Cesarean section & delayed clamping

Cesarean section and delayed cord clamping

Delayed clamping of the umbilical cord in cesarean section delivery is possible for many babies.

In fact, delayed clamping in cesarean section is standard for some practitioners - to enhance placental transfusion and increase the baby’s blood volume at birth (closer to a physiological level than immediate clamping).

This may involve:

• the baby’s head is delivered and the surgeon is hands-off as the baby auto-resuscitates while still attached to placental circulation. The baby is allowed time to transition to breathing - and after a few minutes once the baby begins to cry, the baby’s shoulders are eased out.The remaining delivery is a steady process of active movements by the baby and assistance from the obstetrician. The cord is not clamped until after the baby is completely delivered and the baby’s wellbeing is confirmed. (Smith, Plaat, Fisk, 2008)
• ‘milking’ or ‘stripping’ blood in the umbilical cord toward baby before clamping;

• and/or holding the baby below the level of the placenta for 30-60secs before clamping;

• covering the umbilical cord with a towel while stimulating the baby to achieve adequate respiration prior to clamping; (the cord constricts with exposure to cold)

• the baby is born and then the placenta is removed – keeping the baby, umbilical cord and placenta intact (without clamping). The placenta is kept level or above the baby, and this method can allow a lotus birth if the parents wish.

Parents are encouraged to speak with their clinical care providers about cesarean section and delayed cord clamping. This may be best covered when discussing a birth plan/ birth preferences, since the need for a cesarean section may arise late in pregnancy, during labour or be an emergency situation.

Some practitioners have limited knowledge or experience in delayed clamping with cesarean delivery. Parents may experience strong resistance or issues with lack of support from other key staff involved in the surgery, including anaesthetic, pediatric and nursing staff.

However, it is helpful to know during your discussions with your provider that delayed clamping with cesarean section is standard practice with some providers.

For example:

• Nicholas Fogelson MD, an American OB/Gyn states on his website: ”We delay cord clamping at cesarean routinely in my cases, and a lot of my partners have followed suit.  It isn’t difficult and doesn’t add a great deal of time to the case.  The pediatricians that are routinely at cesarean need to be brought on board, though, as they will be waiting for the baby wondering why it is still on the field!…Most OBs are happy to delay cord clamping if you let them know.  A lot aren’t aware of the data.  Point them to the video and they will probably change their tune.” (March 27, 2011) comment #124

• The protocol for some studies of delayed versus immediate clamping involves cesarean section with delayed clamping (1).

There are situations where delayed clamping may not be safe or beneficial - for example, where cesarean section for anterior placenta previa involves incising the placenta or the baby is bradycardic (slow heart rate). In these cases, blood in the cord may be “milked” towards the baby before clamping and the residual blood volume in the placenta can be a source of blood for auto-transfusion (Source). Again, please speak to your health care provider about your particular case.

Examples of delayed clamping in cesarean section delivery

BJOG article A Natural Cesarean: A Woman Centred Technique (video embedded below) features a surgical team discussing their approach to delayed clamping with ‘woman centred’ cesareans. An excerpt from the article:
“Fetal safety is paramount, and we immediately resort to routine management if the baby is unexpectedly born in poor condition. The uterine incision-to-delivery interval is prolonged compared with routine practice, but usually still within the 3 minutes formerly recommended for optimal neonatal condition.¹⁴ However, during this period with the head out but the trunk still inside, not only is the crying baby establishing a resting lung volume but also the placental circulation remains intact. Experience with the partially exteriorised fetus during EXIT (Ex utero Intrapartum Treatment surgery to establish the neonatal airway) procedures suggests that fetal oxygenation can be maintained over much longer intervals, the largest series showing an average cord pH of 7.20 after a median of 17 minutes on ‘placental bypass’.¹⁵ Because birth is timed when the baby is completely expelled from its mother’s womb, natural caesarean babies often achieve a healthy Apgar score before they are actually born.”

Guideline for the management of Caesarean Section deliveries (David Hutchon) 
“The baby is delivered onto the mother’s thighs and time of delivery recorded. The baby is wrapped in the warm towel and held on the right side of the mother’s thigh about 20 cm below the height of the incision. 40 seconds after delivery the cord is clamped and cut and the baby taken for resuscitation if necessary.”

“The time of the delivery of the baby and the interval before clamping the cord must be recorded. This guideline does not apply to Crash Caesarean sections for acute fetal distress, Ceasarean sections for abruption placenta and placenta praevia or vasa praevia.”
http://www.hutchon.net/NFMMSIG/cordclamp.htm

‘Milking’ the umbilical cord at term – cesarean section
“New evidence suggests immediate clamping of the umbilical cord may contribute to anemia of infancy. It can deprive a full-term infant of 25% of its blood volume, representing up to 50 mg/kg of iron. Poor iron stores can affect the developing brain. Immediate clamping is routine at cesarean section but lacks scientific evidence. Delayed clamping for two minutes can reduce anemia but is not always feasible at cesarean section.

Cord milking may offer an alternative at cesarean section for the prevention of anemia. Cord milking is easy to implement at cesarean section and may aid in the prevention of anemia in infancy. While some clinicians focus on polycythemia, a parallel concern is the incidence of anemia found in infants with immediate clamping. Cord milking appears to be an effective alternative to delayed clamping with no associated harm. More research is needed to discern causes of hyperbilirubinemia.”
http://www.grin.com/en/doc/274036/milking-the-umbilical-cord-at-term-cesarean-section-effect-on-hemoglobin

Cesarean Lotus Birth Story
http://www.womenofspirit.asn.au/StoriesMelissaLotus.htm

“The Caesarean section was performed and our son, Jarrah was born at 7.50 am on Friday 2nd July.     He was immediately taken over to a table to have meconium suctioned from his lungs     – Josh was with him at all times -  the placenta was still attached. 8.00am saw a shift change in staff and a new nurse came in who tried to cut the cord saying it was hospital procedure!! Fortunately Josh was with Jarrah and intervened letting her know of our arrangement with the doctor.

Jarrah was having difficulty breathing, so his father requested that the clamps be removed to allow the blood to flow freely from his placenta back into his body. The Paediatrician refused to do this and we again asked to seek higher authority.  He left and then came back and removed the clamps. Once this was done Jarrah’s breath, colour and strength picked up immediately – this amazed the paediatrician!”

Video: The  “natural”  cesarean: a woman- centered technique 

(1) Studies where infants assigned to delayed clamping including cesarean section include Kugelman et al (2007), Mercer et al (2003), Mercer et al (2006)

References

Smith J, Plaat F, Fisk N. The natural caesarean: a woman-centred technique. BJOG 2008;115:1037–1042.

References cited in Smith, Plaat & Fisk (2008):

14. Bader AM, Datta S, Arthur GR, Benvenuti E, Courtney M, Hauch M. Maternal and fetal catecholamines and uterine incision-to-delivery interval during elective cesarean. Obstet Gynecol. 1990;75:600–3.[PubMed]

15. Bouchard S, Johnson MP, Flake AW, Howell LJ, Myers LB, Adzick NS, et al.  The EXIT procedure: experience and outcome in 31 cases. J Pediatr Surg. 2002;37:418–26.[PubMed]