Delayed cord clamping may become standard practice

After years of lobbying by the NCT, medical bodies and senior doctors, the National Institute for Health and Care Excellence (NICE), which advises the NHS in England what medical practice it should follow, is now reviewing its cord-clamping guidance, which it originally published in 2007. Doctors hope its new advice, due in June 2014, will lead to delayed clamping replacing immediate clamping as the NHS's standard procedure.

It is thought that infants may be at risk of becoming anaemic by being denied the chance to receive as much as a third of their blood volume from the placenta through the cord. Anaemia can later be associated with brain development and can affect cognitive ability.


Influential bodies such as the World Health Organisation now urge delay, while research published by medical journals such as the British Medical Journal (BMJ) and the Cochrane Collaboration has also helped prompt a move away from immediate clamping.

A Swedish study published in the BMJ in 2011, which found that infants who had had delayed cord-clamping at birth had larger than usual iron stores at four months and were less likely to be anaemic, has proved influential.


The Guardian 25 April 2013

Jacob's Birth

by Emma Ashworth

Jacob's birth was planned as a homebirth.  There are many reasons for this; the main one being that I have a wish to be left alone in labour, not to be following a schedule or conveyor belt system, but just to allow my body to labour as and when it wants to.  I know that to be distracted by being talked to, having someone there, I don't know, even bright lights all affect labour and I didn't want that.  My birth plan specified no vaginal examinations because I feel that they have no value in most cases, labour will progress as it does, cervix opening is not linear and the single most painful part of my first baby's birth was vaginal examinations.

I chose to have an independent midwife with Jacob because I wanted to know who I was having as my midwife, and I wanted Philip (my husband) and I to make our own informed decisions rather than follow NHS guidelines which may not be suitable for us as individuals, and in our own personal circumstances.

For three weeks before Jacob's birth I experienced prodromal labour.  This is when labour starts and stops and can be very frustrating.  It was generally going on between about 3am and 7am so I was getting very tired and needed to sleep some afternoons.  I felt very nesty and was doing a lot of housework which is not like me at all!  I had a pool from Birthworks which was heated and filtered, ready to go, so every evening I would get into it and float in front of the TV, which took all the pressure off my pelvis, which was very achy.  That was lovely.

Sometimes the prodromal labour was quite strong and I had to breathe through the contractions.  They were exciting though, and quite bearable really.  Once I thought that we were good to go and called our midwife to say so, but it all stopped again which was a bit frustrating.  We were hoping to have a friend of mine as a birth companion but she lives in Oxford so trying to judge when to call her was also challenging!  I spent as much time as I could listening to my hypnobirthing CD, every day where possible in the last 6 weeks, and trying to enjoy what would be my last pregnancy.

One afternoon I'd taken a nap on the sofa and was just about to get up to go to school to collect my oldest son when my waters broke.  I scooted into the loo and checked that they were clear - they were.  I went to tell my husband (who works from home) that he'd need to go to school, and could he take our toddler, too.  Labour started up pretty quickly and by the time that my husband got home about 45 minutes later I had to really focus on the now intense contractions, breathing through each one and focusing on not tensing up, leaning over my ball.  My husband called the midwife and our friend in Oxford, Philippa, and then he helped me upstairs.  I found a position on the bed which was comfortable enough and felt right, which was on all fours leaning over duvets and pillows, bum in the air in a way that I could move my hips if I needed to.  I needed the light off (that was bliss and I found out later it really helps the hormones to flow), and I listened to the hypnobirthing CD that I knew so well and it helped a great deal.  I also had my TENS machine on and the boost button was great. 

I didn’t try to time contractions but I counted through one (it took a count of 20) and then for each one I counted to 20 knowing that when I got to 20 it would pass.  That was a great focus and helped me to remember that each one was transient.  I did cheat a bit as they got longer and more intense and didn't start counting for the first few moments!

I think I was there for about an hour and my husband was watching me on the baby monitor we have (with video).  I could hear my boys playing downstairs and that was nice.  Suddenly I felt things were really strong and I didn't want to be alone and somehow my husband was there (he told me later I'd been totally still, then I moved and he came to me).  I was sick, which we were prepared for as I'm always sick in labour and I remember thinking it was probably transition.  Then my husband was gone and my midwife, Debs, was there.  I felt she was behind me sitting on the floor (those of you who know Michel Odent will know what I mean when I say she was doing “virtual knitting”!).  After a contraction or two I said, "Debs" and she said "yes".  I told her that this baby was coming and I needed to get downstairs as I really wanted a waterbirth. I was feeling slightly different about the contractions and while I was not yet pushing I knew that the sensations were changing. 

I'm not sure how, but I knew my husband was taking the boys to a neighbour.  Then he was back and I remember summoning all my strength to get downstairs between contractions and we made it and I shouted at them to get my clothes off!  Hub pulled my trousers and knickers off and couldn't get them past my feet because I wouldn't pick them up.  I remember wondering why he was wanting me to pick my feet up!  The lights were down low and that felt so right.

Up to this point I’d been very quiet with each contraction.  I found that my own birthing sounds distracted me, and I lost concentration.  I preferred to breathe through them quietly.  With Toby this had been the same all the way through but at this point with Jacob I started to feel the pushing sensation take over and I got very grunty.  I was worried that my husband would feel that the pain was too much as I’d been silent all through with Toby, so I told him it sounded worse than it was (which it did).  I felt very calm and comfortable; while it did hurt it's a totally different thing to pain when injured and it was ‘Just OK’. 

I remember leaping into the pool as someone very athletic might leap over a 5 bar gate (although apparently my husband’s recollection of it is less elegant!).  I had maybe two contractions in the pool and then I felt his head crowning.  I think I naturally breathed his head out and I remember saying, "baby's head's out" and then his body followed immediately, not in the next contraction which was a surprise!  I reached down and grabbed him, brought him to the surface and just said, "hello baby" a lot! 

After a few minutes I suggested to my husband that we checked out the variety so we took a look - another boy.  I know my midwife was watching carefully for blood loss and it crossed my mind a bit as I'd had a postpartum haemorrhage with Toby, and it was my only fear about this birth, but I trusted Debs and put it out of my mind. 

I felt no pressure, I know I take ages to deliver the placenta so I just relaxed.  The cord was a bit short to comfortably hold him above water so my husband bailed out enough to make it easier to hold him and over the next hour or so he latched on to me and I just relaxed in the pool. 

I was getting some contractions but not many (as is my norm) and after an hour I was getting very uncomfortable holding him out of the water and I felt it was ok to cut the cord which was now very small, thin and white and had clearly passed his blood across.  We called our older son from the neighbour over to cut the cord, which he did, and that was lovely.  I passed Jacob to his daddy and was able to really focus on what were now painful contractions which took some deep concentration and use of the hypno CD. 

In the end it took 1 hour 50 minutes for the placenta to arrive, just 10 minutes less than it took for Jacob to be born after my waters broke.  That was all fine, there was no pressure as there would have been in hospital and I know my midwife was watching me like a hawk so I could relax.  I know I'm very sensitive to oxytocin release stopping after birth which messed up the placenta delivery for my older two, and this time it worked like a dream, just slowly.

The placenta was intact and lovely and I enjoyed watching Debs check it over and she showed me all the different parts, and we took some photos.  Some time later I wanted to get out of the pool, so I did.  Philip phoned Philippa to say that there was no hurry anymore as she’d missed the main event – she had only got as far as Watford!

I didn't dress Jacob for ages, not even in a nappy, I don't think I did until we went to bed that night.  I just laid on the sofa holding him against my breast allowing him to feed when he wanted and just stroking him and smelling him.  He'd not been dried off or cleaned and he had a lot of vernix and I felt that it was important to allow him to keep that smell that he knew and not to bath or rub him down.  He was very calm and lovely and happy.

I had some food and we all just chatted - it was so lovely. Philippa arrived armed with champagne, cakes and some lovely baby vests and got her first cuddle.  Debs cleaned up although there was really no mess at all - and Philip got our children from the neighbour.  Debs cut Jacob’s cord short and sealed it with a tiny Sterifeed cord ring rather than the huge and uncomfortable plastic clips.  Eventually we went up to bed and my family was snuggled up together at about midnight, so utterly different to in hospital where my husband had to leave me, bereft, and go home alone.  I’d hated the post natal ward and to be together with my family was just amazing.

Jacob's birth was an extraordinary experience and I would do it every day. I desperately want to do it again.  I envy anyone who may be able to ;)  However it was seven years in the making and it took two less than perfect births to get there.  I took everything I'd learnt from Peter and Toby's births and added into it seven years of research and, more than anything, a wonderful midwife.

To summarise, things which were most important to me are:

• my independent midwife, Deborah Rhodes
• low lighting
• not being talked to
• no vaginal examinations
• being able to move how I want, when I want
• counting through contractions
• water - with Toby's labour it was amazing.  Jacob's was too fast for it to help the birth but it REALLY helped with the placenta
• TENS
• hynobirthing
• delayed cord clamping and Sterifeed cord ring
• respecting my body's messages to me
• holding my baby.  He wasn't weighed until he was 3 or 4 hours old and he wasn't wiped off, dried or dressed.  No one held him other than me for the first hour which from Jacob’s point of view must have been calming and reassuring.  Wonderful.

Campaign to Delay Cord Clamping

NCT is encouraging and supporting this campaign - we have supported change in this practice now for more than a decade and have been encouraging researchers to carry out research in the area so the evidence to force a change in practice is there ... it's getting there slowly - we need a big push by everyone to get it to happen. Belinda Phipps

I am a practicing Midwife with 24 years experience. Seven years ago, I truly reflected on my practice with regards to the third stage of labour and the wide spread practice of Immediate Cord Clamping after teachers voiced their concern at the increasing numbers of children with medical or learning problems. I also observed the same in friends and family children.

After extensive searching and confirmation of very worrying statistics, I had an epiphany and realised that this common practice implemented 40-50 years ago was an interruption of a fundamental birth process, which deprived the baby of up to 40% of its intended blood volume, with unknown results and for the most part absolutely unnecessary.
 
On approaching managers and doctors, I was told I had an interesting scientific theory which was not evidence based. I pointed out at that time that Immediate Cord Clamping was not evidence based. I was informed that to change practice I would have to produce evidence.

I wrote to the RCM and asked for immediate national clarification on timing of clamping the umbilical cord. At the time there was little evidence but George Morley from the US was convinced that Immediate Cord Clamping was the cause of irreversible brain damage leading to Autistic Spectrum Disorders. From that time, I immediately started offering all my women informed choice with regards to delaying the clamping and cutting of their babies cord. Over the years I have received a good deal of antipathy.

Over the past 7 years, there has been a growing body of evidence to support the delay in clamping and cutting of the umbilical cord. The World Health Organisation, Unicef, ILCOR, International Confederation of Midwives, FIGO and more recently the Royal College of Midwives have all recommended Delay in Cord Clamping as best practice. Timings vary from 1 to 5 minutes. 
 
NICE are intending to review and publish new guidelines but not until November 2014 and there is no guarantee that they will include Delaying Cord Clamping in the new guidelines.

Many hospital doctors are reluctant to change their guidelines until NICE give the go ahead, whereas other hospitals i.e. Darlington, Liverpool and Worcester have taken the lead and changed their guidelines despite NICE recommendations.

Two years is too long to wait when there is ample evidence to indicate that Immediate Cord Clamping is detrimental to babies. I am part of a national team which includes Consultant Paediatricians, Obstetricians and Neonatologists. Together we developed the basics trolley, a small resuscitaire which enables the umbilical cord to remain intact whilst resuscitation occurs. Much of the evidence shows that compromised and premature babies benefit from delayed cord clamping.

As part of a growing global network, I was delighted to be approached by the NCT and I would like to invite you all to join the campaign to lobby the National Institute of Clinical Excellence to change the Current Guidelines which recommend Immediate Cord Clamping (NON evidence based practice, proven to be detrimental to babies and normally performed before baby has breathed) to recommend Delayed Cord Clamping for at least 3-5 minutes, but ideally until the cord stops pulsating.
 
http://www.change.org/petitions/nice-implement-delayed-cord-clamping-immediately?share_id=QmzivsMSYS&utm_campaign=petition_created_email&utm_medium=email&utm_source=guides 

Amanda Burleigh RGN RM