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Latest recommendations on timing of clamping the umbilical cord

RCM members, Amanda Burleigh and Hannah Tizard
8 April, 2015

Latest recommendations on timing of clamping the umbilical cord

The RCM are very engaged with members who are currently moving forward with their own Better Births initiatives at a local level. The RCM has been asking members to tell us about their projects, initiatives and case studies.

One important message regarding better births was led by an experienced clinical midwife and a student midwife. Timing of clamping the umbilical cord was highlighted via social media and both midwife and student were keen to share the message and spread the word regarding the importance of the timing. The engagement was astounding as Amanda Burleigh a midwife from Leeds and Hannah Tizard a first year student at the University of Central Lancashire drove the discussions, day after day, tweet after tweet and Facebook message after Facebook message. Social media was swamped with engagement. Still keen to spread the word, they jointly wrote the following blog which will help midwives and students with the latest evidence base regarding delaying cord clamping in all births. Rupa Chilvers (Better Births advisor) with myself  (Jacque Gerrard, Director for England Midwifery) are facilitating the meeting of a small  group including Amanda and Hannah who are working together to explore the important message regarding timing of clamping the umbilical cord can be spread further.  

Please do keep the RCM posted about your own local Better Births initiatives and key messages so that we can continue to share best practice.

 

Guidance out in December 2014 has recommended that best evidence based practice should include delayed cord clamping in all deliveries.

  • Do not clamp the cord earlier than 1 minute from the birth of the baby unless there is concern about the integrity of the cord or the baby has a heartbeat below 60 beats/minute that is not getting faster.
  • Clamp the cord before 5 minutes in order to perform controlled cord traction as part of active management.

In our view, delaying for even one minute is a welcome change in guidance providing all babies with one minute of transition from inter-uterine to extra-uterine life However as transfusion is known to continue during the first 3-5 minutes of life, it is suggested that this process is allowed to complete without being interrupted.

History

Immediate cord clamping has been practiced globally for approximately 50-60 years when oxytocic drugs were introduced and active management of the third stage was recommended in all deliveries to reduce the incidence of Post-partum haemorrhage. This management did reduce the incidence of post-partum haemorrhage. However at the time, the effect of immediate cord clamping on the baby was not considered, and so immediate cord clamping was written into hospital trust policies and indeed adopted as routine practice across the UK and the world. Immediate cord clamping is a medically imposed intervention which can now be re-thought due to advances in research and evidence.

Evidence

Evidence shows that immediate cord clamping can deprive the fetus of up to 214g of cord blood, equating to approximately 30% of their intended blood volume (Farrer 2010).

Ola Anderson 2011 carried out an RCT which showed that babies who had ICC had higher incidences of Iron deficiency anaemia at 4 months of age. 

Judith Mercer a Professor of Midwifery in the USA has done extensive research showing that premature babies benefit more from DCC and have less incidence of Intraventricular haemorrhage and necrotising enterocolitis. Judith Mercer recommends that all babies have delayed cord clamping for at least 5 minutes.

Midwives are usually in the fortunate position of delivering babies which do not require resuscitation. In these cases, as long as there is no bleeding or other risks, there is no reason to rush to give oxytocic’s or clamp and cut the cord thereby allowing a natural transition to extra uterine life. Certainly Midwives should refrain from giving an oxytocic with the anterior shoulder and wait until the baby has been assessed. Oxytocic’s can be administered after the cord has stopped pulsating and active management practiced then. The best start for any baby and their parents is optimal cord clamping for the baby (allowing the cord to stop pulsating of its own volition) along with skin to skin, early feeding and time alone to bond.

As stated in the RCM guidelines 2012 Midwives should be competent in both active and physiological third stage of labour management and that “when physiological management is offered to women as a reasonable option, many will choose it. Physiological management can be seen as the logical ending to a normal physiological labour.”

Time to adopt immediate active management is if the following occur:

  • Haemorrhage
  • The placenta is not delivered within 1 hour of the birth of the baby.
  • Parental request (along with informed choice)

Timing of clamping the umbilical cord and reasons for early clamping and cutting should always be documented in the delivery and baby notes.

Where ever possible resuscitation with the umbilical cord intact should be performed. As NICE recommend that all babies receive a delay of at least 1 minute before the cord is clamped, it is prudent that hospitals devise ways of delivering this evidence based practice. Most parents if they are given the evidence of the benefits of delaying cord clamping in premature and compromised babies will be happy to forgo any potential discomfort in having their babies resuscitated next to them with the cord intact in order for their babies to receive the benefit of the extra blood volume particularly for the important one minute that is recommended.

What can midwives do?

  • Familiarise yourself with the physiology of DCC, keep up to date with the new evidence and research.  Practice OCC as best practice whenever possible, allowing baby to receive their full blood benefit.
  • In the Antenatal period, facilitate discussion about OCC with mothers, use the OCC stickers on the NHS Change day website to signify the discussion point and document preferences in her notes.
  • Join your hospital policy group, ask about how the NICE guidelines for DCC will be introduced into trust policy and get involved with writing new guidelines based on the evidence.
  • Its important that all maternity providers need to devise  ways of enabling resuscitation with an intact umbilical cord.

 

This RCM Blog was prepared or accomplished by Amanda Burleigh and Hannah Tizard in their personal capacity. The opinions expressed in this blog are the author's own and do not necessarily reflect the view of the Royal College of Midwives.

 


 

 

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