When Jane Austen lived, midwives and man-midwives were advised to delay tying off or clamping the umbilical cord—what an early 19th-century midwifery practitioner would call the “navel-string” or funis—until a newly birthed child had gained some mastery over its breathing. Austen herself likely knew very little about this important topic, but it appears that what was old has become new again, for there are parallels between this midwifery practice during Austen’s day and today’s approach to the timing of cord clamping.
Dr. Denman’s Approach to Cord Clamping
Dr. Thomas Denman, who was a licentiate in midwifery of the College of Physicians and an Honorary Member of the Royal Medical Society at Edinburgh, wrote movingly of this process in his 1807 book on midwifery:1
“Perhaps the changes which take place in the body of the child, immediately after its birth . . . are not perfectly understood at this time. But we know if the child is in a healthy state, that it usually cries lustily and continually, when the air rushes into its lungs, which are thereby expanded . . . But the change from uterine life, as it may be called, to breathing life, is not instantaneous, but gradual; uterine life continues till the breathing life is perfected, and is proved by the continuance of the circulation between the child and placenta for some time after it has cried . . . We may therefore safely conclude, that the navel-string of a new born infant ought never to be tied or divided, till the circulation in it has ceased spontaneously.”
Dr. Denman believed that if the navel-string was tied or cut the instant the child was born, then in some cases, although the child had been lively, it would decline immediately and might die within a short time, having never perfected its breathing. This was especially true if the child were in a “feeble or dubious state” to begin with. He advised first to wait to tie off or clamp the navel-string and, secondly, to stroke it from the placenta toward the body of the child to encourage the passage of blood.1
Modern Practice for Cord Clamping
In healthy term infants, more than 90% of blood volume is achieved within the first few breaths after birth.2 When this fact became widely known, practitioners in the 1950’s began to shorten the interval between birth and umbilical cord clamping, such that only 15-20 seconds lapsed after birth before the cord was clamped, with the infant being held at or below the level of the placenta. This practice may have arisen as a precaution to protect against delay in carrying out the resuscitation of preterm infants.3 Even so, its benefit raised a question: Are preterm infants different from term infants with regard to the timing of cord clamping?
Clamping Time for Term Infants
The American College of Obstetricians and Gynecologists published a committee opinion in 2012 that concluded there was insufficient evidence to support a delay in umbilical cord clamping for term infants born in “settings with rich resources” (that is, infants born in hospitals or other care centers with good obstetric services).2 Delaying umbilical cord clamping for up to 60 seconds may have the benefit of increasing the iron stores and blood volume of term infants, but it may also increase the infant’s risk of needing neonatal phototherapy—a light treatment applied when an infant is born with jaundice, which is a yellow appearance of the skin due to high blood levels of bilirubin. Thus, the jury is still out on the timing of cord clamping for term infants.
Clamping Time for Preterm Infants
Delaying the umbilical cord clamping in preterm infants, however, has definite benefits.2 Delaying the clamping for 30-60 seconds after birth, with the infant held at a level below the placenta, results in improved circulation of blood from the placenta to the premie, better red blood cell volume, and a decreased need for blood transfusion. Perhaps the most important benefit of delaying umbilical cord clamping in preterm infants is a 50% decrease in intraventricular hemorrhage (IVH). IVH is a condition in which bleeding occurs into the fluid-filled areas (the ventricles) of the newborn’s brain and occurs most often in premature infants.
Milking the Umbilical Cord
Dr. Denman’s recommendation to stroke the navel-string “from the placenta towards the body of the child”1 suggests a sort of milking action. This idea has legs even today: a few studies have been published on the issue of milking. Among preterm infants, milking the umbilical cord has been shown to increase their initial hemoglobin level and blood pressure, improve cardiac function, decrease the need for blood transfusions, and shorten the time spent on supplemental oxygen and mechanical ventilation.3 More research is needed to confirm these findings because the dataset is small.
What Was Old is New Again
Medical practice stands today where Dr. Denman stood in 1807 when he published his book on midwifery. He wrote that it appeared to have been a practice among the ancients—referring, presumably, to such Greek physicians as Hippocrates and Galen—to wait for the expulsion of the placenta after the birth of the child before tying or dividing the navel-string.1 “It has since been the practice, to divide the funis immediately after the birth of the child,” he wrote, noting the change in current practice from ancient times. In his opinion, it was better to milk the navel-string and wait to tie or divide it.
In recent decades, some practitioners have been been clamping the umbilical cord within 10-20 seconds of birth.4 Research now suggests that for preterm infants, it is better to wait 30-60 seconds before clamping the cord. If in a few years, research also shows benefits to term infants of delaying cord clamping, then the cycle of medical practice will have come full circle and returned to that of the ancient physicians.
1Denman T. An Introduction to the Practice of Midwifery. (Brattleborough, 1807), pp. 177-179 (PDF pp. 216-218).
2Committee on Obstetric Practice, The American College of Obstetricians and Gynecologists. Committee Opinion No. 543: Timing of Umbilical Cord Clamping after Birth. Obstet Gynecol. 2012; 120(6):1522-1526.
3Raju TNK, Singal N. Optimal timing for clamping the umbilical cord after birth. Clin Perinatol. 2012;39(4). Accessed October 14, 2014.
4Hutton EK, Stoll K, Taha N. An observational study of umbilical cord clamping practices of maternity care providers in a tertiary care center. Birth. 2013;40(1):39-45.
5Bust of Hippocrates: Engraving by Peter Paul Rubens, 1638. Courtesy of the National Library of Medicine. http://wwwihm.nlm.nih.gov/ihm/images/B/14/555.jpg