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Robin Elise Weiss, LCCE

Delayed Cord Clamping

By April 23, 2010

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I was doing some homework for my epidemiology class and I came across something that reminded me about a story I had heard on NPR about delayed cord clamping at birth. The story said that the average time form birth to cord cutting was 17 seconds. Wow.

One of the doctors says that really it's only done this way because the hospital staff have better things to get on to with the baby. What they found out was if they waited, just a bit longer (94 seconds) that the baby had more blood and tended to have less anemia later in the first year. This increased iron can have many benefits, including cognitive benefits. Dr. Fogelson, from Academic OB/GYN Blog, says that there is benefit to this and he's not sure why it isn't standard yet.

Midwifery advocates have long said that the cord should not be clamped right away. Some say wait a minute. Some say that you should wait until the cord stops pulsing on its own. Others say you should wait for the birth of the placenta. My midwife preferred leaving the cord attached until baby was at least out and breathing well, saying that as long as the cord was attached baby would be safer.

What were you told about cord clamping? What do you want to do at this birth? Is it in your birth plan? What does your practitioner say about it?



Chaparro CM et al., Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomized controlled trial, Lancet, 2006, 367(9527):1997-2004.

September 10, 2009 at 12:41 pm
(1) Carrie Swartz says:

Actually, the literature does not support delayed cord clamping and the “science” does not say it’s because “hospital staff have better things to get on to with the baby”. Certainly, there are examples of medical reasons to expedite cord clamping (preterm baby, risk for meconium aspiration, depressed baby, etc), but even in healthy births, the risks of delayed (longer than one minute) cord clamping in the US appears to be greater than the benefits. (see the Cochrane review “Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes” April 2008). The biggest concerns are polycythemia and jaundice in the newborns and hemorrhage in the mothers, potentiallly leading to ceomplicated and dangerous treatments. Additionally, because of the design of the maternal-fetal-placental system, there is no protection against baby’s blood flowing back into the placenta, potentially causing severe anemia. In my experience as an obstetrician, it is precisely my concern for mom and baby that leads me to naturally wait about a minute to clamp the cord. By then, about 90% of the time, the cord will have stopped pulsing. I hope we can continue to educate more women and their providers on this issue to allow a discussion as to what will be best for each individual birth.

September 10, 2009 at 1:12 pm
(2) pregnancy says:


Thanks for your thoughtful comments from a doctor in the trenches! I’ve added the reference and the exact times to the post. It sounds like your idea of a normal time limit is more in line with the study recommendations. It may not be like this everywhere and the point of having this discussion with your practitioner is a valid one. In fact, there are times that one might need to cut the cord well before 94 seconds. But knowing when that is and what the patient preference is gives the practitioner a chance to consider their position as well as educate if there is a differing of opinion.

Thanks again!

January 21, 2010 at 12:03 am
(3) Danae Steele, M.D. says:

Carrie, I am an MFM, and I beg to differ. There is actually a growing body of lit which shows significant benefits, particularly to preterm babies of delayed cord clamping. The biggest benefit is a huge (may be as much as >50%) reduction in risk of IVH in preterm infants, with as little as 30 seconds delay of clamping cord. That is huge!!! That has the potential of improving outcomes for development as much as steroids improved outcomes for lungs. And babies do NOT “bleed into the placenta” except in extreme cases like abruptions. I was taught that myth in residency as well, and it turns out that it is nothing more than a myth.

March 9, 2010 at 9:49 am
(4) Michelle says:

Yes I support Danae’s statement. Carrie’s statement is another example of how “random controlled trails” can be used to support bad practice. Furthermore 90% of cords will NOT stop pulsating at 1 minute. And there is NO clinical trials that prove that there is any increase in “pathological” Jaundice or polythycemia, this too is a myth. And the woman is more likely to bleed if you leave the placenta engorged with blood meant for the baby!

WARNING! Doctors often make statements, and just because they are a doctor everyone thinks it must be correct.

March 23, 2010 at 9:16 pm
(5) Concerned Pedi TX says:

In response to the statement that there is no evidence of pathological cause of polycythemia and jaundice, I beg to differ. I am a pediatrician and work as a hospitalist with neonatalogists and I just recently had an infant who was full term and was delivered by a midwife and the infant had delayed cord clamping. Immediately after birth, infant began having problems and was found to be polycythemic and was admitted to the NICU. It was a very scary situation and with immediate intervention we were able to stabilize the infant and prevent any complications. However this required an IV and for mom to hold off on breastfeeding which can be still traumatic for the family. In fact, there are more risks involved including developing jaundice, hyperviscosity of the blood which can lead to hypoperfusion of organs which could lead to complications such as necrotizing enterocolitis, renal dysfunction and hypoglycemia all of which can be fatal. Infants that have severe polycythemia may need partial exchange transfusions to prevent these complications. Please do not pass around information that without complete medical knowledge may affect an infant’s life. All parents need to do adequate research and consult medical personnel before making such decisions. Get educated and the knowledge to make the right informed decisions first!

April 25, 2010 at 3:56 am
(6) Jenn aka Future Mama says:

I think many studies on both sides are controlled to come with certain outcomes… Sorry for my pessimistic stance.

BUT, my OB says she’ll wait about a minute, which I think it a nice in the middle time for me, and I don’t mind it being not “94 seconds.” My husband is also gonna cut the cord.. I kinda am more excited about that than stressing about the time limit.

April 25, 2010 at 6:51 am
(7) Robin Elise Weiss, LCCE says:

Hey Jenn,

The good news is that delayed is defined as 30 seconds, which is nearly double the time that the one doctor was talking about as average in their area (17 seconds). So at a minute you’re all good according to the research. I think the point is merely that doctors and midwives need to stop and think before they cut the cord immediately. One of the benefits of having them stop and think about it, is that it allows things like husbands cutting the cord! :-) See, it’s a win-win-win!


April 29, 2010 at 10:47 pm
(8) Erin says:

Where is the evidence that shows immediate cord clamping is safe and/or benefical? It is an intervention that was put into practice without any evidence to back it up. Now all these years we need proof that it’s safe to delay cord clamping? Where was the evidence to cut it early? There was none and there still is none. It seems backwards to look for evidence to do the physiological norm instead of looking for evidence to inervene.

To answer your question, I requested delayed cord clamping and my OB told me it was dangerous. I decided not to have a hospital birth. Instead, I had a home birth and did not clamp the cord until over an hour after my baby was born.

May 18, 2010 at 11:32 pm
(9) Susan says:

I appreciate all these comments and ask only that we each acknowledge that just because someone comes to a different conclusion than ourselves, doesn’t mean they don’t know what they’re talking about or didn’t do their research.

Pretty much all the research I’ve been doing finds a clear benefit in iron stores at 3 or 6 months with no complications.

I was just looking at a meta-analysis from 2007 by Eileen K. Hutton and Emam S. Hassan that backs this up pretty convincingly. Iron stores were better and there was no increased risk of jaundice, respiratory distress, or NICU admissions in the groups with delayed cord clamping (generally 2-3 minutes) in term infants of healthy mothers. They did have a significantly higher risk of polycythemia, but no infants in the study had any of the complications normally associated with polycythemia.

Unfortunately, though this analysis looked at almost 2000 infants, most of the studies had fewer than 100 total. Clearly more research needs to be done, but going on what we’ve got now, delayed clamping seems like the best choice.

June 15, 2010 at 11:25 pm
(10) Michelle K says:

I’m all for delayed cord clamping/cutting, and I don’t mean by just 90 seconds. We delivered our son out-of-hospital and did not cut the cord until over one hour after the birth. He had a tremendous amount of meconium present as well, yet the midwives were able to aspirate him and still leave the cord intact.

He was at birth, and remains, healthy, robust and thriving. I’m thrilled that he received the benefit of his own cord blood and stem cells and I won’t hesitate to take the same path with any other children we may have in the future.

July 15, 2010 at 5:35 pm
(11) David J R Hutchon says:

I am a very recently retired UK obstetrician and realised the folly of eraly cord calmping about five years ago. I certainly agree that until there is evidence that clamping the cord before the placental circulation ceases (about 3 -5 minutes) it is virtually unethical to do. However it is common practice here in the UK as much as in the USA. However it is not recommended by the Reusucitation Council (UK) NLS which in their bood “Resuscitation at birth” Newborn Life Support – Provider Course Manual 2nd edition ISBN1-1-903812-16-X they state on page 4 Chapter 4 as follows

The cord can usually be clamped about a minte after birth, the baby being kept at approximately the same level as the mother’s uterus until tis time. Very early clamping, and clamping while the baby is held above the level of the placenta can cause hypovolaemia. and this statement is referenced to Moss AJ et al Placental transfusion : early vs late clamping of the umbilcal cord.Pediatr 1967,40. 109-126
and Yao AC et al Effect of gravity on placetnal transfusion. Lancet 1969;ii 505-508

Chapter 4 states that the objective of the chapter is “This chapter revises the principles of thermal managment and considers the needs of babies within the first few hours of life. It also reviews the immediate management of newborn babies including the majority who require no resuscitation.”

Note the statement “including the majority” so the bit about waitn a minute also applies to babies who need resuscitation. This is the theory of practice in the UK at most practitioners do not know about it. However UK and US practice are closely linked and if the UK reuscitation council think delaying a minute is beneficial then I would expect the US to agree.

Of course there is a huge lot more to support delayed cord clamping but this above is a very good start for anyone wondering what is best. Most babies are fine whatever you do but there are a small number of babies that will die from mmediate cord clamping. ie those babies with a cord around the neck, venous congestion, placental engorgement and fetal blood hypovolaemia.

David J R Hutchon FCOG

August 24, 2010 at 9:54 pm
(12) mystic_eye_cda says:

@Concerned Pedi TX;

One case, in which there is no evidence that the delayed cord clamping caused the problem is not “evidence”. Polycythemia happens in babies with immediate cord clamping -in fact some list immediate cord clamping as a CAUSE of pathological polycythemia, so its not diagnostic that it happened in a baby with physiological cord clamping. The plural of “anecdote” is not “fact”

There are literally dozens of studies which show NO increase in anemia, in fact some show a decrease, of jaundice. And there are a few which show an increase in the need for phototherapy

Yes there are studies which show an increase in polycythemia, but not pathological polycythemia. Which suggests that there is just a lack of understanding of what is normal.

Late vs Early Clamping of the Umbilical Cord in Full-term Neonates
Systematic Review and Meta-analysis of Controlled Trials

Eileen K. Hutton, PhD; Eman S. Hassan, MBBCh

“Conclusions Delaying clamping of the umbilical cord in full-term neonates for a minimum of 2 minutes following birth is beneficial to the newborn, extending into infancy. Although there was an increase in polycythemia among infants in whom cord clamping was delayed, this condition appeared to be benign.”

the early effects of delayed cord clamping in term
infants born to libyan mothers

Musbah Omar Emhamed1, Patrick van Rheenen2, Bernard J Brabin1,2

“No significant differences were found inclinical jaundice or plethora. Surprisingly, blood analysis showed that two babiesin the early clamping group had total serumbilirubin levels (>15mg/dL) that ne-cessitated phototherapy. There were no babies in the late clamping group whorequired phototherapy. Three infants in the delayed clamping group had polycy-thaemia without symptoms, for which no partial exchange transfusion was neces-sary. Delaying cord clamping until the pulsations stop increases the red cell massin term infants. It is a safe, simple and low cost delivery procedure that should beincorporated in integrated programmes aimed at reducing iron deficiency anae-mia in infants in developing countries.”

The Effect of Timing of Cord Clamping on Neonatal Venous Hematocrit Values and Clinical Outcome at Term: A Randomized, Controlled Trial
José M. Ceriani Cernadas, MDa, Guillermo Carroli, MDb, Liliana Pellegrini, MDc, Lucas Otaño, MDd, Marina Ferreira, MDa, Carolina Ricci, MDa, Ofelia Casas, MDc, Daniel Giordanob, Jaime Lardizábal, MDb

“layed cord clamping at birth increases neonatal mean venous hematocrit within a physiologic range. Neither significant differences nor harmful effects were observed among groups. Furthermore, this intervention seems to reduce the rate of neonatal anemia. This practice has been shown to be safe and should be implemented to increase neonatal iron storage at birth.”

Neonatal plethora, polycythemia, and hyperviscosity

In a review of the literature, I found three gravity-drained cases of plethora clamped at 1 to 5 minutes that were cured by phlebotomy.” Uterine contraction was not documented. It is unclear whether the infants’ excess blood would have flowed back into the cord during uterine diastole if the clamp had been quickly removed.3
Polycythemia (hematocrit >65%) is often produced by late clamping. Hemoconcentration normally follows placental transfusion. It also occurs during normal labor. Serum albumin and colloid osmotic pressure (COP) rise with the hematocrit. Pulmonary function requires a COP high enough to prevent pulmonary edema. At elective cesarean section with rapid cord clamping, this COP increase does not occur. Not surprisingly, wet lungs occasionally result.

Oligohydramnios results in vein compression, causing increased capillary pressure in the placenta, which leads to fluid loss, dehydration, and hemoconcentration. Amnioinfusion may correct this; otherwise, rapid fluid replacement at birth is needed to amend this pathologic polycythemia.

The multifaceted (and uncertain) hyperviscosity syndrome11-13 is based on the premise that increased viscosity (high hematocrit) results in decreased tissue perfusion.2,11 However, factors other than viscosity also affect tissue perfusion.

According to Poiseuille’s law, the blood flow through vessels (liquid flow through tubes) is inversely proportional to the length of the tube and the viscosity of the liquid, and directly proportional to the pressure differential and to the fourth power of the radius of the tube. Therefore, if the radius is reduced from 3 to 2, flow is reduced 81:16, or by four-fifths; whereas, if viscosity is increased from 2 to 3, flow is reduced 1/2:1/3, or by one-sixth. Clearly, vasoconstriction reduces blood flow much more than a similar change in viscosity.

In clinical practice, late clamping produces a high hematocrit, 2, 9,14,15 high blood pressure, and vasodilatation to accommodate the large volume of blood.9,16 These latter two factors should increase tissue perfusion. In searching the literature, I was unable to find any documented case of hyperviscosity syndrome in which the cord was clamped late,” although I did find many documented cases of late clamping involving normal newborns with high hematocrits. 2,9,15,17,18

There are, however, many documented cases of hyperviscosity syndrome with high hematocrits (e.g., cases involving gestational diabetes or postmaturity) in which the cord was clamped before physiologic cord closure, thus creating low blood volume, low blood pressure,16 and vasoconstriction coupled with the polycythemia.11 The inadequate tissue perfusion is blamed on the high hematocrit, when the root cause of the hyperviscosity syndrome is hypovolemic vasoconstriction enforced to the fourth power.

1. American College of Obstetricians and Gynecologists. Umbilical Artery Blood Acid-Base Analysis. Washington, D.C.: ACOG; 1995. Educational bulletin 216.

2. Linderkamp O. Placental transfusion: determinants and effects. Clinics in Perinatology 1982;9:559-592.

3. Gunther M. The transfer of blood between baby and placenta in the minutes after birth, Lancer 1957;i:1277-1280.

4. Yao AC, Lind J. Effect of gravity on placental transfusion. Lancet 1969;ii:505-508.

5. Botha MC. The management of the umbilical cord in labour. S.A. J Obstet Gynecol 1968,August:30-33

6. Philip GS, Teng SS. Role of respiration in effecting placental transfusion at cesarean section Biol Neonate 1977;31:219-224.

7. Darwin E. Zoonomia. Vol III 3rd ed London, 1801:302.

8, Kinmond S, et al. Umbilical cord clamping and preterm infants: a randomized trial, BMJ 1993;306:172175.

9. Peltonen T. Placental transfusion-advantage and disadvantage. EurJ Pediatr 198 1; 137 141-146,

10. Saigal S, Usher RH Symptomatic neonatal plethora. Biol Neonate 1977;32:62-72.

11. Mentzer W. Polycythemia and the hyperviscosity syndrome in newborn infants. Clinics in Haematology 1978;7(1):63-74.

12. Oh W. Neonatal polycythemia and hyperviscosity. Pediatric Clinics in North America 1986;33:523-532.

13. Weinburger MM, Oleinick A. Neonatal polycythemia, Clinical Research 1971;29:209.

14. Usher R, Shephard M, Lind J. Blood volume in the newborn infant and placental transfusion. Acta Paediatr Scand 1963; 52:497-512,

15. Moss AJ, Monset-Couchard M. Placental transfusion: early versus late clamping of the umbilical cord Pediatrics 1967;40(1):109-126.

16. Arcilla RA, Oh W, Lind J, et al. Portal and atrial pressures in the newborn period. Acta Paediatr Scand 1966;55:615-625

17. Nelle M, et al. The effect of Leboyer delivery on blood viscosity and other herriorrheologic parameters in term neonates. A m J Obstet Gynecol 1993; 169(1):189-193

18 Linderkamp 0, et al. The effect of early and late clamping on blood viscosity and other hemorrheologic parameters in full-term neonates, Acta Paediatr Scand 1992;81(10):745-750.

19. Inall JA, Bluhm MM, et al. Blood volume and hematocrit studies in respiratory distress syndrome of the newborn. Arch Dis Childb 1965;40:480-484.

20. Brown EG, Krouskop RW, McDonnell FE. Blood volume and blood pressure in infants with respiratory distress. J Pediatrics 1975;87(6):1133-1138,

21. Landau DB. Hyaline membrane formation in the newborn: hematogenic shock as a possible etiologic factor, Missouri Med 1953;50:183.

22. Faxelius G, Raye J, et al. Red cell volume measurements and acute blood loss in high-risk infants. Pediatrics 1977;90(2):273-281,

23. Usher R, Saigal S, O’Neill A, Surainder Y, Chua L. Estimation of red blood cell volume in premature infants with and without respiratory distress syndrome. Biol Neonate 1975;26:241-248.

24. Linderkamp 0, et al. Association of neonatal respiratory distress with birth asphyxia and deficiency of red cell mass in premature infants. Eur J Pediatr 1978; 129:167-173

25. Yao AC, Wist A, Lind J. The blood volume of the newborn infant delivered by caesarean section. Acta Paediatr Scand 1967;56:585-592.

26. Linderkamp 0, Versmold HT, et al. The effect of intra-partum asphyxia on placental transfusion in premature and full-term infants. Eur J Pediatr 1978; 127:91-99.

27. Cashmore J, Usher RH. Hypovolemia resulting from a tight nuchal cord at birth, Pediatr Res 1973;7:339

October 16, 2010 at 1:01 am
(13) Elizabeth says:

It would be hard to top “Mystic’s” research in the Aug comment, and I won’t even try. I just want to say that other mammals do not seem to be in a great hurry (with lots of staff handy) to sever the cord. Could nature really be so stupid as to leave human beings so vulnerable to problems from a cord closing itself, as nature would have it do?
Most new mammal mothers seem to be concerned with stimulating the newborn with touch (licking etc) and keeping them warm and safe. The placenta and cord are left for a bit later. Millions of years of evolution can’t be totally wrong.
I guess some modern ob practices might throw a monkey wrench in this nice pattern. Such as the shot of oxytocin given in the thigh as the mother births. Some say the rush is on then to prevent the placenta from getting trapped in the uterus by the artificially strong contractions. Maybe this active management of 3rd stage labor needs to be rethought or redesigned with the delayed clamping in mind. Could that shot wait, or be optional (used only if obviously needed)?
For the record, I have had 2 home births, to avoid a lot of these well-meaning, but unproven medical practices from being practiced on me and my children.
I keep thinking of all the things in medicine that were once considered normal and safe, but they have been quiety phased out. Progress does not happen if questions are not asked and and research not done, and training not changed. Too often, a long process.

January 12, 2011 at 1:51 pm
(14) Nicholas Fogelson, MD says:

I have written on this topic a bit, and recently have been preparing a Grand Rounds for my hospital’s Peds and OB departments. In this research, I have found no literature that suggested that infants with delayed cord clamping have a higher incidence of pathology polycythemia. There are a few non-blinded studies that suggested higher rates of bili-light use in delayed clamp infants, but given that the pediatricians knew about this intervention the data are somewhat biased.

One can argue all the data, but at the onset one has to accept that the natural course of events is that the cord will not get cut and clamped until long after delivery, resulting in a substantial transfusion of blood from the placenta to the infant (20-40 cc/kg in most studies). Choosing to immediately clamp the cord to avoid any particular outcome is a deliberate fetal phlebotomy done for that purpose. In those terms, few would argue that this was the right thing to do without clear evidence to show it was correct. Despite this, people claim that immediate clamping is the standard and argue that the data for delayed clamping is inadequate. This is not rational.

Delayed clamping has clear effects on fetal iron stores, total red blood cell volume, and postpartum fetal blood pressures. Preterm infants with delayed cord clamps have shown a substantial decrease in intraventricular hemmorhage and sepsis. There are also theoretical benefits in increasing the number of pluripotent stem cells available to the fetus in early development, as well, as immediate cord clamping robs the infant of as much 40% of its total pluripotent stem cell population.

January 12, 2011 at 2:28 pm
(15) Nicholas Fogelson, MD says:

The comment above mine demonstrates one of the real problems the natural birth community has in promoting the issues they feel are important, and this problem is the crazies.

Donna Young’s letter to the President is a bizarre document, almost a manic rant, that no person in power would ever choose to read. Its formatting and language is so strange that it makes Ms Young look just nuts. While I agree that delayed clamping is the better way to go, taking it so far as to say that doctors that immediately clamp an umbilical cord should be brought up on criminal charges is leaving reason for insanity.

Such rhetoric does no one any good, and hurts Ms Young’s underlying cause.

April 11, 2011 at 4:53 am
(16) M. Morillo. (Parent) says:
May 21, 2011 at 9:17 am
(17) Erica says:

The first comment on this post (by Carrie Swartz) refered to the Cochrane review “Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes” April 2008) This review does NOT show that, “the risks of delayed (longer than one minute) cord clamping in the US appears to be greater than the benefits” as Ms. Swartz claims. The review in fact concludes with the author’s statement:

“In this review delaying clamping of the cord for at least two to three minutes seems not to increase the risk of postpartum haemorrhage. In addition, late cord clamping can be advantageous for the infant by improving iron status which may be of clinical value particularly in infants where access to good nutrition is poor, although delaying clamping increases the risk of jaundice requiring phototherapy.”

August 7, 2012 at 9:52 pm
(18) Wrylilt says:

I had delayed cord clamping with both my children, and a drug free birth. Both fed really well almost straight away and had great apgars and no health issues at all.

And as for the blood “flowing back into the placenta”. Heard of wharton’s jelly? It’s the stuff that dilates the placenta so nothing can flow back up it. And have you ever seen the difference between a DCC and ECC placenta? The DCC placenta has almost no blood in it.

October 24, 2012 at 1:40 pm
(19) Donna Young says:

No. 14 has comments of Dr. Nicholas S. Fogelson, MD, as well as No. 15. In response to No. 15, in reference to myself, Donna Young, and my Open Letter to the current U.S.A. President at http://www.medical-truths.com . . . I admit, sure the writing is not perfect, but the medical reviewed articles and given as qualifying references are perfect for the common folk to know their child will be weakened and put in some testable internal danger if they trust their medical business person to stop the natural inflow of placenta blood. If the common folk are given to reason or logic, the hasty cord clamping is not a logical afterbirth care and not seen done to animal births, why not the higher professional trained persons?
This placenta blood is naturally intended to be inside the baby rather than to be medically taken for science research projects or for use in transfusions to another’s need. This placenta blood should not go to private or public cord blood banks when it should legally be inside the owner-infant. The duty is the legal protection to the infant-citizen – do no harm or the risk of it, and this is a duty when safer options are a choice for the afterbirth care to the baby or babies.
What is Delayed cord clamping compared to no cord clamping, whatsoever?
Dr. Fogelson admits delayed clamping is the better choice to go for the afterbirth care of the newborn citizen-child. Exactly what time period does he think is sufficiently delayed that will not weaken the baby whose umbilical cord is being clamped, or tied off, or finger-squeezed off? If he states a time period of no cord compression for five minutes or until the placenta is birthed there is no blood left in the placenta for another’s use.
Therefore, I suspect that delayed clamping has a concealed motive of yet seeking and sharing trapped blood in the placenta that otherwise should or ought to have been inside the baby.

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