Optimal Cord Cutting : is it all about timing?

The recent publication of a Lancet article on the outcome of delayed cord cutting (which I prefer calling Optimal Cord Cutting or OCC) in very premature babies, finding that clamping the cord at least 1 minute after birth reduced the risk of death or major disability at 2 years old by 17%, reflecting a 30% reduction in relative mortality, brought the topic of the benefit of OCC (back) to the forefront of the birthing debates.

The umbilical cord:

The umbilical cord is a real wonder of nature. It provides baby with essential nutrients, blood, oxygen antibodies and holds those precious stem cells you probably have heard about, during pregnancy and until it stops pulsating after birth - unless it is clamped before hand (what I would call Sub-Optimal Clamping).

Clamping, milking the cord…:

Sub-Optimal Clamping deprives baby from receiving the optimal physiological amount of all of those goodies listed. In the UK, the Resuscitation Council (Resus) guidelines recommends (where immediate resuscitation or stabilisation is not required) a clamping of the cord after at least 60 seconds from birth and recognises that a longer period before clamping may be more beneficial.

They also encourage medical practitioners to try to attend to the thermal care and initial resuscitation interventions with the cord intact where possible - and it is possible in most cases.

Where delayed cord clamping is not possible, Resus recommends cord milking for infants above 28 weeks gestation - even where a 2019 study has shown that compared with OCC for preterm babies, milking significantly increased the risk of severe intraventricular haemorrhage (aka : bleeding inside or around the brain of baby - not good!) . Yet the same study shows that cord milking, when compared with immediate cord clamping, reduced the need for packed red blood cells (RBC in medical jargon ) transfusions but did not improve clinical outcomes.

…but when?

Why am I telling you all of this?

Most parents do not think/cannot imagine that they have any options around cord clamping, from what is shared in/on (social) media to what your medical practioner would discuss with you (and let’s face it - there are so many things your midwife, doctor, obs and gyne need/want to discuss with you in the limited time of a visit, that often the cord is not discussed all or only regarding positionning of baby - i.e. is the cord around baby’s neck : yes no maybe…- and I do not blame them for it!). With the medicalisation of births (full disclosure : my dad with an obstetrician, birthing wards were my playground as a child and I love hospitals! but moving births from the homes to hospitals is a thing: a trend we have historically observed all over the globe - although with the Covid-19 pandemic home births have boomed including in the west) a lot of ancestral birth-keepers knowledge has been lost . We are slowly (re)discovering their command of birthing and we are in the process of proving (with hard data) that their knowledge does benefit birthing parents and babies . OCC is one of those ancestral lost practices, science is inviting us to consider!

The 60 second/1 minute mark after birth for cord cutting is also an arbitrary one and birth-workers (and Resus) have observed that leaving the cord for longer and until the cord stops pulsating, preferably until it is white and thin is beneficial and can take up half an hour.

In short:

There is no need to clamp and curt the cord unless you want to, or if the cord is too short and gets in the way of caring for baby (medical emergency for birthing parent or baby including resuscitation, holding, caring for, feeding baby etc).

You have a choice and a voice to decide every aspect of your pregnancy and birth including cord cutting. You “just” need to ask for it and repeat your request if necessary.

In the UK a 2018 survey shows that up to 40% of babies are not receiving OCC in spite of NICE guidelines and irrespective of parental choice.

I know how hard it can be, in the middle of labour or just after birth, to find one’s voice but I want to reassure you: nature, the law and science are on your side.

We looked at nature and science above. As to the law: as long as you have legal capacity (i.e. unless a judge has deemed you unfit to make decisions for yourself) you have the right to decide on every aspect of your care - cord clamping is no different.

Birthing partners are often asked to clamp the cord so discuss this with yours and clearly state your preference/instructions to them - whatever route you want to go for.

You are also allowed to envisage different scenari too and change your mind accordingly. It will not make you “difficult” or “indecisive” - you have the right to give and withdraw consent at any time (and this may be a recurring theme on this blog).

On top of discussing cord clamping with your birthing partner/doula/midwife/obstetrician I would highly recommend making your wish/wishes clear in writing in your birth plan, and any correspondence you have regarding your birthing environment - delivery.

If your medical team tells you it is “not possible to go for OCC” as they need to care for baby and cannot do so with an unclamped cord, please :

• do remind them of Resus/NICE guidelines on the matter;

• do go ahead and ask them (yourself or brief or your birthing partner to ask on your behalf) for an explanation and to have that explanation documented in your notes;

• remember that even after your receive an explanation you still have a choice in clamping the cord whenever your want .

Your medical team is not allowed to tell you things such as “ you cannot” or “you must” in terms of the care you or your baby is receiving.

Why do they do it though? They can be under a lot of stress because of long working hours and may not want to take any risk in doing things differently - and OCC can be something they are not accustomed to. If OCC is something important to you then, I hope that this blog post encourages you and helps you feel empowered to insist on it!

If you have any questions, please do reach out!

PS - giving birth at home:

If you give birth at home or in a setting without a medical professional and before the midwife’s arrival, the cord should be left unclamped and intact until it starts pulsating becomes white and thin. Keep you baby warm by holding him or her skin to skin with a thick towel or blanket as babies get cold very quickly otherwise.

Finally - if you or your birthing partner have not called the emergency services or your midwife - go ahead and do that (unless you elected for a non attended birth also known as a “free birth” - I personally am not a fan of this term as it implies that assisted births are not “free” but this may be a discussion for another blog post).