may be given to reduce the red blood cell concentration.
            A markedly increased concentration of red blood cells may result in the blood being too thick, which slows the flow of blood through small blood vessels and interferes with the delivery of oxygen to tissues. A newborn who is born postmaturely or whose mother has diabetes, has severe high blood pressure, smokes, or lives at a high altitude is more likely to have polycythemia. Polycythemia may also result if the newborn receives too much blood from the placenta at birth, as may occur if the newborn is held below the level of the placenta for a time before the umbilical cord is clamped. Other causes include a low oxygen level in the blood (hypoxia), maternal diabetes, growth restriction in the womb, or a large transfusion of blood from one twin to another (twin-to-twin transfusion).

            A newborn with severe polycythemia has a very ruddy or dusky color, is lethargic, feeds poorly, and may have seizures. If the newborn has such symptoms, and a blood test indicates too many red blood cells (high hematocrit), some of the newborn’s blood is removed and replaced with an equal volume of saline solution, thus diluting the remaining red blood cells and correcting the polycythemia.
            But you demand literature why ICC is evidence based or best practice for term infants, when DCC has little evidence to persuade anyone that DCC any longer than 1-2 minutes has any benefit in a term infant, and may in fact cause some harm. And you researched this? Good god. Had you researched Dr Amy’s blog a little, you would see you both nearly agree on the topic.

          • lakestella

            Are you kidding me? You are lecturing me on this topic? Holy shit. I know all about polycythemia and it’s issues. However, Captain Obvious, ( an appropriate name, by the way)………the studies show that there is no increase in polycythemia in term babies who don’t have any other risk factors for it………………such as SGA, lGA, IDM etc. Those babies can EASILY be excluded from OPTIMAL cord clamping. It really shouldn’t be called DELAYED cord clamping but OPTIMAL Jam the baby with it’s own blood? Wow. What studies say that the baby is better off without that placental blood? All I am asking is for one of you to name ONE study that says that is so…………just one.

          • Captain Obvious
          • Birthbuddy

            You need to chill a little.

          • Captain Obvious

            By your own comments I see you must theorize that the baby is in a relative anemic state. Because you feel that the baby needs the blood that is within the umbilical cord and placenta along with what blood is already in the baby to make the delivered baby’s Hgb normal. But in reality, the baby is not already anemic. And when you jam all the blood from the cord and placenta into the baby, your risk issues. Lets say a baby has about 80ml/kg blood, so about 300 ml total. Cord blood banking at delivery can yield 80-100 ml. So you basically want to jam almost a third more blood into a baby that really isn’t anemic. Nice research, because ICC was killing off babies left and right for years.

          • Rachel L

            Is Cord Blood donation one of the issues here? What is the standard, Captain Obvious? Is the blood that remains in the placenta always thrown out? What happens to it, in the case of ICC? What does the hospital want to happen to it? Do they encourage parents to donate the cord blood?

            I just wonder if there is a conflict of interest here.

          • lakestella

            Captain: No one is saying that the optimal time to delay cord clamping is BEYOND the 1-2 minutes that you state. Actually, that is ALL we are asking for. Current practice is generally to clamp the cord ASAP ,meaning in the first 15 seconds of birth.

          • Captain Obvious

            Current practice is not to clamp the cord ASAP. Where did you research that? Doctors and midwives individualize care per patient. If the baby needs resus, then yes the cord is clamped so baby can be brought over to bassinet to resus. Otherwise everywhere I work clamp and cut the cord as things progress after birth. No one waits longer than 10-15 minutes or performs lotus births. Dr Amy already has many posts related to preterm advantages an lack of term benefit. Dr Amy even has research articles demonstrating little benefit to term infants in those threads I linked to. You my dear have not provided any mind blowing benefit of DCC or detriment if ICC is practiced. One if your posts even stated that DCC can be deleterious if other risk factors for polycythemia were present. One more strike against your thesis/research. Because I haven’t seen any detriment to ICC in my 21 years of practice. I also find Dr Amy’s comments about CURRENT research accurate. Sure she spins some of her bias into her posts. But her articles are contemporary and her analysis is thorough.
            So where is your research links?

          • Captain Obvious
          • lakestella

            ‘Doctor’ Amy is a fraud. I get it that she is against home delivery. I TOTALLY agree with her on that. However, one must take into consideration that she, by her own admission, has not practiced medicine for MANY MANY years, Considering when she graduated from medical school, she is older than I am. That likely means that her kids, whom she quit medical practice to raise, are older than mine……………….which means that she has been out of medicine for 20+ years. Lots have changed in that time. Tradition played a big role in the olden days. The emphasis in modern medicine is evidence based practice. Her thinking is still in the 1980’s. We have moved on.

          • Young CC Prof

            That’s funny, all the studies she cites are current. Matter of fact, she probably has more time to stay up to date on the details of the literature than a practicing physician.

          • lakestella

            Whoa. Yes, let’s just go with tradition, 1980’S style. That is always best.

          • lakestella

            The studies I cite are current too. Actually, the same studies. Her take on them is totally clouded by her 1980s nurse midwife vs md struggle. TODAY, we all try to work together. She forgets that it was nurses who insisted that md’s wash their frickin hands before surgery to avoid infection. Took a LONG time before the medical profession admitted that they were WRONG. Dinosaur.

          • Vyx

            Actually the washing of hands to prevent purpueral fever was Semmelweis, an ob. Unless you are talking about the germ theory of disease, in which case you mean Lister, also not a midwife.

          • Linz

            The reason he got the idea was because he noticed that less women died during childbirth when attended by a midwife (who were washing their hands) so he suggested that doctors try it to.

          • AlisonCummins

            No. *Nobody* was washing their hands. The difference was that doctors were not-washing their hands after dissecting bodies and examining sick people.
            When doctors washed their hands with bleach (which midwives didn’t do either) the incidence of puerperal fever dropped by two-thirds. Getting doctors to wash their hands with bleach was a hard sell. We have better disinfectants today.

          • Young CC Prof

            I thought it was carbolic acid? Either way, vicious nasty disinfectants that practically took the skin off. And yeah, no one was washing, but the midwives weren’t touching cadavers between deliveries.

          • AlisonCummins

            Carbolic acid was Lister. Semmelweiss used calcium hypochlorite.

          • Young CC Prof

            Yes, Dr. Tuteur was definitely practicing in 1850, before hand washing. And you were right there, yelling about it.

          • Captain Obvious

            How many babies have died from ICC? So glad you spent so much of your life researching something that has made NO impact on anyone’s lives.

          • Vyx

            Seems like everyone is trying to point out to you that the current evidence shows no significant benefit for delayed cord clamping, not that immediate clamping is the best. You’re setting up a straw man argument. Your whole line of ‘Show me the studies that ICC is best!’ is completely ignoring the fact that no one is trying to say that, only that the decision is best left to individual clinicians and the parents.

        • lakestella

          Ah, just as I suspected. No data to back up what she says and no argument to counteract good data and a logical argument=no reply from the ‘doctor’.

          • Amy Tuteur, MD

            Did you even read the post? Did you read the paper on which it is based, the actual paper, not the abstract? I didn’t reply to you because you didn’t say anything remotely relevant.

          • lakestella

            Yeah, I actually did as part of my research on the topic. Did you? I am a practicing medical professional, I actually need to be current on the latest evidence based practices. I try not rely on tradition and how it has ‘always’ been done. I didn’t retire 20 years ago. And AGAIN, where is your data that immediate cord clamping is best practice? Please site your references. I am open to and interested in other evidence based points of view. I am not interested in tradition.

          • Amy Tuteur, MD

            Do you have a problem with reading comprehension? I didn’t say early cord clamping is best practice; I said the benefits of delayed cord clamping in term infants are trivial. If you’d like to rebut that claim with actual scientific evidence, feel free.

          • lakestella

            No, you make fun of delayed cord clamping in term infants as nurse midwife nonsense AGAIN, where is the evidence that this is true? One reference please. Just one. Again, I am a PRACTICING professional. You are not current doctor. What does it take to renew your medical license? Not much obviously. .

          • Captain Obvious

            “A practicing professional”, so you are not a medical doctor?

      • Captain Obvious

        “delayed cord clamping actually can be viewed as the first step in resusitation as the placenta is still fully functional in gas exchange”. Please provide a reference of how efficient the placenta performs gas exchange benefiting the baby after birth as the uterus is contracting down compressing the myometrial spiral arteries which in term limit the oxygenation to the baby. As the baby takes the first breaths through the lungs, the partial pressures throughout the lung have resonating affects towards the placenta unit again limiting the gas exchange efficiency of the placenta.

      • Captain Obvious
  • Maggie

    Have you overlooked this exhaustive review from the Journal of American Medical Science?

    “Our results showed that delaying clamping of the umbilical cord for at
    least 2 minutes after birth consistently improved both the short- and
    long-term hematologic and iron status of full-term infants.

    …Perhaps the most important finding was that the beneficial effects of late cord clamping appear to extend beyond the early neonatal period. Our
    meta-analysis estimated a significant 47% reduction in risk of anemia
    and 33% reduction in risk of having deficient iron stores at ages 2 to 3
    months with late clamping…”

    http://jama.jamanetwork.com/article.aspx?articleid=206143

    • Lizzie Dee

      47% reduction in risk of anaemia. How big is the risk of anaemia?

      If, in the past, there had been a critical problem of anemic babies, then this might be a good solution. Was there such a crisis?

  • Cynthia Amber Downer

    So my OB told me she wouldn’t do delayed cord clamping because gravity actually makes the blood rush down from the baby into the placenta.. Not the opposite. Any truth to this, was this just her way of not having to deal with delayed cord clamping, or did she not know what she was talking about?

    • I can’t give any help with this question, but there are plenty of providers who will do delayed clamping unless there’s a health/safety reason not to. Both OBs and midwives. If whatever answers you find on this don’t line up with what your OB said, ask around and I’m sure you can find someone more willing to work with you.

      I have a separate question that this reminded me of (and I’ll be bringing it up with my midwife when the time comes but I figure doesn’t hurt to post here). I did delayed clamping with my son… and he ended up with jaundice. There’s obviously no way to know if he would have had jaundice regardless, but I know it’s pretty widely accepted that delayed clamping increases the odds. Does my son having jaundice indicate that I’m more likely to give birth to babies who are more susceptible to jaundice (delayed clamping or no)?

      • Cynthia Amber Downer

        Oh, my son was already born, no delayed cord clamping. 🙂 My delivery doctor was different than the doctor(s) I saw throughout my pregnancy, so the delayed cord clamping was somewhat of a last minute thing and I just went with what she said because it kind of made sense and delayed cord clamping wasn’t a big enough deal to me to make a fuss about it with a doctor. Hope you get some answers!

    • araikwao

      See Captain Obvious’ comment below

  • camille

    Considering my son was anemic at 9 months, slightly higher iron levels would have been great. Wish my damn hospital would have been willing to delay the cord clamping. Amy, I think you harm your cause of being anti-homebirth by lashing out against anything/everything ‘ap’/’crunchy’/’natural’ or whatever you want to call it. It IS possible to be an attachment parent who does not support homebirth. When I was pregnant you were writing about homebirth and definitely talked me out of it. Now that I have a toddler you instead are railing against my way of life in many of your posts. Maybe next you’ll write about how awesome circumcision is…

  • Anne

    Oh, and I love this final line from the abstract-

    “Delayed cord clamping is likely to be beneficial as long as access to treatment for jaundice requiring phototherapy is available.”

    Echoes of PPH management- as long as you have access to PPH treatment, you can play run the risk by not providing the safer active management in the name of “nature”.

    Ugh.

  • Anne

    Immediate cord clamping is part of active management of the third stage of labour (along with oxytocic and controlled cord traction).

    This reduces PPH by approximately 50% compared with physiological management.

    I am not sure whether removing one of the components of active management will effect the PPH rates.

    Anyone know?

    • Becky05

      They’ve studied this and found it doesn’t worsen outcomes for women to leave the clamping out, while doing the pit, etc.

    • lakestella

      Absolutely no studies have shown an increase in PPH by delayed clamping.

      • Birthbuddy

        Is that you expert Neonatology opinion?

      • Rachel L

        Yes, that was my understanding from my reading, Lakestella. The ‘WHO Recommendations for the Prevention of Postpartum Haemorrhage’ (2006) do not favour ICC. According to that booklet, “There is very little evidence to suggest that the timing of cord clamping has an impact on the incidence of PPH.”

        “Recommendation:
        • Because of the benefits to the baby, the cord should not be clamped earlier than is necessary for applying cord traction in the active management of the third stage of labour. (Weak recommendation, low quality evidence)
        > For the sake of clarity, it is estimated that this will normally take around 3 minutes.
        > Early clamping may be required if the baby is asphyxiated and requires immediate resuscitation.”

        Given that the booklet is all about preventing PPH, I would take it that DCC has no effect on it in active management (which is the recommendation of the booklet, provided that it is performed by a qualified person – “The panel does not recommend active management by non-skilled attendants.”). I’m not sure if there is a newer version of this booklet now.

  • Captain Obvious

    A newborn has 80-90 ml/kg of blood. So a 3-4 kg baby has 240-360ml of blood total. A minimum of 40-60 ml of cord blood is required for a decent donation collection. And some donation collections are as high as 105 ml. A typical neonatal blood transfusion is 10-20ml/kg or 30-80 ml over 2-4 hours. Assuming DCC allows much of this potential blood to infuse into a baby that is normocytic (normal blood volume) you are infusing 60-100 ml over several minutes which increases the total neonatal blood volume by 25-33%.
    I am sure the actual numbers may be off here a little because this is a rough estimate, but I can see why hyperbilirubinemia, jaundice, and polycythemia is a risk of DCC. Luckily babies are resilient and can correct the damage we cause them. And when they can’t, there are always phototherapy, and partial exchange transfusion interventions to offset the DCC intervention.

    • lakestella

      Sorry, you are incorrect. While some studies showed a slight increase in jaundice needing phototherapy, there was no increase in the need for an exchange transfusion or polycythemia UNLESS there was another risk factor for polycythemia such as IDM, SGA, LGA. In those babies, you can skip the delayed cord clamping.

  • Me123

    My perspective is that we have no biological imperative TO clamp immediately, so why do so? After most women deliver vaginally, you can watch them look at their babies, perhaps lean back and breathe a sigh of relief that its over, not one of them is worried about clamping the cord. You don’t see any other mammal eating its cord before they deliver the placenta. It seems like immediate cord clamping became standard because doctors do not want to stand there longer than they have to. So if there is no clear benefit to clamping EARLY, then why bother to do it? My thinking is that the onus is on the early clampers to prove why that is okay, not the people who are fine to wait a few minutes.

    • Captain Obvious

      “My perspective is that we have no biological imperative TO clamp immediately,”
      There are enough babies who need some form of resuscitation that ICC and moving baby to the bassinet for bag and mask etc is priority. Are you suggesting to delay resuscitation instead of cord clamping in these instances? You must not work with delivering babies. Many cords are too short to even get the baby up to the woman’s chest for skin to skin. I DCC 1-3 minutes, and the last 3 births the baby lay there over her mons as mom waited to pull her baby up closer. One actually asked me “what are you waiting for, I want my baby up here!” Moms and babies with mismatch blood types are at more risk for jaundice, allowing more blood into baby will more likely lead to hyperbilirubinemia, jaundice, polycythemia, and need for phototherapy or partial exchange transfusion. Studies, including this one show when you do DCC, you only need to do it for 1-3 minutes, what about these women who want to DCC for hours or lotus birth? What is the benefit to that?

    • Gene

      If you place the baby ABOVE the level of the placenta (like on top of mom’s abdomen or in her arms), blood runs from the baby back to the placenta (gravity). So unless mom is a great post-birth contortionist, she won’t be looking at her baby in a nice placental-level position.

      Personally, I clamped ASAP so that I could donate my children’s cord blood to people who TRULY needed it (MD Anderson Cancer Center).

      • The Bofa on the Sofa

        If you place the baby ABOVE the level of the placenta (like on top of mom’s abdomen or in her arms), blood runs from the baby back to the placenta (gravity).

        SNORT!

      • Captain Obvious

        I was taught this too, in residency. UpToDate along with other studies have demonstrated that with so many midwives placing the baby on top of the abdomen, no harmful effects have occurred, even infant laboratory values are comparable that now it is considered appropriate to place the baby upon the abdomen.
        I’ll give this you to the NCB. They dispelled this common practice. But they didn’t do it by controlled randomized studies. They just did it because they trusted birth. And now observational evidence doesn’t show any harm.

    • PJ

      Isn’t it easier to look over your baby and get to know it when it isn’t attached to a cord?

    • Hava NaturalMama

      Amen. You said it so eloquently

    • Sue

      ”You don’t see any other mammal eating its cord before they deliver the placenta.” Sorry, ”Me”, but this line generally destroys an argument about birth, unless you also want to accept all the other mammalian birth processes, like licking your baby clean, accepting a few deaths in the litter, or dying yourself (and not having anyone blog about it). We are all mere mammals, after all, aren’t we?

  • I have been through the whole content of this blog which is very informative and knowledgeable stuff, I would like to visit again.

  • Antigonos CNM

    As always, it comes down to common sense. I have seen [and clamped] many cords so thick with Wharton’s Jelly that it took considerable time to even get the clamp closed, and so the baby got some extra blood, I suppose. I’ve also delivered babies with nuchal cords wrapped three times around the neck so tightly that I was forced to clamp and cut the cord before the baby was even entirely born. I’ve worked in hospitals where a cord blood sample was mandatory for each baby [for blood typing] and Junior was theoretically deprived of up to 5 cc of blood and other hospitals where, unless the mother was Rh negative, blood was never taken. Since a baby is normally born with a Hgb of up to 24 [drops to about 17 within a couple of days or less], the whole business of when the cord is clamped seems like a tempest in a teapot, unless the baby is premature.

  • Ob in OZ

    The point that should have been made-
    The “benefits” have no clinical significance as those with lower iron levels required no treatment for what is essentially a lab finding. However, the risk that was confirmed was neonatal jaundice, which does require blood tests and phototherapy for the newborn, which if can result in serious sequelae to the newborn if they do not respond to this therapy.

    • Captain Obvious

      And possible need for partial exchange transfusion.

    • theadequatemother

      I don’t think this can be stressed enough – no evidence of a significant benefit, but there is evidence of harm.

    • Rebecca

      Bit of a “cascade of interventions”, then, hm?

  • Prudent planner

    It makes sense to me, that babies recieving appropriate amounts of placental blood are protected from dehydration between birth and when breast milk “comes in”.

    I used delayed cord clamping (kept the baby low at my side -not really above or below the level of my uterus). When the baby was first born, the cord was purple-black, so heavy and thick with blood; the cord still looked/seemed important. After 90-120 seconds it looked dramatically different. The umbilical cord was thin and white and limp. It looked ‘finished’, so my husband cut the cord. I don’t feel like we rushed it, and I was really amazed at the transformation.

    http://www.nurturingheartsbirthservices.com/blog/?p=1542 has some very illustrative photos.

    • suchende

      That’s an interesting theory. I would be interested to see research on the subjects of hydration and delayed clamping.

      • Captain Obvious

        Again polycythemia is too many RBCs. Sludge essentially going through the tiny neonatal blood vessels. A markedly increased concentration of red blood cells may result in the blood being too thick, which slows the flow of blood through small blood vessels and interferes with the delivery of oxygen to tissues. A high concentration of red blood cells makes the blood thick (hyperviscosity) and may slow blood flow through small blood vessels.
        Most affected newborns do not have symptoms but occasionally have a ruddy or dusky color, are sluggish (lethargic), feed poorly, and very rarely may have seizures.
        Treatment for polycythemia is hydration to dilute the numerous RBCs or partial exchange transfusion.

        • fiftyfifty1

          Yes I cared for a newborn last month with polycythemia. Fluids were not enough. Had to be transferred out and stayed in NICU 5 days for partial exchange transfusions. Very stressful for parents. It’s nothing to sneeze at.

    • Captain Obvious

      More RBCs and hydration are two different things.

    • Sue

      “planner” = you have misunderstood blood volume vs dehydration. Hydration is about the amount of water diluting the red blood cells. That water can cross through membranes and go to the body’s tissues. A certain amount of fluid is held within the blood vessel space by the proteins in the blood ) so-called oncotic pressure – which involves albumin and other proteins, manufactured by the liver.

      It is easy to be amazed by something you don’t understand, I guess.

  • suchende

    Surprisingly honest piece on Mothering.com:

    http://www.mothering.com/community/a/a-healthy-dose-of-birth-fear

    “If you combine the pain and the danger of birth and add in the inevitable unpredictable beauty of this natural process we come away realizing that fear and pain in birth are not new inventions spewed by ‘A Baby Story’ or the underlying ugliness of modern medicine, but rather a constant that has always been and always will be.”

    • KarenJJ

      That is surprising and refreshing from Mothering. Minimising the experiences of women and children around the world and throughout history by romanticising birth is rife through NCB.

      It’s easy to find out what people think of birth without access to interventions. Just ask someone that experienced birth back in the days or in another country without access to medical assistance. If you want the truth, don’t ask someone involved in selling their services to ‘help’ you have a NCB.

      • suchende

        I could hardly believe my eyes.

    • R T

      I’m really hoping at some point they perfect artificial wombs and no one will have to fear pregnancy and birth because no one will ever have to do it again! After suffering so horribly with my partial abruption I daydream about women never again being put in a position to go through what I went through. Can you imagine how the NCB crowd would react if women started forgoing pregnancy and birth all together and using external artificial wombs instead, lol! They would lose their minds!

      • rh1985

        I would love to have baby in an artificial womb just to be able to keep an eye on my baby and not worry about every little thing and be able to see that the baby is ok and not being hurt by medicine I have to take or not being able to eat very much and so on and so on…

        7 weeks and already a nervous wreck about everything.

        • R T

          Oh yes I understand! I had my abruption at 20 weeks and then battled preterm labor for the rest of the pregnancy. I had to take Terbutaline, Indomethacin, Procardia and other drugs for one thing or another. It was excruciating to have to decide if I wanted to take drugs known to have side effects on the baby and mother or risk him coming early. I don’t think I’ll completely relax, even now, until my little guy is walking and talking. I was so afraid he wouldn’t be normal or would have autism. However, the blessing is he didn’t know anything was wrong in his little comfy womb! Thankfully since birth he appears to be even better than I could have hoped. He’s big, beautiful, smart, advanced in all aspects of development! I would never want to go through it again though!

  • Seattle Hannah

    Delayed cord clamping represents my brief foray into wooville. When I was pregnant, I said to my OB, I have been reading about cord clamping, and I think that it sounds beneficial. Is that something I could do? She said, well since you are planning a C-section, my first priority will be to close up your incision, so sorry that won’t work. I said, hmm I understand where you are coming from there. And that was the end of that.

    • R T

      I have heard of delayed cord clamp of some form during a csection. My first thought was I want to be closed up as soon as possible! I don’t even want to wait 90 seconds!

  • R T

    Is delayed cord clamping still considered beneficial for preemies?

    • CanDoc

      Extremely. Decreases need for transfusion and risk of intracerebral hemorrhage (major risk factor for CP). We do DCC even at CS for preemies in our centre, if micropreemies (<1000 g) we use sterile warm blankets and everything if baby appears well to maximize transfer.

  • Haelmoon

    Like many things, there may have been an evolutionary benefit to this transfusion in the past. With a diet that was not rich in iron and extended breasting is older times, I suspect that iron deficiency was a bigger concern. The availablity of iron supplementation complete makes this a moot point now.

    My personal concern is the general like of understanding about anatomy and physiology these women supporting delayed cord clamping have. They all want to wait unti the cord has stopped pulsing, but this is irrelavent. The artery pulse, it sends blood into the placenta. The vein does pulse and takes blood back to the baby. After delivery, the uterus contracts and squeezes the placental bed, forcing blood back into the baby. This corresponds with the initial breaths and prefusion of the lungs. However, after the initial squeeze, the pressure is increased in the placenta vascularature and litle blood will flow from the artery into the placenta, because the resistance it too high. The pulsations don’t mean blood is flowing. With the drop in blood volume, the umbilical vein collapses. however, with delivery of the placenta, the pressure is gone. If the venous circulation remains open, the placenta, like a big sponge amy suck blood back. If the artery is still patent, more blood can be pumped back into the placenta. There are case reports of fetal exsanguination into placentas, particularly after the delivery of the placenta. They studied the position of the neonate for delayed cord clamping ages ago, but this information seems to be forgotten and delayed cord clamping (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(69)90213-X/abstract). The transfusion is from the uterine contraction, and can be affected by gravity. It is not a arterial circulation issue. Any don’t even get me started on the oxygentation arguement. ACK!!

    • Lisa from NY

      Expandable baby theory — DCC magically doubles the baby’s volume, because babies are made of rubber.

      • VL

        Congratulations! It’s a bouncing baby boy!

        • Mrs Dennis

          Yup, we always test babies’ bounciness like this: BOINGG!! Part of the Apgar scoring system. See? This one’s all perished.

    • Sue

      THANK YOU, Haelmoon. We see so much of what I call ”evidence creep”. Breast milk reduces the incidence of NEC for premmies – it must do so for everyone, Extra iron is important in the malnourished – it must be important for the over-nourished too. Severe protein malnutrition causes swelling from fluid leakage – pregnant women must need more protein. Some people get C difficile after antibiotics – EVERYONE must need pro-biotics. SOmebody lost weight by cuttingvout all fructose – fructose must be banned for everyone, And so it goes. Like DCC, I blame the press spitting out press releases without critical thought, and the population wanting to embrace simple messages.

  • Bombshellrisa

    Here is the Penny Simkin argument for delayed cord clamping-the blood belongs to the baby! Even if the baby needs resuscitation, you ought to be leaving the cord intact and doing the resus while the mother holds the baby! The visual with the water bottles-yikes! http://youtu.be/pYD3h_S70ek

    • Lisa from NY

      A baby can only hold a certain amount of blood. Delaying the clamping won’t make it hold more blood, unless she means the baby blows up like a balloon.

      • Bombshellrisa

        I don’t think she can put those two things together. And this is someone who had taken anatomy and physiology (Penny Simkin was trained as a physical therapist).

  • Kelly

    In another post I referenced having delayed cord clamping in my hospital birth experience. It wasn’t done for the alleged benefits, but simply because there was no rush to cut it either. However, I do have the question about cord blood banking. There is a clear value placed on the blood present in the cord, so much so that people spend a hefty sum having it collected and banked. If that blood is so great, why not allow it into the newborn’s system? Maybe the effects are different or more long term than this 3-6 month study suggests. Or, Dr. Amy, is cord blood banking a hack too?

    • Ainsley Nicholson

      I thought the point of cord blood banking was to obtain stem cells that could be used to benefit the child at a later date, if they develop leukemia or something. Not that the cord blood itself was “so great”.

      • Sullivan ThePoop

        Exactly! I was hoping someone else would answer that because I would have made the reply too convoluted I am sure.

      • Hava NaturalMama

        The question is what happens to those stem cells if the infant gets them at birth and I don’t think anyone knows. They might or might not make a difference.

        • Captain Obvious

          The baby is getting those stem cells at birth. The blood flowing through the baby, the cord, and the placenta have the same fetal Hgb and stem cells. The baby’s blood has those stem cells and the excess blood still in the cord and placenta are being collected for adults or older children who don’t have those stem cells (or fetal Hgb) anymore. So yes, if the baby develops leukemia at 2 years old after maintaining all those same stem cells you collected at his/her birth, wouldn’t those banked units potentially be bad too. That child would be better off receiving banked cord blood from a healthy sibling or random healthy donor.

          • R T

            I was always under the impression cord blood banking was potentially more beneficial to other children you may have, not the child it was collected from?

          • Captain Obvious

            Exactly. Hava’s comment made it seem like immediate cord clamping prevents the baby from getting any stem cells, but DCC may allow them to get to the baby and that may make a difference in preventing leukemias. Not the case. But then again I may have misinterpreted her comment.

    • suchende

      If cord bl

      • Becky05

        “If cord blood had a benefit to a well newborn, wouldn’t it show up in studies?”

        Only if the studies are sufficiently powered to detect differences in those outcomes. Some of the outcomes affected by DCC in preemies — sepsis, intraventricular hemorrhage, necrotizing enterocolitis — have much lower incidence in term babies, such that it is possible that the effect is still occurring but that huge sample sizes would be needed to show a significant difference.

        Also, the decrease in iron stores shouldn’t be underestimated. Iron deficiency anemia is still a real concern for breast fed babies in the United States, and it can be potentially very serious.

        You can easily do a compromise — delay for a minute or two. Some “delayed” studies only delayed for 30 or 45 seconds.

    • Captain Obvious

      During pregnancy the baby-cord-placenta vascular space is filled with blood that has all the same fetal Hgb and stem cells. This volume of blood for the Baby-cord-placenta unit is obviously more than what the baby can hold or needs. Why would you want to force all the blood from the cord and the placenta into the baby at birth? To make a statement in woo fashion, natural has made it possible that more fetal blood is circulating in the baby-cord-placenta unit that if any gets lost or bleeds out that the baby may still survive. But people have this idea we need to put every last drop into the baby and risk polycythemia, hyperbilirubinemia, and jaundice. Please bank the blood for someone who needs it. The baby has all it needs.

      • Ainsley Nicholson

        I’m getting the idea that the optimal cord-management is something of a balancing act- too little could result in iron deficiency, too much could increase the risk of jaundice. And it varies between babies- a preterm baby might benefit from getting more of the blood, a jaundice-prone baby might benefit from immediate cord clamping. I’m curious about what exactly it is that would “force all the blood from the cord and placenta into the baby”, Captain Obvious? Would that be milking the cord? Extreme delay in cord clamping? Anything that is not immediate cord clamping? Does an extreme delay result in more blood going into the baby than would occur in the first few minutes (seems unlikely)?

        • fiftyfifty1

          More blood goes back into baby if you milk and raise placenta above level of baby.

          • Ainsley Nicholson

            Ah…that law-of-gravity thing…and here I thought that OBs ignored science!
            (yes, that was sarcasm)

          • Mrs Dennis

            Also you can wring out the placenta, rinse out the last drops of blood with a small amount of vinegar, and babies have a hidden zip that unlocks extra packing space. Much like a fancy suitcase. See? Thrift begins in the delivery suite.

      • Lisa from NY

        Inflatable babies.

    • fiftyfifty1

      “There is a clear value placed on the blood present in the cord”

      The value of the blood in the cord is that it is fetal blood and thus still contains a significant number of stem cells. Stem cells are immature cells that have not yet committed themselves to being one certain type of blood or another. Thus they are valuable for things like bone marrow transplants. For instance if you baby grew up and developed a blood cancer such as leukemia, you could do a bone marrow transplant using his or her own banked stem cells. So to answer your question “If that blood is so great, why not allow it into the baby’s system?” totally misses the point. It just doesn’t work that way. It’s like saying “Without sperm there can be no new life. So since sperm is so life-giving, why don’t men keep it for themselves?”

      • Lisa Miller

        Thank you for saying this better than I could. I was having a hard time typing whilst banging my head on the keyboard.

      • CanDoc

        Actually, you wouldn’t give a child with leukemia their own cord blood stem cells in a bone marrow transplant, since those are the same stem cells that resulted in the leukemia in the first place. But you could give them to an HLA-matched sibling who needed a BMT. Current private cord blood banks where you save the blood for your own baby are pretty much a scam. Public blood banks show some promise in a more altruistic way.

        • Antigonos CNM

          And it seems quite probable that stem cells can be, and will be, derived from sources other than cord blood in the fairly near future, so that banking cord blood becomes unnecessary. Not to mention that i always wonder about the longterm results of [1] storage, and [2] what if the company goes out of business, after parents have paid huge amounts of money for the storage. I think it is all a scam, frankly.

          • Isramommy

            Antigonos- one of the news investigation shows here in Israel (maybe Kolbotek or Orly and Guy’s evening thing? I can’t remember) did an expose on exactly that problem, including private companies who improperly stored cord blood samples, rendering them unusable.

            I do like the idea of donation, but it isn’t so easy to do. We tried to arrange it and were basically told that it can only be done if you deliver at Sharei Tzedek and not if the baby is born over Shabbat.

        • Isramommy

          Not for leukemia, no, but there are other conditions where a child’s own cord blood could be used. Duke University has a trial using babies’ own cord blood to treat brain damage caused by hydrocephalus. My understanding is that they’ve had some very positive results. But again, that isn’t the same as private commercial banking. The babies are identified in-utero and their blood is sent directly to Duke for storage until it is transfused after shunting surgery.

    • KarenJJ

      It saves trying to draw blood from the actual baby.

      We needed a blood sample from my newborn for genetic testing. They took it from the cord, to save him from having to get a needle.

  • GuestB

    OT: http://m.washingtonpost.com/blogs/worldviews/wp/2013/07/11/a-hospital-in-zimbabwe-charged-women-5-for-each-scream-during-childbirth/

    “The United Nations reports that, on average, eight mothers die during childbirth every single day in Zimbabwe.”

    Trust birth!!

    • I don’t have a creative name

      It’s all those interventions! Women don’t have PPH or other complications unless you interfere with the natural birthing process!

      Oh wait…

    • Captain Obvious

      World Health Report 2007 stated that in the UNITED STATES, 2-3 women die every day due to pregnancy related complications. Worldwide 160 million women become pregnant each year. Of these, 15% develop complications which leads to 600,000 women dying every year.

  • Hava NaturalMama

    How about “first do no harm!”? If there is NO evidence immediate cord clamping is helpful, how about giving nature the benefit of the doubt. If an intervention has no evidence supporting it, why do it. Give the mom and baby a few minutes. How can it hurt?

    • Sullivan ThePoop

      What evidence do you have that there is any harm in immediate cord clamping?

      • Hava NaturalMama

        None that I know of. So why not wait?

        • Sullivan ThePoop

          No one is saying not to wait if you want to. There seems to be little harm with waiting, but there also seems to be no real benefit.

          • Hava NaturalMama

            How about looking at the other mammals of the world and seeing what they do instinctively? If they all wait, maybe there is something to it that we don’t fully understand yet. Dr. Amy has used that argument against water birth. (If no other land mammal does it, why should we?)

            It seems sometimes Dr. Amy is determined to diss the natural birth community no matter what.

          • expat in germany

            I think that in a perfect world, there would be no difference between what midwives think is best and what doctors think is best. If everything has been measured, there is nothing to argue about anymore. What you find on this page is a conviction that there is an optimal way and that it is not found through blind intuition or based on ancient (untested) “wisdom”

          • Sullivan ThePoop

            The problem is that midwives feel like they have to do things differently than OBs or they will not have employment so they make all these nonsense arguments over nothing.

          • Hava NaturalMama

            There is no scientific evidence to support that generalization. I gtg. If you think of a good reason for immediate cord clamping, please let me know.

          • expat in germany

            Jaundice

          • Hava NaturalMama

            Can you provide any evidence documenting that delayed cord clamping increases incidence of newborn jaundice? This study measured that and saw no difference either way.

          • Renee Martin

            Academic OB has done some great work on DCC (he is pro DCC, IIRC), and I think increased jaundice was shown in some studies.

          • Hava NaturalMama

            The American Congress of Obstetricians and Gynecologists mentions the jaundice issue in their position paper, but they say its not enough of an issue to merit across the board immediate cord clamping. I haven’t read enough of the primary literature myself so I’ll take their word for it.

          • Birthbuddy

            College not Congress

          • Hava NaturalMama

            I agree. It would be great if there was real scientific evidence for all issues, but until that happens, we have to make our best guesses.

          • Allie P

            yeah, because they promote practices as being the right and only way to do things that are either dangerous or provide no real benefit. Delay clamping, don’t delay clamping, but don’t talk about its massive benefits, don’t make moms feel like they failed if their babies’ cords were immediate clamped, don’t fight for hospital policies that require delay cord clamping at the expense of more important safety measures (similar to the push to lower c-section rates at all costs) and don’t write fawning articles about benefits that DONT EXIST. She doesn’t say “don’t breastfeed” either, she just says “it’s not as good as the crazies make it out to be, and it’s DEFINITELY not worth hurting you or your baby to get your NCB merit badge.” See the difference?

          • Hava NaturalMama

            I 100% agree with you. There are much more important issues than changing medical standard regarding cord clamping.

          • KarenJJ

            Why not have confidence in the way that we do things? We’ve been around as long as some of these other animals are? We’ve been pretty successful in breeding and adapting to our environments as well as adapting our environment to us.

          • Hava NaturalMama

            Because the US birth stats suck compared to most industrialized countries. Because my local hospital has a 40% C-section rate (obviously unrelated to cord clamping). Clearly there is room for improvement.

            Immediate cord clamping is a very modern practice, we survived for a long time before that, but maternal/infant mortality was high for other reasons. Modern medicine has helped a lot, but that doesn’t mean it’s all good.

          • KarenJJ

            But this study shows that it doesn’t mean it’s all bad either.

            I don’t think the c-section rate is going to go down in a hurry. Unless some amazing technology is discovered.

          • Amy Tuteur, MD

            But they don’t suck. That’s just another lie that natural childbirth advocates tell each other.

          • Hava NaturalMama

            You have yet to convince me on that one. I read your blogs with an open mind, and will continue doing so.

            It’s not just the natural birth community, it’s everywhere you look. Birth is the US is more expensive, but we still have more babies and mothers dying.

            I’ve read yours posts like http://www.skepticalob.com/2011/09/us-newborn-death-rate-tied-with-qatar.html and you explain for some individual studies that they were flawed in making inter-country comparisons accurately, but I have yet to see you cite a single study where the US isn’t embarrassingly low. If I missed it, please let me know. If you want to cry measurement error and ignore a problem, that’s your call.

          • Hava NaturalMama

            Even you have said “The US does not have the lowest neonatal mortality rate in the world, and we certainly have plenty of room for improvement”

          • expat in germany

            If one tends to deliver jaundiced babies, there may be a harm associated with delayed cord clamping.

      • Amy M

        My take-away from this post, and previous ones by Dr. Amy on the subject is that if there is no emergency, baby is full term and mother and baby are healthy, then immediate clamping OR waiting a minute or two are equally fine. If that interpretation is correct, there really shouldn’t be a big deal in the media or on facebook or anywhere about this, and it should be parental preference. It would then come down to which do you want more: immediate skin to skin, or delayed cord clamping, since they may be mutually exclusive depending on the length of the cord, and whether or not it is wrapped around the baby at all.

        • Hava NaturalMama

          How about looking at the other mammals of the world and seeing what they do instinctively? If they all wait, maybe there is something to it.

          Dr. Amy has used that argument against water birth. (If no other land mammal does it, why should we?)

          It seems sometimes Dr. Amy is determined to diss the natural birth community no matter what.

          • Amy M

            No one is saying there is a problem with waiting a minute or two though….if that is what your preference is, go for it.

            Other mammals chew through the cords pretty quickly, but I am thinking of cats and dogs that have litters, so there is generally another baby coming right behind, so the placenta of the first one follows it right out usually. I’ve seen cows and sheep give birth, and sometimes those cords break on their own as the baby is born.

            I’m not getting your reference to water birth here though…

          • Hava NaturalMama

            I was referring to this post: http://www.skepticalob.com/2013/06/unnatural-childbirth-5-goofy-things-that-natural-parenting-advocates-do-that-never-occur-in-nature.html

            According to In the Shadow of Man, by Jane Goodall, chimps do not focus on severing the cord immediately and initiate nursing with the cord still intact. So if Dr. Amy is going to be consistent in her arguments, she should be promoting delayed cord clamping.

          • Amy M

            But what does that have to do with water birth?

          • Hava NaturalMama

            Read http://www.skepticalob.com/2013/06/unnatural-childbirth-5-goofy-things-that-natural-parenting-advocates-do-that-never-occur-in-nature.html

            #1 and #2, Dr. Amy uses comparisons to primates as evidence against water birth and placenta encapsulation

          • Amy M

            Oh I see, you are saying she compares us to primates who do don’t do those things, so we should do as other primates do, and not sever the cord….ok, you are going for consistency here, I understand your argument now.

          • Hava NaturalMama

            Yay…. it’s always refreshing when people actually listen to each other.

          • T

            In all honesty, I don’t care what chimps do. I don’t live as as a chimp in general, so why should I particolarly worry about it?

            There is no benefit to delayed cord clamping. Vaccines don’t cause autism. Yes, global warning is anthropogenic. Homeopathy is water. Keep making studies about those things is just pointless. Can we focus on something else, now?

          • Birthbuddy

            Please!

          • Sullivan ThePoop

            Nonsense! You are talking about one mammal now when just a minute ago you said look at all mammals. I guess you realized that looking at all mammals will not jive with your premise so you had to change it.

          • Hava NaturalMama

            I thought of the idea because of this post by Dr. Amy where she uses the closer relative arguement to reject placenta encapsulation. Dr. Amy argues that since no primates eat their placentas we should even though other mammals do. So if some mammals sever the umbilical cord immediately and some don’t, we can look to our closer relatives for a clue.

            http://www.skepticalob.com/2013/06/unnatural-childbirth-5-goofy-things-that-natural-parenting-advocates-do-that-never-occur-in-nature.html

          • Sullivan ThePoop

            Most mammals who eat their placenta do it so that there is no smell to attract predators when they are in a delicate state and unable to defend themselves. Primates do not have the same concerns because they are not solitary animals.

          • Amy M

            Who cares what chimps do though? It has been PROVEN that it doesn’t matter. Do whatever you want, unless there is some emergency reason to cut it immediately. Hell, do lotus birth—it is wicked gross, but pretty much harmless as far as we know.

          • Hava NaturalMama

            No it has not been proven that it doesn’t matter. Absence of evidence is not evidence of absence. Dr. Amy is arguing that the NY times is overreacting to a study that does not show enough evidence of benefits. That doesn’t mean there aren’t benefits that are yet to be proven.

            I will do whatever I want, but my concern is that the standard practice of immediate cord clamping has no known benefits. The evolutionarily supportable method of delays cord clamping might have benefits. Given that, I think standard practice should be to delay unless there is a medical reason (or parental preference) to cut immediately.

          • Amy M

            Ok, maybe “proven” is too strong a word. I think “shown” is appropriate though.

          • Hava NaturalMama

            Shown doesn’t work either. There is NO way to scientifically show the absence of an effect.

          • Amy M

            I meant shown there is no harm.

          • I don’t have a creative name

            That doesn’t mean there aren’t benefits that are yet to be proven.

            So if you’re admitting that there are no real known benefits, why such a tizzy about it? That would be like me being enraged that not everyone dances naked in the street at 5 pm. Sure, there are no provable benefits NOW, but there might be later. (especially if Ryan Reynolds was there, but I digress….)

            Look, do what you want. I don’t care, and I don’t think Dr. Amy cares. What I don’t like is the NCB community promoting this as THE way to do things, and seeing weepy posts from moms, just devastated that their child did not get delayed cord clamping. WHICH HAS NO KNOWN BENEFITS! They’ve been shnuckered by the NCB movement into feeling guilty about not doing it a certain way, even though those ways are merely preferences with no significant benefits to baby.

          • Hava NaturalMama

            I am not in a tizzy. I just think that we should have a good reason to support the decisions the OB community makes about standard practice.

            I agree with you about cord clamping not being worth being devastated about or putting down another mother over.

          • suchende

            You think we should have a good reason to deviate from what natural birth advocates support, you mean. If you really just thought there should be evidence-based care, you would see that this research indicates that there is no evidence at this time to change the current practice.

          • Hava NaturalMama

            I believe in evidence based care and there is no evidence to support the current practice. If it were expensive to change, I would say it isn’t worth it. But if its not expensive and it might help, why not?

          • Hava NaturalMama

            and of course we have established that it doesn’t hurt

          • suchende

            Why do you think your default position is better than their default position when the evidence favors neither? That is NOT evidence based care.

          • Renee Martin

            I’m not sure why “natural” should be the default, as its not known for safely birthing babies, or allowing women to survive. Technology is doing a better job at allowing women to survive and be whole, and babies live with their full brainpower, than nature ever did.

            I am all for evidence. I agree 100% we should follow the evidence we have, and in cases it’s a wash, parents preference rules.

            In THIS case, it appears DCC has a small possible benefit of extra iron at 3-6 months. We don’t know if thats helpful or not, but assuming it is, is it worth the chance of making other babies more jaundiced/ increased bili?

            Obviously I would say it’s NOT worth it, because MY kids have issues with jaundice. I am glad we didn’t DCC because it would have made more problems.

          • Hava NaturalMama

            Evolution does not lead to perfect solutions, and thank G-d for interventions like C-sections. When they are really needed they save lives. But evolution/nature shouldn’t be totally disregarded either, and we should only disrupt a natural process if we have evidence of a benefit. Suspecting jaundice would be a benefit, but according to the American Congress of Obstetricians and Gynecologists, its not a big enough issue for them to support immediate cord clamping across the board.

          • KarenJJ

            But evolution is not just a passive thing that happens. We’ve been using technology and adjusted it to suit our preferences for a long time..

          • Hava NaturalMama

            I think we are using the term evolution differently. I use it to refer to natural processes that lead to change in species over time, which is a passive process. I’m not quite following your logic.

          • KarenJJ

            For example: we’ve been saving babies from starvation by supplementing them for a long time now – so the idea that we are ‘meant to breastfeed’ was busted out of the water thousands – millions of years ago.

            Humans have been cooking food and using technology for a long time and evolution would be taking this into account.

            I was talking with a friend about this once “who do we know would have survived living on the savannah?”. Most people we could think of (including ourselves) would have been lion food a long time ago..

          • Hava NaturalMama

            The age of the human species is usually estimated at 200,000 years. So evolutionarily the impact of modern technology is relatively small. That’s why lactose intolerance is so prevalent and the paleo diet is so effective. Our underlying physiology has changed some (new genetic diseases for example) but not drastically.

          • Sullivan ThePoop

            Evolutionarily supportable? You have no idea what you are talking about. If there was some benefit and it had evolutionary evidence to support it there would be more of a consensus among placental animals and there is not. That is the opposite of being supported by evolution.

            I think what you really want is to feel that your ideas are superior. Just like most people in the NCB movement.

          • Hava NaturalMama

            There is no need to make this personal. A degree in Biology with a 4.0 says I may know what I am talking about.

            Just as you said before, in some mammals there is a cost benefit issue with predation. Humans don’t have that issue.

            I am open to any reasonable arguments to support maintaining immediate cord clamping as standard practice, but I haven’t heard any yet.

          • Sullivan ThePoop

            What? Do you think that impresses anyone around here? Especially when you make comments that are completely counter to what you should have learned. You could have only made it to the eight grade for all I know or care and your statements do not convince me either way.

            All I am saying is if there is no difference immediate clamping would be the most efficient way. So, clamp it and get it over with so everything else can be done in a timely manner. You have made no arguments that sway me to believe that a switch to delayed clamping as a standard should be made.

          • Hava NaturalMama

            I am not trying to impress anyone. I am just providing some evidence that I am not clueless. I take Dr. Amy’s comments with a lot of respect because of her training as an MD, and I think my comments are better informed by my training in science as well.

            What make immediate cord clamping more efficient? So the doctor can leave the room sooner? That in of itself does not seem like a good argument to be. If that’s the best argument that we can come up with to defend current practice then that’s a problem.

          • Sullivan ThePoop

            Well, I am just telling you that when people say things like “I have a degree in biology with a 4.0” I think they are lying. I am a biologist and I have never once said to anyone online or in real life. I got a degree in biology with a 4.0. Who says things like that? I would more likely say that I was trained in biology or that I am a biologist. I do not even think back to school too much these days.

            Since immediate clamping is the standard I would say that it would have to be shown that there is a reason to change that and I have not seen a good reason. There is no reason not to delay if you want to. Why do you need the standard changed when the evidence is not there either way?

          • Hava NaturalMama

            Only brought up my background because you said “You have no idea what you are talking about.” There is no need to make this personal.

            I think any intervention should have evidence of a benefit to support it. I think immediate cord clamping is an intervention. That is my personal bias. If one could argue that it would be very expensive to change this standard practice, then I would probably agree it is not worth the cost.

          • BeatlesFan

            Why is it an intervention to clamp the cord 5 seconds after birth, but it’s no longer an intervention 5 minutes after birth? Either way, the process is the same- clamp and cut.

          • Hava NaturalMama

            Because immediate cord clamp prevent the baby from getting as much blood from the placenta as possible. After the cord stops pulsating, there is no reason to think it makes a difference.

          • Amy Tuteur, MD

            But there’s no evidence that the baby needs any more blood than what it has with early cord clamping. If the extra blood were beneficial, why would the baby’s body destroy it?

          • Hava NaturalMama

            The baby’s body still gets extra iron from destroying those red bloods cells. Isn’t the destruction part of the normal conversion from fetal or adult hemoglobin?

            But why do early cord clamping? It would seem if an OB is going to rush to do something after birth, there should be a reason. Maybe take a few seconds to ask “Would you mind if I cut the cord now? Would your partner like to cut the cord?” Take the time to obtain explicit consent, because why not?

          • Haelmoon

            I rarely clamp the cord quickly, but it because the babies are loud and screaming. Once I do clamp, I always have time to ask who is cutting the cord. If mom is at risk for bleeding, or the baby is at risk fo polycythemia or has meconium, then I do clamp right away. The meconium babies it is for safety reasons, for the other babies, they are already at risk for jaundice, why increase the risk?
            If the extra iron is important, it is easy to supplement iron in today’s world. Chimps don’t use iron supplements. maybe that is the evolutionary benefit, but no a real world benefit today.

          • Hava NaturalMama

            You sound like a really thoughtful doctor. 90 seconds really isn’t that long.

          • Hava NaturalMama

            Maybe, but not all pediatricians test for iron levels before 6 months, so one may not know to supplement.

          • Tim

            Is there really anyone in the developed world who doesn’t give their infant poly/tri/vi-sol? So what difference does it make if the pedi tests their iron levels or not?

          • Hava NaturalMama

            Yes. My pediatrician doesn’t routinely recommend it, and none of my friends/family used it for their baby that I know of.

          • Tim

            No offense, but how exactly are you and your friends making sure your babies get enough vitamin d then? Your choices are basically

            a) Bring them out unprotected into the sun, and increase their cancer risk

            b) give them a multivitamin

            c) take a risk on them getting rickets

            I would have serious questions about the abilities of a pediatrician who didn’t recommend a multivitamin for my kid.

          • Hava NaturalMama

            Since you can’t use sunscreen on babies less than 6 months, unless you never leave the house, they will get some sunlight. At my latitude, my pediatrician and a few others that I have spoken to are confident that my baby got enough incidental sun exposure to make vitamin D. World Health Organization information [Butte 2002, p. 27 ] states, “Two hours is the required minimum weekly amount of sunlight for infants if only the face is exposed, or 30 minutes if the upper and lower extremities are exposed.” If I had a December baby I would consider supplementation. But with a spring baby, we’re outside enough, and they are getting that small amount of sunlight they need.

          • Tim

            I guess we just see things differently there. I can’t imagine not having my kiddo (or myself) on a multivitamin when they are so cheap and widely available – better safe than sorry. We rarely left the house with her after she came home except to take her for dr appointments, but even if she had been better off and those had been less frequent, we still were not planning to drag her around places for a while. We figured newborns belong at home napping and growing and we would try to fit our lives around that for the stuf that required going out. I mean, we still have her on a MV anyway even though shes eating tons of food and still drinking a ton of formula now, just seems like the best thing to do for anyone to fill in the gaps where diet isn’t cutting it.

          • Hava NaturalMama

            Sounds like its the right choice for your family.

            That’s definitely not the life I led with my newborn. Different people do things differently and that’s okay.

          • Box of Salt

            Tim, why does a formula fed infant who’s eating also a variety of other foods need extra vitamins?

            As for sun exposure – it’s sunburns which correlate with increased cancer risk, not moderate sun exposure (even in infancy) – such as the WHO recommendation Hava quoted above.

          • Tim

            a) She’s tiny, so she drinks less than 32 oz of formula a day (17.5 pounds @ 15 months old) – she has never even come close to 32oz of day. Previously she was getting breastmilk fortified with formula powder, but my wifes supply tapered off due to her not being able to actually bf, and just pumping. MV are specifically indicated for any formula fed baby who drinks less than 32 ounces a day, and all breastfed babies. Not sure if that’s not in vogue with the all natural crowd, but I don’t see anyone complaining when their chiropractor sells them priobiotics for 40$ a jar, so I am failing to see how giving enfamil 15 bucks for 2 months worth of polyvisol is some big pharma scam.

            b) she eats a variety of foods, but on her terms, when she feels like it. its not like she eats a perfect balanced diet every day. some days she will only eat animal crackers. some days she only eats sweet potato. some days she only eats spaghetti. she’s a toddler, they arent usually bastions of sensible eating

            c) I eat a good varied diet and I still take a mens one a day, it seems silly not to make certain the cracks are filled in if it’s cheap and easy to do so.

            d) check your facts on skin cancer. melanoma is associated with brief intense sun exposure (burns), carcinomas are associated with accumulated exposure to UV over your lifetime. The sun is plain old bad for your skin, in any amount, ever. That doesn’t mean you should never go out in the sun, but I didn’t bring my infant out for more than a minute or two at a time when she couldn’t wear sunscreen still.

          • Birthbuddy

            GOLF!!!!

          • fiftyfifty1

            Why the pulsing? Explain the biology you think underlies that.

          • Hava NaturalMama

            The pulsing is an indication that blood is still being pumped through the cord. When it stops, the fetal heart has switched over and is no longer sending blood through the cord, so the blood is no longer returning the baby at a significant rate.

          • FormerPhysicist
          • Hava NaturalMama

            Not worries.

          • Sullivan ThePoop

            I said you have no idea what you are talking about because you are saying that something that is counter to evolutionary evidence is evolutionary evidence. Your statement about grades and biology degrees concrete that opinion in my mind.

          • Hava NaturalMama

            I am sorry you feel the need to make personal judgements about other people. I disagree with you on some issues, but I am happy to treat you as respect and I will not judge you for your opinions.

          • Box of Salt

            Hava “I am just providing some evidence that I am not clueless.”

            May I suggest putting more thought and logic into your posts instead? That would be more compelling than boasting about your grades.

          • Hava NaturalMama

            I did not intend to boast just countering the personal accusation that I am clueless. But you are correct, I should not have dignified that personal attack with a response. I apologize.

          • fiftyfifty1

            So you take Dr. Amy’s comments with a lot of respect because she’s an MD. Why not give the same respect to other OBs who seem to prefer early cord clamping? Since DCC doesn’t show much in the way of benefits, why not let the OBs do what works best for them if the parents don’t care? Why accuse OBs of just wanting to get out of the room? Have you ever delivered a baby? Why should you have an opinion about what works best for procedure in L&D?

          • Hava NaturalMama

            I give Dr. Amy respect, but I don’t take her word without asking questions the same with an OB. They should have a good reason for early cord clamping, is that too much to ask? I don’t know what the reasons are because every OB I spoken to personally does delayed cord clamping, but I have not surveyed a representative sample.

          • Birthbuddy

            The doctor has to get to golf, for goodness sake.

          • suchende

            Unless that degree is a PhD you are embarrassing yourself. I can’t think of any expert in any field who cites their UG degree as the basis for their expertise. Can you imagine anything more absurd?

          • Hava NaturalMama

            I would read Dr. Amy’s blog if she wasn’t a MD. Try getting a paper published without a degree.

            I apologize that I only have a masters.

          • Guestll

            Did you really just support your argument by referencing the fact that you have an undergraduate degree in biology?
            My undergraduate degree is in English. From now on, I think I will reference it when I’m debating with Eng. Lit profs on the relative merit of Jane Austen’s body of work.

            I’m scrolling through this thread chuckling. I thought the comedy gold couldn’t get any better — alas, I was happily mistaken!

          • Hava NaturalMama

            If you want to correct my grammer based on your English degree, I will listen. If you want to lecture me on Shakespeare based on your English degree.

            I only cited by masters to refute the accusation that I am clueless. I may be incorrect, but I am not clueless.

          • Guestll

            My English degree qualifies me to say “Would you like fries with that?” and not much more, other than be pedantic and correct things like grammar/grammer. Which I don’t need an English degree to do. 😉
            I don’t think you’re clueless. I do think you’re incorrect. The evidence demonstrates that there is no real benefit to delayed cord clamping. If it’s a parental preference and it doesn’t interfere with other, more important things (like helping/saving Mum/baby) then sure, go right ahead. I don’t object to the procedure, I object to the grossly inflated claims surrounding the procedure.
            BTW, all cord clamping is an “intervention” whether it’s immediate or minutes or even days after the birth.

          • Hava NaturalMama

            Okay, so how about we agree that doctors should take the time to ask before clamping? So parents have time to indicate their preference if it doesn’t matter either way.

          • S

            Question for the OB’s and labor nurses around here. What percentage of parents, if asked, would have a preference? And what percentage of parents would say, “I don’t know. You’re the doctor!” Just curious.

          • Hava NaturalMama

            great question

          • Guestll

            How about we agree that since whether the cord is clamped immediately or within 1-3 minutes matters so little for healthy term infants, we trust the professionals delivering our babies to manage their own L&D, and if DCC is of primary importance to the parents, they sort it out ahead of time with whomever is delivering their baby?

            There’s a key word in there, it’s the word trust. My educational ad professional background (aforementioned English degree and MBA) means that on the subjects of science and medicine, I listen to the people with educational backgrounds in science and medicine.

          • Hava NaturalMama

            You’re right, I don’t trust the medical field. Did you see today’s headline http://www.cbsnews.com/8301-204_162-57592954/hospital-errors-lead-to-dead-patient-opening-eyes-during-organ-harvesting/ Doctors make mistakes all the time. Standard protocols are often not the best option.

            If I really trusted doctors, I would take the ACOG position at face value without question.

          • Guestll

            You don’t trust doctors because you don’t want to. You want to be edgy and cool and differentiate yourself from the mainstream. Your arguments for DCC/against ICC thus far demonstrate an apparent lack of critical thinking skills and I will bet my house that your belief system has zero to do with anything remotely resembling one single fact.

            And trust is not blind faith. I don’t have blind faith in my doctors, but I do trust them. If I didn’t, I wouldn’t continue as their patient.

          • Hava NaturalMama

            Why do you feel the need to insult me as a person? I just want to have a reasonable discussion.

          • Amy Tuteur, MD

            Perhaps it is YOUR attitude.

          • Hava NaturalMama

            I am trying to be as polite, reasonable and respectful as possible.

            I’m not sure what is so offensive about the idea of respecting all mother’s choice as long as they do not endanger anyone.

          • The Bofa on the Sofa

            Offensive? You are the one claiming offense. No one here has said you are offensive. You are the one making it personal.

            I’m not sure what is so offensive about the idea of respecting all mother’s choice as long as they do not endanger anyone.

            Perhaps others respond better if you avoided idiotic strawmen?

            BTW, while we are talking about respecting mothers, shall we talk about your pretty massive insult in the other thread that women in labour are delicate little flowers that can’t handle being asked simple question? I have been actually impressed at the number of people who have responded to you thoughtfully, relaying their own experiences and even clinical research. Such restraint!

          • S

            No one here is arguing against delayed clamping upon parental request. That’s entirely different from what you’re advocating, which is _routine_ delayed clamping, an across-the-board change.

          • Guestll

            Fine, you’re right. I apologise. I should not insult you, the person.

            Do you see doctors you don’t trust? How does that work for you? I’m genuinely curious. Because I can’t imagine having a relationship with a HCP I didn’t trust.

            I didn’t like my RE very much. But she was an excellent clinician and I mentally thank her quite often as she’s pretty much the reason I’m a mother. I learned to trust her judgment. I didn’t want to, because I didn’t like her bedside manner. She was abrasive and curt. But I chose to trust her because she knew what she was doing and she had my best interests at hand.

          • Hava NaturalMama

            If I can avoid doctors that I don’t trust, I do. I left my OB practice who delivers at a hospital 5 min from me for a CNM practice 45 min away, because I did not trust the OBs. My CNM practice is a joint practice with an OB group, so its not a 100% anti-OB stance.

            I trust my daughter’s pediatrician immensely, and I am lucky she practices a few blocks away.

            I had a surgeon that was similar to your RE; sometimes you can’t get the complete package.

          • The Bofa on the Sofa

            I am re-reading Guestll’s comment, and I am trying to find this “personal” insult.

            “Your arguments …demonstrate a lack of critical thinking skills” the only thing that could be considered an insult, but that is not about you as a person, it is a direct criticism of your demonstrated skills, or lack thereof.

          • Hava NaturalMama

            “You want to be edgy and cool and differentiate yourself from the mainstream.”

            Sounds like she thinks she knows what motivates me. I can explain to you what motivates me, if you would like to know (hint; she’s incorrect).

            “An apparent lack of critical thinking skills”

            Sounds like she is judging my skills as a person.

            “I will bet my house that your belief system has zero to do with anything remotely resembling one single fact.”

            Sounds personal to me.

            None of that has anything to do with general ideas about cord clamping and options that should be available to mothers.

          • The Bofa on the Sofa

            “You want to be edgy and cool and differentiate yourself from the mainstream.”

            Sounds like she thinks she knows what motivates me.

            But how is it an insult? Edgy isn’t insulting?

            “An apparent lack of critical thinking skills”

            Sounds like she is judging my skills as a person.

            She is talking about how you LOOK. “Apparently” refers to how you appear. And she is saying that you have demonstrated a lack of critical thinking skills. If you take that personally, then perhaps think about what gave her (and us, btw) that impression. What are you doing to make others think you have a lack of critical thinking skills?

            Remember, for us, you are what you say. That’s it. We don’t know you as a person from adam, only what you have said.

          • Ainsley Nicholson

            I don’t trust doctors to be perfect and never make mistakes. But I do trust their intentions to be good, and their training to be sufficient. I think a certain ammount of skepticism towards doctors is normal and healthy. It is what drives me to ask questions, to double-check that my doctor has heard what I said if I describe a symptom that he/she appears to disregard, and to make sure I understand all the possible ramifications of any particular treatment decision.

          • fiftyfifty1

            ” A degree in Biology with a 4.0 says I may know what I am talking about. ”
            An undergrad degree in Biology means you know what you are talking about? Um no.

          • The Bofa on the Sofa

            There is no need to make this personal. A degree in Biology with a 4.0 says I may know what I am talking about.

            I don’t know you as a person, I only know what you have said. And what you have said clearly shows you don’t have a friggin clue, gpas and degrees be damned.

            I am open to any reasonable arguments to support maintaining immediate cord clamping as standard practice, but I haven’t heard any yet.

            “There is no reason not to”

            You haven’t said anything to dispute that.

          • Hava NaturalMama

            I think you have shown that you are not interested in interacting respectfully, so I will try my best to ignore your comments.

          • The Bofa on the Sofa

            Yeah, that’s easier than actually trying to address them.

          • The Bofa on the Sofa

            Yes, it is “evolutionary supportable” that chimps don’t cut the cord because there is an advantage in doing so.
            OR

            it could just not matter, and since chimps don’t have the cognitive reasoning skills to even think about the question, they don’t bother doing it.

            Either explanation is “evolutionary supportable.” Generally when biologists argue that there is an evolutionary pressure for a trait, they explain why it is beneficial. However, traits that are survival neutral will also survive, and if they are secondary to other factors, they could even propagate. For example, the fact that giraffes cords are pretty much broken immediately demonstrates this. As giraffe’s grew taller, there was a larger chance of immediate cord breaking. However, if that does not affect survival, then it doesn’t matter, and it becomes the default for that animal.

            The variation of outcomes in the animal kingdom shows that when the cord is broken is not a factor for survival, which is consistent with what we have learned through studies of humans.

            Actually, in terms of “evolutionarily supportable” I’d suggest that “it doesn’t matter” is far more consistent with the claim that it does. It explains the variation we observe in the animal kingdom, and explains the outcomes we observe for humans. Hava’s 4.0 gpa insistence that the chimps approach matters is pretty much special pleading, and begs the question of why it doesn’t matter for giraffes. Simply saying “giraffes are different from chimps” isn’t an explanation for anything.

          • LibrarianSarah

            “Absence of evidence is not evidence of absence.”

            Funny Rush Limbaugh said the same thing about the “weapons of mass destruction” in Iraq look how that turned out. I am sorry but in science absence of evidence can be evidence of absence. If you do study after study and keep getting a null result chances are there is nothing there. If you keep insisting otherwise, you get into celestial teapot territory.

          • Hava NaturalMama

            I 100% agree with you. I have no idea how much money has been spent researching the costs and benefits of immediate vs. delayed cord clamping, but I doubt we’ve reached the celestial teapot territory already. Given the huge impact that we know of with umbilical stem cell research, it might make sense to look further.

          • fiftyfifty1

            Are you saying we shouldn’t do immediate cord clamping because it might deprive the child of stem cells or something? You really don’t understand how stem cells work.

          • Hava NaturalMama

            I don’t think the scientific community knows enough to say either way. But stem cells are immensely powerful, they are the reason some tissues heal and others don’t. I want my baby to have his/her stem cells, because why not?

          • BeatlesFan

            So you’re saying that delayed cord clamping might have benefits, they just haven’t been proven yet.

            You’re also saying that immediate cord clamping has no known benefits… which means it could also potentially have benefits which haven’t been proven yet.

            Why choose one over the other as standard practice, if either method could possibly boast yet-undiscovered benefits?

            Personally, I don’t give a damn either way, I just wanted to point out that you seem to be arguing in circles.

          • Hava NaturalMama

            I agree with you. The fundamental question in my mind is which approach should be considered an intervention. “First do no harm” Only intervene if there is evidence that it will help. I view immediate cord clamping as an intervention, so I would like some evidence that it helps.

          • PJ

            “Absence of evidence is not evidence of absence.”

            You could use exactly the same argument for immediate clamping. Or you could use the same reasoning to argue that there could be negative effects of delayed clamping that just haven’t been discovered yet.

          • Hava NaturalMama

            100% true. The question is establishing what in this case is an intervention. Interventions should only be used if they have a documented benefit. I have tried to argue why I think delayed cord clamping is more biologically normative and immediate cord clamping is an intervention that needs to be justified. But it seems like most of the other readers are happy with the status quo of immediate cord clamping and want compelling evidence before they will consider a change.

          • Amy Tuteur, MD

            In what way is it an intervention? And why are interventions presumed to be bad things? Birth is not inherently perfect; it is inherently dangerous.

          • Hava NaturalMama

            I categorize it as an intervention because it is a relatively modern practice (last 300 years for sure, but maybe only last 100 years) and it doesn’t happen on its own.

            In medicine don’t we assume interventions are negative? We don’t do surgical procedures or give medications unless there is evidence of the efficacy. Many interventions saved lives, but there is no sense in interventions just for their own sake.

            If immediate cord clamping saved babies/mothers lives, I would 100% support it. You’ve convinced me about home birth and water birth, but you have yet to give me any good reason to support immediate cord clamping as a norm.

          • The Bofa on the Sofa

            chimps do not focus on severing the cord immediately and initiate nursing with the cord still intact.

            But why do they do it?

            a) Because there is a benefit to the baby if they don’t cut the cord? or

            b) Because it doesn’t matter what they do, and since they don’t have scissors nor the wherewithall to create one, they don’t bother?

            One of these is consistent with empirical studies carried out with humans, which are very closely related genetically to chimps, and both are consistent with evolutionary development.

            So if Dr. Amy is going to be consistent in her arguments, she should be promoting delayed cord clamping.

            Apparently somewhere in your wonderful 4.0 GPA biology degree, you failed to learn logic.

            Dr. Amy’s “argument” is that delayed cord clamping or not does not matter. The chimps’ practice does not contradict that at all. Nor does the practice of any mammal.

            The chimps practice does not demonstrate that there is a benefit to DCC. It does show that there is no downside to DCC, but it also doesn’t show that there is a downside to immediate cord clamping. That is what we learn from our friends the chimps. It is not much.

          • Hava NaturalMama

            There is no way to conclude a or b without further research.

            My consistency argument refers to a previous post by Dr. Amy (linked above somewhere) where she argued that since chimps don’t eat their placenta that there is no reason humans should. If you buy that argument, then why not buy the argument that since chimps do delayed cord clamping, humans should too.

          • The Bofa on the Sofa

            There is no way to conclude a or b without further research.

            So if either a or b are possible, and we don’t know which one, then it makes no sense that we should assume that it is a, as you have suggested. Moreover, as I pointed out below, b is consistent with the research that has been done, AND is consistent with the variation observed throughout the animal kingdom. You say “more research is needed” but the observations we have are more consistent with b than a.

          • Sullivan ThePoop

            If you look at every other mammal there is no real consensus. Some chew through the cord right away and some leave it attached until it falls off on its own. It seems to be more about what kind of predators they are dealing with and how dangerous the smell is. This tells me that there is no real benefit or harm in either case if there are no predators to worry about.

          • Hava NaturalMama

            Then look to our closest relative, the chimp, which does not focus on severing the cord immediately and initiate nursing with the cord still intact.

            It’s fine to say there’s no harm or benefit either way, but something has to be “standard practice”, and why not make cord clamping standard practice, unless there is a reason immediate clamping is necessary.

          • Sullivan ThePoop

            Well, let us clamp it quick and get it over with so there are no worries then. I say that should be the standard.

          • Hava NaturalMama

            Why get it over with? Why would waiting cause worries?

          • Sullivan ThePoop

            Because there is no need to wait.

          • Amy M

            What is wrong with “parental preference” as standard practice, if there is no benefit/harm either way?

          • Hava NaturalMama

            Because it isn’t efficient to ask every parents every time. Of course if a parent has a preference there is no reason not to go with that.

          • Amy M

            Some will state their preference before going to the hospital, or maybe they can put it on the registration form.

          • Box of Salt

            It isn’t efficient? Why is efficiency an issue for a process (labor) than in general takes hours?

          • Amy Tuteur, MD

            Human beings diverged from chimpanzees approximately 8 million years ago. There’s no reason to think that what is good for chimpanzees has any relationship to what is good for humans.

          • Hava NaturalMama

            Then why did you use chimp birth practices to support your views in this post? http://www.skepticalob.com/2013/06/unnatural-childbirth-5-goofy-things-that-natural-parenting-advocates-do-that-never-occur-in-nature.html

            Why should immediate cord clamping be standard practice if there is no evidence that it helps?

          • The Bofa on the Sofa

            Moreover, even if chimpanzees do effectively DCC, it doesn’t contradict the conclusion that DCC or not does not matter. Maybe the reason they don’t is because they don’t care?

          • Sullivan ThePoop

            Exactly! New mother’s are taken care of by their group. They have little fear that the placenta will attract predators and no sharp instruments to make the cutting easy. They just don’t care about it.

          • Box of Salt

            Our closest relative, the chimp, also does not forge sharp blades, nor have they invented computers (and the internet).

            I’m not sure why you think the default position for chimps should be the default for humans.

          • Hava NaturalMama

            I don’t think chimp birth should be if we have better to make a decision. But if we have no idea what’s best, why not turn to our closest relative.

          • Box of Salt

            Why not turn to our closest relative?

            Because we have larger brains than they do, allowing us to do scientific studies answering these questions in our own species – such as those discussed in this very post.

          • I don’t have a creative name

            But if we have no idea what’s best

            But what I don’t get is why you keep saying, we don’t really know, when I thought this study showed that we DID know – that there’s no discernible difference.

          • Hava NaturalMama

            The study showed there was a slight difference. Dr. Amy argues that the NY times overstated that difference. So we don’t know either way.

          • Captain Obvious

            But some of those babies ended up under phototherapy lights for hyperbilirubinemia. You know what jaundice, polycythemia, and kernicterus is? How many of the immediate cord clamp babies had problems or need for phototherapy compared to DCC babies?

          • Box of Salt

            Hava, When I took the Zoo tour, they told us that when giraffes give birth, the long drop to the ground breaks the cord. Wikipedia agrees (it’s several sections down): http://en.wikipedia.org/wiki/Giraffe

            Giraffes don’t wait.

          • Amy M

            Similar with cows.

          • Hava NaturalMama

            Okay, but our closer relatives do wait. If we use Chimps to insights into so many traits and diseases why not birth standards?

          • Hava NaturalMama

            Okay, but our closer relatives do wait. If we use Chimps to insights into so many traits and diseases why not birth standards?

          • Captain Obvious

            Monkeys throw feces.

          • KarenJJ

            Well yeah, but there are probably some humans that do that too…

          • Squillo

            I think Amy’s assertion about land mammals is intended to demonstrate the cognitive dissonance suffered by some natural birth advocates that promote water birth, not as an argument that we should eschew it and follow nature.

          • Hava NaturalMama

            She uses it as an argument against water birth, but to be consistent that logic it can also be used as an argument for delayed cord clamping.

          • Squillo

            But she doesn’t use it as an argument against water birth; she uses it as a demonstration of the hypocrisy of the “natural is best” and “women are designed to give birth” brigade. Look at the context of the post you refer to below. Her argument isn’t that humans shouldn’t waterbirth because no other land mammals do it, it’s that it is dangerous for humans.

          • LibrarianSarah

            When I was a kid our class had “class gerbils” and I remember watching in horror while the mother ate 2 of the babies. Gerbils are mammals of the world should I follow that mothers instinct?

          • Hava NaturalMama

            Obviously not. Ethics play a roll, which is why in a case of little evidence either way, parental preference should trump all. However, not all parents have a preference, so whatever the OB community chooses to establish as standard practice it should have a good reason.

          • LibrarianSarah

            But neither delaying cord clamping doesn’t have any benefits so there is not “good reason” to do so. Cutting right away has the benefit of having the cord blood be donated or banked at least.

          • Hava NaturalMama

            True. But from what I have read cord blood banking is a hoax. I would love to here Dr. Amy chime in on that issue.

          • Mariana Baca

            Cord banking is a bit of a ripoff because the odds of a given baby needing stem cells for anything is pretty low. But, this type of stem cells are useful in general and not morally problematic, and stem cell donation allow there to be some available for any person who might need them for treatment

          • Hava NaturalMama

            I wish it was easier to donate cord blood stem cells. I looked into it, but my hospital couldn’t promise that I wouldn’t be charged for the procedure.

          • Captain Obvious

            The number of privately banked units that are actually used for ones own family member is 1/2700. Not very good. Public donation can help any of these…Acute/chronic leukemia, lymphoma, aplastic anemia, sickle cell, multiple myeloma, fanconi anemia, thalassemia major, congenital thrombocytopenia, SCID, Hurlers syndrome, leukodystrophies, myelodysplastic and myeloproliferative disorders, and other genetic and acquired disorders.

          • LibrarianSarah

            Then donate it.

          • Hava NaturalMama

            I would have happily done so if I could have gotten my hospital to work with me on the issue.

          • Captain Obvious

            It’s not a hoax. Really, with all the things the NCB do with evidence based medicine you call cord blood banking a hoax. It is not great for private banking if the family is healthy, but with a child that has any number of hematologic disorders it can be worthwhile. Public banking may help save lives. And you call it a hoax. Yet you make a big deal out of ICC vs, DCC.

          • Hava NaturalMama

            You’re right I should have been more specific. Donation for public banking or if there is a specific family issue are both important practices, but for most people private banking is a waste of money.

            I don’t think ICC or DDC is a huge deal. I just think that people should have the choice or if the health care professional chooses they should have a good reason for their choice.

          • fiftyfifty1

            “why in a case of little evidence either way”…….”so whatever the OB community chooses to establish as standard practice it should have a good reason”
            You can’t have it both ways. You can’t in one breath admit there is little evidence of benefit either way and then in the next demand that the OBs base their default on a “good reason”.
            If evidence does not show a true medical benefit, then the decision is based on personal preference. If the parents have a preference, and there is no contraindication then go ahead and do what the parents prefer. But if the parents don’t care, why not base the decision on the OB’s preference? If there is no harm, what’s the harm?

          • Hava NaturalMama

            If the parents truely don’t care that’s fine, but what if they do care, but aren’t even asked.

          • suchende

            Nature is a fucking bitch, if you haven’t noticed.

            Why are mammals waiting? Could it be because they’re, uh, recovering from unattended, dangerous birth? No, I am sure it’s some inherent spiritual understanding of magical cord blood.

          • Hava NaturalMama

            Assume some waited and some didn’t. One of two options would lead to increased survival for mom and baby and would become more common according to natural selection. That being said, your idea could be right.

          • Antigonos CNM

            Clamping and cutting the cord with some sort of implement requires thumbs, an item few animals have [let along a cord clamp or some string]. I think animal analogies are useless. Humans are indeed animals, but not all animals are human. Our offspring don’t stand up after birth, either, nor do we have marsupial pouches [well, there’s “kangaroo care” for premies, I admit]

          • Hava NaturalMama

            The animal equivalent seems to be chewing through the cord.

            Our birth physiology did not evolve in isolation. We used other animal for studying many aspects of human health, why not birth? We test our drugs in mice, study heart disease in dogs to find genes in humans, etc.

          • Antigonos CNM

            Not a good example. Animal testing is to weed out those drugs which are obviously lethal, or have severe undesirable side effects, and to determine whether they have any benefits, but it cannot really determine how it will work in humans. IF the animals survive, then testing is done on humans, and a lot of medications fall at the first hurdle. There are some similarities in the metabolism of mice, dogs, etc and humans, but some very big differences, too, which is why ultimately a new drug has to be tested on humans before approval.

            It wasn’t all that long ago that new drugs were tested on humans from the outset. Condemned criminals, for example [they were going to die anyway]. Persons of “inferior races” were deliberately infected with certain diseases without their knowledge in order to test new treatments, and so on. This is no longer thought to be ethical, so animals are substituted — not because we are also “animals” and so what works in a mouse is good for us.

          • Hava NaturalMama

            I am familiar with the stages of clinical trials. If animals weren’t a useful model they wouldn’t be used, but yes there are a model and like a model they have limitations.

            Given the inclusive nature of the study Dr. Amy cited above, obviously more research might be warranted.

          • Captain Obvious

            Dr Amy posted that waiting a couple minutes is fine as long as the baby doesn’t need resuscitation. She is against water birth, although laboring in water is fine.

          • Lisa Miller

            Annnnd then the gnaw it off with their teeth. And sometimes eat their babies

          • Lisa Miller

            And I’m going out on a limb here but there are very few things that “allllll mammals do” Can you provide a source that says all mammals wait to gnaw the cord?

          • Sullivan ThePoop

            All mammals do not even gnaw the cord. In a lot of mammals it breaks before the placenta is delivered. In a few mammals they just leave it until it dries and can be pulled off. Actually, most of the ones that gnaw the cord do it quickly.

          • Hava NaturalMama

            I am happy to embrace sterilized medical equipment. I am not a total nutcase.

          • Birthbuddy

            OK- good luck delivering your baby through your clitoris.

    • suchende

      So doing no harm means also not doing things that are not shown to harm? What’s next, don’t change mom’s sheets after labor in case during labor she sweats and bleeds magical labor hormones that she needs to reabsorb in the days post labor?

      After all, as you pointed out below, absence of evidence isn’t evidence of absence! That’s why I eat a cup of pinecones every day. Even though there is NO EVIDENCE that it will improve my health, no one can prove it won’t!

      Truly that statement is the mark of a great fool.

      • Hava NaturalMama

        I am sure the benefit of clean sheets is worth that risk, and if you love pine-cones go right ahead.

        If there is a benefit to immediate cord clamping, whether personal preference or ease of the newborn exam, that’s fine. But if there is no need to rush, why rush?

        • suchende

          If there’s no need to change the sheets, why change the sheets? If you want to find fault in physician led care, you can make these arguments all day: don’t hat. Don’t let baby hear voices other than mom and dad. Don’t let anyone but mom and dad touch baby. People are earnestly advocating for some of these things, not because there is evidence of harm, but because OBs do them, so it must be wrong. It’s exhausting. Get evidence of harm or benefit, then challenge the status quo.

          • R T

            But there are obvious sanitary benefits to changing the sheets. You need a better analogy!

          • suchende

            You could easily split the sheets into top half and bottom half and only change the top half if it gets soiled. That way mama can bask in all her birthy pheromones.

          • R T

            There are religious reason behind “silent birth” so again this doesn’t do your position any favors.

          • suchende

            Because some religions promote silent birth, that should be the standard of care?

          • R T

            Who said anything about making it a standard of care? I’m just pointing out it’s a religious act for some families.

          • suchende

            Who cares if a few religions require silent birth? What does that have to do with the NCB push against talking around the neonate?

          • Antigonos CNM

            Actually, not true — or, at least, not true some years ago. Before the Black Muslims became orthodox Sunni Muslims, they had a number of bizarre customs [which they thought were Muslim] such as the father kneeling on his prayer mat in the delivery room and intoning prayers when the baby’s head crowned, and anointing the umbilical cord stub with wheat flour and honey. I remember one birth, when I was a new RN graduate, when the father demanded that no “white men” attend his wife at all at any time during her labor, and the resident said to me “I’ll wait outside the room. If you need me, call” [I wasn’t yet a midwife]. I managed to hold the cord in such a way that the husband anointed the placental end, rather than the baby’s, without realizing it, as I didn’t think flour and honey would do the baby any good, even with the stump clamped. Later, the father said to me that “I was OK” and that it would be a shame when blacks took over the world and had to kill all the whites, including me. [This was in the days when Malcom X was still alive]

          • R T

            Lol, what a great story you have! However, you didn’t mention delayed cord clamping just the honey on the stump, which actually makes sense as it had antibacterial properties! suppose even in modern times rituals are important to some people. We humans are funny animals!

          • KarenJJ

            It’s been a long day for me and I read ‘annointing’ as ‘annoying’ the cord with honey and flour…

          • Rachel L

            Why would you deliberately deny the family their religious ritual? Flour and honey are unlikely to harm a healthy baby at all. That just seems like disrespectful meddling to me.

          • Antigonos CNM

            On an open cord stump? Would you allow someone to anoint your unsutured episiotomy with ordinary flour and honey? It would be a grand way to give a baby septicemia!

          • Birthbuddy

            Not yet! Give the NCB cult a bit of time.

          • Hava NaturalMama

            If you are going to use the status quo argument, then let me suggest a compromise. How about just asking before cutting? If it doesn’t matter either way, take the time to get consent.

          • Box of Salt

            Hava, you argued against this approach (just asking) downthread. Did you change your mind?

          • Hava NaturalMama

            I am thinking about it… it does have a cost, it takes time. But probably not anymore than always waiting 90 seconds to clamp cut.

          • Box of Salt

            Hava, as I pointed out down thread, labor takes time – most patients show up at the hospital before they’re crowning. The time is available. Someone else also pointed out that the question could be included as you’re checking in. Or it could be added to the patient’s chart.

          • Birthbuddy

            I think you have hit the nail on the head. DCC has become the latest NCB ”you’re not the boss of me” chant.

        • Lisa Miller

          Why not rush? There is a question, which by you logic is equally valid. You say “oh so you have evidence showing it is not beatifically, but why rush??”. Why do you care? I mean, I could go around right behind you and yell “For mercies sake people, hurry the heck up!” and neither one of us has supplied either evidence for our suggestion, or even a reason for making it.

          • Hava NaturalMama

            Because birth is a special process and I think its worth savoring, but it the parents prefer to rush, that’s their call. I don’t think the OB should be in a hurry and make decisions based on that.

          • KarenJJ

            So is cuddling the baby. Should we savour the moments that matter to us, or not? If delayed cord clamping has no difference in outcomes and the parents aren’t fussed, then hand me my baby please! Birth is special to some, but a means to an end for many.

          • Hava NaturalMama

            I cuddled my baby with the cord still attached. A very short cord that would delay cuddling sounds like a good reason for immediate cord clamping/cutting, but that is not the norm.

          • Captain Obvious

            You would be surprised how many cords are not long enough to reach the mommas chest.

          • Hava NaturalMama

            I don’t have enough info to know for sure either way. Like I said, if an OB wants to cut the cord so the mom can hold her baby sooner, that sounds like a good reason to me.

          • Lisa Miller

            No, you missed my point. There is no reason to support you claim that we should not rush it. I assure you that if someone told me “There is no proof that this will benefit you,during the moment when you will be meeting your baby” That I would not give one strand of peach fuzz if it happened or not. I don’t go to medical providers to be savored–I go to get medical care and to get treatments that have been proven to work. I understand that some people are totally different and want to squat in the woods and sing with the birds, but just because some people want to do that, does not make wrong the medical model of care (that encompasses CNMs).

            What you are saying is like”You could wipe you ass right after you crap OR you could wait five minutes. It won’t hurt you unless you’ve got a cut on your butt!” When what we are saying is “Wipe your butt. There is no reason to wait. Why are you drawing all this attention to a mother’s butt when all she wants to do it get off the damn toilet (meet her baby–unless you are the aforementioned tree birther type, in which case please see the above “Not the medical establishments problem”

          • Hava NaturalMama

            There is a lot that happens in the first 90 seconds taking apgar scores and making sure mom and baby are okay. It’s a time of great joy and danger. All I’m saying is that I have yet to hear a good reason to make cord clamping a universal first step in that process.

      • I don’t have a creative name

        “What’s next, don’t change mom’s sheets after labor in case during labor
        she sweats and bleeds magical labor hormones that she needs to reabsorb
        in the days post labor?”

        I predict that this sarcastic statement will plant seeds in the minds of gullible NCBers (is that redundant?) and we will see this notion portrayed as fact at some point in time.

        • violinwidow

          There may even be an entire movement towards not letting the mother bathe after delivery. They already don’t anyone to bathe the baby for days and days, now the mother can be just as covered in blood and fluids for as long as the baby is. Something like…mom and baby need to be able to smell each other in order to bond, don’t wash those precious bonding fluids away until they both smell like carrion on a hot day.

          • suchende

            Oh God what have I done

          • Prudent planner

            To be totally honest, following a traditional Chinese practice, I didn’t use soap on my breasts for a while after the birth. ( but I relished each and every hot shower). It made sense to me that the baby should have strong and familiar signals from the breast to promote effective breast feeding.
            Breast feeding was perfectly easy for us, and I didn’t experience any significant nipple soreness. I can’t say if my au naturale breasts contributed; but it was easy to do and had no side effects, so I’d recommend it.

          • KarenJJ

            My Chinese friend lives with her parents and she had to sneak in a hair wash during the first 40 days or so post birth. Not sure why she wan’t meant to wash her hair, but was meant to be tradition.

    • Captain Obvious

      1-3 minutes is fine in a low risk delivery not requiring resus and is being practiced more and more. Some women are demanding 10-15 or more minutes or want a lotus birth.

      • Ainsley Nicholson

        Every time I hear about lotus birth, I can’t help imagining all that decomposing blood and tissue still attached to the baby…doesn’t that pose a risk to the child? Or does the infant’s blood supply separate from the cord in short order?

        • S

          I think the cord closes off pretty quickly and then dries up. So not an actual significant threat to the baby, just really, really gross.

    • Renee Martin

      I personally dont think waiting a minute or so is a big deal for MOST babies. Personal preference. But, let’s not pretend that there’s a huge benefit when there is NOT.

      Especially since there ARE risks, even if they aren’t too common (more bilirubin, jaundice, and very rarely, exanguination) Plus, in order to get the benefits for already healthy babies (assuming there is even a benefit), you have to put other babies, who already have issues, at risk.

      Nature is NOT perfect, evolution hasn’t created the best, just the good enough. I don’t know why you think “natural” means DCC anyway, or that “natural” means better outcomes. If you leave birth to nature, you get a high rate of death for mom and baby.

      Example of ACTUAL harm: I have extra antibodies and they destroy my babies red blood cells, which was only discovered right after I had DS- he was SO yellow! Both my kids have had serious jaunice, and had we done the DCC, it would have made it even harder to treat, or pushed the hyperbilurubin into more severe levels.

      To much bili causes BRAIN DAMAGE. No thanks, I will skip that. It was bad enough that it required 4-6 weeks of NICU along with immunoglobin, and multiple transfusions.

      • Hava NaturalMama

        I am so sorry to hear about what happened with your babies. However, the American Congress of Obstetricians and Gynecologists says that the jaundice issue is not significant enough to warrant an across the board policy mandating immediate cord clamping.

        Evolution is not perfect; ex. baby head size + adult female pelvis size = tight fit. I was only using the evolutionary argument to explain why if we have no evidence either way, I think immediate cord clamping should be viewed as the intervention that needs to be proven beneficial and delayed cord clamping should be viewed as the physiological norm. Of course specific health issues and/or personal preference should always take precedence.

        • Amy Tuteur, MD

          ACOG also says that there is no evidence of any benefit to delayed cord clamping in term babies.

          • Hava NaturalMama

            Or to immediate cord clamping, so which should be the norm? Maybe it really doesn’t matter any more than the pattern of the bed linens, but I find that hard to believe.

        • Lisa Miller

          So how long did our ancestors delay cutting the cord? I mean are we talking a few minutes or a few days? “I think immediate cord clamping should be viewed as the intervention that needs to be proven beneficial and delayed cord clamping should be viewed as the physiological norm.” Why? Just because you think so? Did you even read the article? Have you reviewed any data? This data was collected by people with an bias towards finding a benefit and still found none.

          • Hava NaturalMama

            They did find a slight benefit, although not worth the hoopla the NY times gave it. Here’s a quote from the summary “improvement in iron stores appeared to persist, with infants in the early cord clamping over twice as likely to be iron deficient at three to six months compared with infants whose cord clamping was delayed” I unfortunately do not have access to the full article without paying to access the journal.

            In terms the ancestral practice of delayed cord clamping, we’re probably only talking about a few minutes. If you read about the history of birth, immediate cord clamping is a modern concept (dates vary, but I’ve never seen anything before 1700). Also our closest primate relative, the chimp practices delayed cord cutting.

    • KarenJJ

      I don’t understand how people know whether immediate cord clamping is NOT natural? How long did people wait to clamp the cord in the past? I’ve no idea. Is it an assumption that our ancestors delayed clamping the cord for any length of time, or do we actually know something about this?

      • Hava NaturalMama

        I’ve heard dates ranging from 1700’s to 1913 as when the modern practice of immediate cord clamping became routine. In any case, it is a relatively modern concept. Here’s an article I found

        http://jrs.sagepub.com/content/105/8/325.full

    • Mrs Dennis

      I’m sorry, but I find that kind of language really silly: ‘give nature the benefit of the doubt’?! There IS no ‘nature’, beneficent or otherwise, to whom we owe any allegiance, and most of the things people did in the olden days have been abandoned because they turned out to be useless or worse. Why glorify ignorance and primitivity?

      Possible risks of DCC: 1) practitioners may forget (and have, with lethal results, forgotten) that the cord hasn’t been clamped, and cut an intact cord. 2) many ignorant people, including home birth midwives, erroneously believe that DCC is a resuscitative measure, which can support a struggling neonate or retrieve a compromised one. So there is a grave risk that proper resuscitation will be delayed in the expectation that DCC is sufficient. 3) jaundice, necessitating phototherapy, which in turn interrupts the mother-infant bond and interferes with breastfeeding, regarded by many as the holy grail. Infants on phototherapy often need supplementing with, yikes, FORMULA!!!

      On the other hand, we have the likely advantage of higher iron levels in older babies, which can also be achieved by offering a suitable weaning diet.

      To my mind, this all adds up to that scientific phenomenon, the ‘no-brainer’.

      • Birthbuddy

        Excellent!

  • S

    I just realized i’m glad my husband forgot to ask for delayed clamping last time, because my kid ended up with breast milk jaundice for six weeks anyway. (He wanted delayed clamping; i didn’t care; and our OB was okay with it, though she doesn’t routinely do it but another OB did the delivery.) Next time i certainly want that cord clamped ASAP.

  • attitude devant

    One area where I always try to delay cord clamping is in the setting of intermittent cord compression—mom is pushing and I ‘m seeing lots of variables and at delivery there is a floppy cord or a body cord or a loose nuchal cord. My reasoning there is that the if the cord is intermittently compressed, there may actually be significant amounts of blood that wind up in the placenta. (Keep in mind that the blood that flows back to the baby is venous, so that flow to the baby would possibly compromised more than the arterial flow from the baby into the placenta. I’m not shooting to prevent transfusions to babes, just to prevent possible volume depletion and hypotension in the newborn. Now, I freely admit that there are no studies to back me up on this, but the physiology makes sense, and it doesn’t hurt (unless I delay resus because I’m delaying cord clamping, which I would not ever do).

    • Haelmoon

      Attitude Devant – I feel the same way. I also hold the baby down a bit while this is happening, speed up the transfusion. I feel better once the baby fills its lungs and is likely perfusing them better, this hopefully means the baby has enough blood. Or milk the cord if there was meconium, because I don’t want to stimulate the baby.
      I am cautious with diabetic moms and suspected macrosomic babies. They are at increased risk for jaundice. I do delay for preemies, but more for the slower changes in blood pressure for potential reduction in intraventricular hemorrhage. But only if the baby is breathing and only for 60 seconds. We actually set the timers, with paeds watching over our shoulders. We will given them the baby immediately if they want it.

  • NICU RN

    This is already on the debate team on babycenter – it’s being touted as “yet another great study showing the benefits” . . . I can’t post there if anybody would like to link this.

    • Captain Obvious

      Love the comments, no harms, only benefits?!
      http://community.babycenter.com/post/a43140040/ob_says_delaying_cord_clamping_is_no_good

      Potential harms; cannot donate cord blood for personal or general banking, may delay necessary resuscitation, may lead to polycythemia, hyperbilirubinemia and jaundice, may delay skin to skin if cord is short because baby may only reach to lower abdomen. Has there ever been a case of kernicterus from extreme DCC?

      Then the researcher makes this huge jump in conclusion regarding this study, “Dr. Raju said. Improved iron stores in theory could help reduce the risk of learning deficiencies and cognitive delay in children, which have been linked to iron-deficiency anemia in school-age children.”
      There is nothing wrong with DCC for 1-3 minutes in a low risk healthy delivery with a vigorous baby, but not this extreme DCC nonsense. And I hate all this waiting until the cord stops pulsing. The cord is pulsing because the baby’s heart is pumping the blood away from the baby through the two arteries to a placenta that is being contracted down upon by the involuting uterus. I would like to see a study that samples cord blood oxygen levels every 30 seconds after delivery. I would speculate it decreases significantly as the uterus is clamping down on all those blood vessels between the uterus and placenta. The umbilical vein is returning some blood back to the baby that will increase total RBCs to the baby, but is it necessary as Dr Amy points out? I certainly wouldn’t delay resuscitation under the premise the baby is “breathing” through that unclamped umbilical cord.

      • The Bofa on the Sofa

        Improved iron stores in theory could help reduce the risk of learning
        deficiencies and cognitive delay in children, which have been linked to
        iron-deficiency anemia in school-age children

        So, is there any evidence that DCC decreases the extent of anemia in school-age children? Hmmmm? Hmmmm?

        And as I asked below, what about those who have NORMAL stores already, and are not anemic? What does it do for them? As fiftyfifty1 points out, too high of iron is not necessarily a good thing, either.

        • fiftyfifty1

          This issues complicating this being an easy thing to know are:
          1. Iron deficiency does not cause anemia immediately. First comes low iron stores and then later comes the anemia.
          2. There is evidence that low iron stores may cause problems (like learning problems) even if the low iron is not low enough, or has not yet had enough time to cause anemia.
          3. It is easy and inexpensive to check for anemia; it’s just a finger prick. It is much harder and more expensive to check iron stores. That involves having to find a vein on a screaming baby or toddler and run a number of send-out tests.
          So the question that matters more is not “Does DCC reduce anemia in school age children” but rather “Does the possible increase in iron stores in kids who got DCC translate into any measurable health or cognition improvement by school age”.

          • Anj Fabian

            ..and would giving supplemental iron to infants accomplish the same thing?

          • fiftyfifty1

            Yes it would.
            But the problem is compliance:
            1. Parents would need to buy the iron
            2. Parents would need to remember to give the iron
            3. The baby/toddler would need to swallow the iron and not spit it out/reject it.
            4. And then we get to the whole issue of iron overdose. If the formulation tastes good (i.e. Flintstones vitamins) then the toddler or its sibs will get the whole bottle and eat all of it at once which can cause poisoning.
            So the nice thing, in theory, about DCC is that it is “one and done” and “idiot proof”.
            But to reiterate: we have no proof that delayed cord clamping makes a real world difference in any of this. In addition the kids at highest risk of iron deficiency are low-income kids. Not typically the ones whose parents are obsessing over this.

          • The Bofa on the Sofa

            But she was the one who brought up the problem of anemia, and the claim that this approach could solve it.

            As such, shouldn’t it show up as improvement in anemia rates? Because how else does it solve anemia caused problems without solving the anemia?

          • fiftyfifty1

            Who is the “she” you are referring to who brought up anemia?

      • Antigonos CNM

        We were taught that babies were born with sufficient iron stores for the first month irregardless of whether the cord was immediately clamped or not. Further, a newborn’s hemoglobin is extremely high and drops precipitously within a few days anyway, so it would seem logical that it would simply drop farther and possibly faster if it was unusually high. I certainly have seen much more jaundice with babies whose mothers insisted on delayed cord clamping. And lastly, a considerable number of cords stop pulsating almost immediately after birth anyway and these babies seem perfectly fine. When there is a tight nuchal cord the baby isn’t getting any more blood by waiting [just being strangled]. In situations where a baby does not pink up and scream immediately, it is often a minute before the cord is clamped in any case since the main effort is directed toward getting the baby to breathe.

  • SkepticalGuest

    I am about 95% in agreement here. But two quibbles:

    1. Delayed cord clamping doesn’t do NO harm. Case in point: I had requested delayed cord clamping based on the fact that it would increase my baby’s iron stores. I have struggled with anemia and virtually negligable iron stores my entire life, so I figured it was worth asking. Well, I was told “NO” to the delayed cord clamping immediately after birth because of a medical issue. Really, I was so knackered, I’m not sure what it was. Maybe it had something to do with me having a PPH. Anyhow, we, of course, gave consent to clamp immediately to tend to something serious. But if a woman were to refuse and in refusing delay treating a real medical problem, well, that could potentially have real harm.

    2. I wouldn’t compare delayed cord clamping to having a blood transfusion. The blood going into baby from the cord is baby’s own blood. There are very small risks for blood transfusion (disease-wise), that would make it unethical to do for virtually no benefit. Think of all those hemophiliacs who ended up HIV+ in the 1980s because people didn’t know to test the blood for it.

    • Captain Obvious

      There is enough blood in the baby, the cord, and the placenta for the whole pregnancy. That volume is more than the volume the baby needs. Why do the NCB feels that at birth you need to milk every last drop of blood into the baby? That is more than the baby needs. So yes, it is like an autologous blood transfusion. Temporarily raising the neonatal Hgb or iron until the baby can degrade the excess into bilirubin jeopardizing hyperbilirubinemia and jaundice and possibly kernicterus if the momma is at home and doesn’t get bilirubin levels checked. In words of the woo, nature made more than enough blood to circulate through the baby, the cord, and the placenta, there is plenty of blood there that doesn’t need to go into the baby, why are you going against nature and trying to milk all that blood into the baby. I loved the BBC comment that natural birth doesn’t provide you a pair of scissors so why are the OBs trying to cut the cord so fast. I guess the husband can chew through it.

    • AmyP

      Wasn’t that exactly what happened back in the 80s with Romanian babies–they were doing routine blood transfusions for newborns, leading to an HIV catastrophe?

      http://www.nytimes.com/1990/02/08/world/upheaval-in-the-east-romania-s-aids-babies-a-legacy-of-neglect.html?pagewanted=all&src=pm

  • Renee Martin

    This is a perfect example of why NCB is so seductive. Few people read the studies, or can actually understand them. so if the NYT says DCC is wonderful, that’s all that matters. Going back over a few months of press releases, it’s all CRAP, but crap that makes NCB look valid.

    • Amy Tuteur, MD

      The real problem here is that JOURNALISTS don’t read the studies; they read the press releases. They simply repeat the authors’ claims without subjecting them to any analysis because most health journalists lack the education and training to analyze scientific papers.

  • expat in germany

    What is the story about oxygenation and cord clamping? Are there any cases where a baby was born blue but pinked up without first breathing? I know that nobody in the hospital would let a baby just wait for a few minutes for resuscitation, but in the annals of history, there must be something. Can one simply sample the cord blood at intervals in order to see how much oxygen is getting through? My point is : is there anything to the claim that the baby still gets oxygen from the placenta after birth?

    • Captain Obvious

      My thoughts too. I hypothesize that since the uterus is actively contracting down upon the placenta and all the blood vessels are being squeezed and contracted that the oxygen transfer must be poor. I speculate the baby is getting poorly oxygenated blood back for ability to increase RBC and iron, but not for resuscitative measures.

      • attitude devant

        Well, and if the placenta was doing a crappy job of oxygenating before birth, why would it do a great job after? I mean, COME ON, PEOPLE! If resus is needed, it’s because the cord and placenta weren’t up to snuff to begin with!

  • The Bofa on the Sofa

    But a new analysis has found that delaying clamping for at least a
    minute after birth, which allows more time for blood to move from the
    placenta, significantly improves iron stores and hemoglobin levels in
    newborns

    Ouch. Beg the question much, NYT?

    At best, you can say that it “increases” iron stores. However, that is not the same as saying it “improves” them.

    is there any indication that increasing the iron in someone who already has normal iron levels is beneficial? Especially if they aren’t planning to run a marathon or ride the Tour de France?

    • fiftyfifty1

      That’s a good question. We know that in adults increasing iron stores in someone who already has normal iron stores is a BAD thing. I would say we don’t know in infants. Is it good? Is it bad? Is it neutral? What exactly are *optimal* iron store levels in a baby, and do they differ from “normal” infant iron store levels? Does it even matter, or are we getting caught up in the trap of obsessing about something that doesn’t have any influence on long-term health? This is why it is so maddening that this issue is being driven by ideology rather than science. If the focus of our energies is drawn toward something that doesn’t matter we are in danger of ignoring what DOES matter.

      • Captain Obvious

        Polycythemia is an abnormally high concentration of red blood cells.

        This disorder may result from postmaturity (see see Problems in Newborns: Postmaturity), diabetes in the mother, or a low oxygen level in the fetal blood.
        A high concentration of red blood cells makes the blood thick (hyperviscosity) and may slow blood flow through small blood vessels.
        Most affected newborns do not have symptoms but occasionally have a ruddy or dusky color, are sluggish (lethargic), feed poorly, and very rarely may have seizures.
        The diagnosis is inferred from a test that measures the content of red blood cells in the blood.
        Usually no treatment is needed except to maintain normal hydration.
        When the newborn has symptoms, treatment with a partial exchange transfusion may be given to reduce the red blood cell concentration.
        A markedly increased concentration of red blood cells may result in the blood being too thick, which slows the flow of blood through small blood vessels and interferes with the delivery of oxygen to tissues. A newborn who is born postmaturely or whose mother has diabetes, has severe high blood pressure, smokes, or lives at a high altitude is more likely to have polycythemia. Polycythemia may also result if the newborn receives too much blood from the placenta at birth, as may occur if the newborn is held below the level of the placenta for a time before the umbilical cord is clamped. Other causes include a low oxygen level in the blood (hypoxia), maternal diabetes, growth restriction in the womb, or a large transfusion of blood from one twin to another (twin-to-twin transfusion).

        A newborn with severe polycythemia has a very ruddy or dusky color, is lethargic, feeds poorly, and may have seizures. If the newborn has such symptoms, and a blood test indicates too many red blood cells (high hematocrit), some of the newborn’s blood is removed and replaced with an equal volume of saline solution, thus diluting the remaining red blood cells and correcting the polycythemia.

        • fiftyfifty1

          But Bofa is specifically talking about increasing iron stores not about increasing hematocrit. So we need to answer 2 questions:
          1. Is increasing iron stores a good thing?
          2. If it is a good thing, is the best way to do it delayed cord clamping (seeing as DCC could potentially have down sides as detailed by Captain Obvious above)

        • MichelleJo

          My baby was born with polycythemia with symptoms more critical than the ones you described. After a normal labor, at birth her blood was too thick to get oxygen to her brain fast enough, and she simply could not breath. Then she started gasping for breath and it took a tea from the NICU quite a while to stabilize her. And all this with no known risk factors, no IUGR, birth at 38 weeks, no diabetes, non-smoker, no twin-to-twin. Her levels at birth are obviously not known, but from lab tests two to three hours later, her HCT was 85, her HG at 26. And all this with immediate cord clamping. Although I have never heard of another case like this, it is possible that extending the time she was receiving red blood cells by delayed cord clamping could have have killed her. As it was, we knew to anticipate possible developmental delay due to the lack of oxygen at birth. This did indeed happen. So I for one, would say DO NOT risk delaying cord clamping for some unknown benefit. And saying you have no risk factors for polycythemia is no guarantee either.

    • Captain Obvious

      And this study doesn’t promote DCC until the cord stops pulses or white and thin or lotus birth.

  • Ainsley Nicholson

    Sounds like the media has once again confused “statistically significant” (which essentially means “we are confident this is a real finding”) with the more common use of the word “significant” (ie, really big and important).

    So far as delayed cord clamping goes, since there appears to be a small benefit to waiting a few minutes, sure, why not? My OB was completely comfortable with that. On the other hand, if baby needs to be detached quickly for any reason, that’s fine too. Maybe he’ll need iron supplements in his first year of life…if so, that’s no big deal. This just seems like an incredibly minor issue.

    • expat in germany

      A small benefit in terms of iron stores, but what about the increased incidence of jaundice and the slightly higher maternal blood loss?

      • Ainsley Nicholson

        I’m no expert, but my understanding is that “delayed cord clamping” can mean simply wait a bit, or it can include “milking” the cord to essentially push the blood back into the baby, and it is the latter approach that is associated with an increased risk of jaundice. Easy to avoid that risk by using the former approach.
        So far as maternal blood loss…hmmm…I was under the impression that the blood in the cord is was derived from the baby, and that the interface between maternal and fetal blood supplies is in the placenta and is not a direct connection. So the risk of maternal blood loss would only exist if the mother was hemoraging, which would definitely fall under the “if the the baby needs to be attached quickly for any reason” caveat.
        I could be completely wrong on both counts, in which case I will welcome anyone’s corrections!

        • attitude devant

          Well, that’s just the thing, Ainsley: nobody has compared milking to delayed clamping to see if the latter is not associated with jaundice while the former is. Honestly, it would make sense that if there is more blood volume sent to the babe, there would be more jaundice, since the babe has to destroy its fetal hemoglobin and switch to adult hemoglobin. The jaundice happens because the immature liver can’t break down the molecules easily. So if there are more molecule in the babes, there should be more jaundice.

          • expat in germany

            In the article referenced in the nytimes article, increased need for phototherapy was described within the context of the study, maternal blood loss too. The article is under Wileyandsons and the lead author was McDonald.

          • expat in germany

            Sorry: onlinelibrary.wiley.com

          • expat in germany
          • Ainsley Nicholson

            Obviously maternal blood loss would be a concern, but the paper describes finding no difference between the early and delayed groups, in terms of maternal mean blood loss, incidence of postpartum haemorrhage, need for blood transfusion, or haemoglobin levels.

          • Ainsley Nicholson

            Well, I guess they did describe a “slightly higher maternal blood loss”, as you state…but not statistically significant at a 95% confidence level.

          • Ainsley Nicholson

            I could have sworn I read that finding somewhere, but when I went back to look for it, you’re right…it wasn’t there. I am now rather annoyed with myself. Thank you for the correction.

  • There’s some pretty heroic assumptions made by the NCB crowd and I imagine a well done economic analysis might demonstrate that what they do is not cost-effective either. It might be cheap, but it’s not cost-effective.

  • ThePinkSuperhero

    Interesting to hear your thoughts on this. When I was pregnant last year, I asked my OB about delayed cord clamping, and she basically said what you said above, that there doesn’t seem to be a benefit for full-term, healthy infants.

  • doc99

    There are two potential downsides – first, as suggested by WHO, the possibility of increased chance for jaundice because of increased blood breakdown. The second is in the setting of cord blood banking – in this case, clamping is delayed but the purported benefit is lost because the blood goes for banking.

    Nice chart btw.

    • Elizabeth A

      Doc99, there are more then two potential downsides to delayed clamping, depending on the situation. One of my kids was clamped and cut immediately so that I could be treated for PPH, the other clamped and cut immediately so that she could be treated for respiratory distress.

      I don’t discuss this in woo discussions, but I have seen plenty of mothers lament “early” clamping and cutting of the umbilical cord in similar situations. It particularly concerns me when they forward the belief that a baby is still getting oxygen from the placenta as long as the cord is attached and the placenta undelivered, and therefore it’s beneficial to delay cord cutting even if the infant is having breathing problems, or if the heartbeat is not reassuring.

      Whatever benefits delayed cord cutting may have (and I do not argue that it has any), those benefits are not a substitute for prompt medical action on a distressed infant, or on a mother who is not having a smooth third-stage labor. That action may be most easily accomplished with the cord cut, and it bothers me that the Cochrane review doesn’t appear to have mentioned that.

      • Amy M

        Mine were clamped and cut immediately, not because anyone was in actual distress but because they were pre-term twins and the nurses and doctors wanted to be SURE that everyone could breathe and that no one was bleeding to death. That was fine with me. Frankly, the ideas of delayed clamping and immediate skin-to-skin time had never crossed my mind nor had they been presented to me by anyone, but those would have been the least of my concerns at the time. Those things would have been fine as well, just not important to me, and clearly the OB team’s aim was healthy mother/healthy babies as well.

      • Michelle

        After reading the paper, the conclusions are largely correct, the advantage of higher iron stores for example would be unclear (except maybe in selected situations like resource-poor countries) and there is the possible effect of increased rates of jaundice.

        The paper does note the rationale for active management: “Active management of the third stage of labour has been described in a recent World Health Organization (WHO)
        report as the “cornerstone” of obstetric and midwifery practice during the latter part of the 20th century”…”A major reason for practising active management is its association with reduced risk of PPH, the major complication of the third stage of labour”… This unfortunately isn’t addressed to a great degree in the media reporting and I think it’s unfortunate that the review is described as “This paper is about midwives and natural childbirth advocates dissing obstetricians.” It doesn’t appear to do so and only one of the authors is a midwife. In fact, it stresses that there is a good rationale for active management to prevent PPH.

        The paper does not deal with sick infants and cord clamping as it is examining the effect with term infants. There is a separate review “Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes”

        The review says: “Although reviews such as Hutton 2007 and van Rheenen 2006 have highlighted beneficial effects from delayed cord clamping compared with early cord clamping, maternal wellbeing has not been a major focus for reviews or trials of cord clamping. This is an important gap as women experiencing ill health postpartum may be less able to mother as effectively which ultimately reflects on the health and wellbeing of the newborn infant and family life in general.”… “A recent review of active management of the third stage of labour (including early cord clamping), showed a reduction in postpartum haemorrhage greater than 1000 mL although the outcomes for infants were less clear, and the authors recommended that the individual components of third-stage management should be examined separately (Begley 2011).”

  • Zornorph

    Thank you for this. I have a baby coming next month and was wondering if there was any point to delayed cord clamping. Now I know that there is not, so I’ll cut that little bugger right away. Unless I decide to freak everybody out and have a ‘lotus birth’!

    • Burgundy

      I read about the “lotus birth” last week and it was the most ridiculous thing that I ever know, Whoever came up with this idea must smoke way too much herb.