The importance of delayed cord clamping for *Aboriginal babies: A life-enhancing advantage☆

Introduction 

At birth each baby is separated from their mother and placenta by clamping and cutting the umbilical cord – usually straight after the birth in line with active management of the third stage. This separation has been a routine task focused on prompt efficiency in most situations and referred to by Hutton and Hassan (p. 1241) as “by far the oldest and most prevalent intervention in humans”.1 The absence of evidence for the timing of this ritual is perplexing given there is no proof that delayed cord clamping is harmful.2 For the baby, timing of clamping and cutting of the umbilical cord is a significant transitional event.3

Traditionally and typically in most hospitals cutting of the umbilical cord occurs within seconds of the birth of the baby. This prompt or early (as it has become known) clamping of the cord was originally advised (without evidence) to avoid the baby becoming hypothermic.4 Haste was believed to be best for the baby so leaving the cord to finish pulsating was not a consideration.

Busy Maternity Units can have persisting habit-based practices to reduce staff workload and be paced to ensure efficient throughput of women rather than facilitate woman centred and baby advantaged care. A woman can have a literal ‘stop watch’ applied to her on hospital admission in labour requiring the birth process to run smoothly and in a timely manner; if she has a birth plan staff may find it difficult to practise outside the confines of their ‘busyness’ and the routine of the maternity unit to allow for ‘alternatives’ such as leaving the cord to stop pulsating before it is clamped. One reason for women to choose to birth in a birthing centre or at home for example, is if delayed cord clamping and unimpeded skin-to-skin contact are important to them and their baby.

This paper provides a review of the literature regarding timing of clamping and cutting the umbilical cord from the baby's perspective, discussing the consequences in particular for Aboriginal babies. Midwives and doctors are urged to rethink routine third stage management and apply evidence that benefits the health and wellbeing of babies (as well as their mothers), especially Aboriginal babies.

Literature search strategy and data bases searched 

The question posed for this literature review was:

What are the consequences and possible benefits (in particular iron stores) versus risks for the baby of delayed (versus early) clamping and cutting of the umbilical cord?

Online data bases were searched using the key words ‘delayed/late cord clamping’, ‘term infants/babies’ and ‘haematology/iron levels’, as well as lateral terms using ‘physiological third stage’, ‘active third stage’, and ‘cord clamping’ and derivatives. Databases and resources used included The Johanna Briggs Institute, PubMed, Medline, The Cochrane Library, CINAHL and relevant publishers’ online databases. Pregnancy and childbirth Internet sites were also accessed and reference lists/bibliographies used to track further sources. Initially the search was from the year 2000 to the present but relevant literature prior to this required extension of the timeline. Obstetric, midwifery and physiology text books (past and present as relevant) were also examined.

Scope of the literature review 

The literature related to cord clamping mostly focuses on the two fundamental management options for third stage – active (also known as routine or prophylactic) and physiological (also known as expectant). Active management usually involves prophylactic administration of an oxytocic drug, early cord clamping and cutting (that is immediately following or close to the birth of the baby) and controlled cord traction to remove the placenta following the signs of separation.5 Evidence suggests this process reduces the risk of postpartum maternal haemorrhage by approximately 50% however the concomitant effects of oxytocics on increased risk of placental retention and nausea, vomiting, headache and hypertension, persist.5, 6

Physiological management of third stage relies on normal birth occurring without intervention, leaving the cord to finish pulsating (without clamping and cutting until after placental expulsion) and awaiting expulsion of the placenta by natural uterine contraction without the use of a prophylactic oxytocic or cord traction.7, 5 Breastfeeding the baby after birth assists with initiating the natural hormone release that contracts the uterus to expel the placenta.7

In terms of timing of cord clamping, early is accepted to be immediate while delayed is generally considered to be 30s or more of waiting time.5 The term delayed is problematic; for example, 30s could be considered by some to be short even for active third stage. Correspondingly very few people if any, actually time the interval to cord clamping and cutting as it is simply done as part of the routine process of active third stage management so confirming the time to clamping can be spurious.

It is noted that lotus birth could be considered to be an extension of physiological third stage. This involves leaving the placenta connected to the baby via the uncut umbilical cord (after the birth and expulsion of the placenta from the mother) until natural separation occurs at about 3–5 days postpartum.8 However, for the purposes of this review lotus birth has not been included.

Motivation for this literature review 

The instigation for this review arose from the concerns of a midwife working with a birthing population of mainly Aboriginal women. Of the total number of women in Central Australia receiving maternity care approximately 75% are Aboriginal. A high percentage of these Aboriginal women are already anaemic before they become pregnant becoming more-so during the antepartum period; their babies typically are anaemic before they reach 6 months of age.9 This ongoing cycle of anaemia significantly compromises the health of Aboriginal mothers and their babies. Globally approximately 25% of babies suffer from iron deficiency anaemia but even more are iron deficient in the absence of anaemia.10 The behavioural, developmental and neurological consequences of this iron deficiency jeopardise infant and child wellbeing.10 Yet this could be prevented.

Maximising Aboriginal neonatal iron stores has been identified as one of several strategies to prevent early onset of iron deficiency anaemia.11 Therefore, any practice that could improve iron stores in Aboriginal babies deserves very serious consideration. Extending the time that the uncut cord is patent for was thought to be a means of doing this and hence the desire to review the literature to confirm or refute this proposition in terms of evidence rather than hearsay; and more importantly, implement evidence-based change to make a difference to Aboriginal babies.

Within the practice setting paediatricians had indicated concerns that delayed cord clamping would increase jaundice in newborns because of increased haematocrit levels with corresponding increased morbidities and hospital length of stay for babies. Many midwifery staff did not it seemed, consider or understand the implications of timing of cord clamping. Active management of third stage was routine and any babies thought to be at risk received immediate clamping and cutting of the cord, removal from their mother and resuscitation. So the milieu provoked consideration for change.

Review findings 

Discussion 

The literature has shown clear advantages in normal term babies (and some advantages for preterm babies) for not clamping their cords immediately following birth. For Aboriginal babies these advantages are literally life-enhancing in terms of increased iron stores – an advantage that should not be denied them. Given the variance of times used to define early versus late clamping and the reality of timing of giving an oxytocic with birth it is quite feasible that even with active management of third stage the cord could be left for 60s before being clamped; this would be without threat of postpartum haemorrhage or retained placenta, and with beneficial transfusion effects for the baby. The question is whether this is really ‘delayed’ clamping of the cord or practice based on sound evidence.

It could be argued that the terms early and late when applied to cord clamping have created a demarcation that has misconstrued cord clamping with harmful effects for the baby. These terms have become distorted in the context of third stage and do not take the typical meaning of their intent. For example, if early clamping was true to its meaning it could be before the oxytocic, or even before the birth if it is early – but earlier than what? Likewise delayed meaning late, postponed or deferred for example, is not the appropriate term for identifying safe practice. Both terms need to be abandoned and clamping and cutting of the baby's cord should simply be stated as that without the addition of inappropriate descriptors.

In the face of such persistent and increasingly strong and sound evidence for the benefits of leaving the uncut cord patent after the baby's birth, there should now only be clear informed justification for clamping and cutting the cord before 60s in a compromised baby; otherwise the cord should only be clamped and cut at or after 3min for all other term (and where possible preterm) babies including Aboriginal babies.13 This is safe practice (in the absence of evidence-based harm) and provides greater concentrations of haemoglobin with less incidence of anaemia in the first 4 months of a baby's life, with the added advantage of increased iron stores for up to 6 months and possibly longer.13, 39, 40, 41 For premature babies there is an important association with the need for less blood transfusions in the neonatal period.13 For Aboriginal babies these advantages are extremely significant. For anyone who has worked in a remote community and had to administer iron injections to Aboriginal babies under 6 months of age, the knowledge that this could have been avoided by simply waiting 3min at birth before the baby's cord was clamped and cut, is profound.

While studies have not explicitly evaluated nor commented on costs involved, this is a strategy that is cost effective and has long-term economic health gains. For developing countries this is obviously critical. For Aboriginal babies the costs associated with iron injections are not cheap so a simple strategy at birth provides the opportunity for better use of primary health funds for them and their mothers.

In considering the evidence base and need for further research, a Women and Babies Health and Wellbeing: Action through Trials (WOMBAT) review of the research gaps in Cochrane Reviews found that for timing of umbilical cord clamping of term infants on maternal and neonatal outcomes, there was a need for more maternal data from trials to ascertain effectiveness for preterm infants.42 The WOMBAT review acknowledged that delayed cord clamping for term infants is likely to be effective; further studies are needed for power and rigour, comparison of maternal outcomes such as postpartum haemorrhage, and extended follow-up of neonates and infants in terms of iron status, physical and psychological health and neurodevelopment.42 The WOMBAT recommendations are sensible and appropriate but should not, given the existing evidence for term babies, preclude the practice now of increasing the time that the uncut cord is left pulsating after the birth of the baby to enable optimal transfer of blood from the placenta before clamping and cutting the cord. The risks versus benefits of this evidence demonstrate that this is effective practice.

Conclusion 

Clamping and cutting of the umbilical cord at 3min following birth (including the need for resuscitation which can be conducted with the baby between the mother's legs while the cord is still patent and attached) is a safe option for optimal placental transfusion regardless of the baby's weight. This practice is completely cost effective (in the immediate and longer term) non-intervening and not harmful for mother or baby. An oxytocic could be administered if necessary to decrease maternal blood loss without needing to clamp and cut the cord. Every baby, and most importantly every Aboriginal baby, regardless of their gestation should have the right and significant advantages of their cord being clamped and cut 3min after their birth to achieve much needed reductions in infancy anaemia and essential increases in infant survival. Such a simple measure of patience and informed practice with such life enhancing advantages for all babies, especially Aboriginal babies, is vital. Keeping the cord patent and extending the time before cord clamping and cutting for at least several minutes after the birth of the baby, or preferably until cord pulsations cease, is recommended for all Aboriginal babies as an effective primary health strategy by midwives and doctors.