Episode 131 Cord Blood

Cord blood is actually an inaccurate description, this is the baby's blood.
Here I am exploring the timing of cutting the umbilical cord and the impact this can have on the baby's health.

Want to know more?
https://www.bloodtobaby.com/
https://www.cochrane.org/CD004074/PREG_effect-timing-umbilical-cord-clamping-term-infants-mother-and-baby-outcomes
https://www.cochrane.org/CD003248/PREG_does-delaying-cord-clamping-or-using-cord-milking-birth-improve-health-babies-born-too-early
https://www.nhsbt.nhs.uk/cord-blood-bank/

Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
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Its easy to explore my back catalogue of episodes here https://padlet.com/WhoseShoes/TheObsPod I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor.
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Transcript

Episode 131 Cord Blood

Florence: [00:00:00] Episode 1 31 Cord Blood. I hesitate in calling this episode Cord Blood because as Rachel Reed, I think said in the episode on the Midwife's Cauldron about this, this blood is not cord blood doesn't belong to the cord, it belongs to the baby, and that's probably where some of the problems start. Today I'm going to explore a little bit about. cord blood in terms of when you clamp and cut the umbilical cord. And also, what do we use cord blood, that is the blood within the cord for? This is not going to be a fully exhaustive scientific exploration of the topic. This is just going to be some of my thoughts and views.

Why this topic? When I thought about it, I thought it was a bit strange that I [00:01:00] hadn't done it as a topic, actually, because clamping and cutting the umbilical cord and the timing of that has been something that has definitely changed during my practice and is currently changing. Why is that? You may find when you explore the topic of clamping and cutting the umbilical cord discussion around early clamping , delayed cord clamping or optimal cord clamping.

So what do these things mean? In the womb, the baby is supplied by everything through the umbilical cord. It's literally a lifeline. It attaches to the placenta, and it's where the fetal circulation can come into contact with the maternal circulation and get everything that it needs. When a baby's born, at some point, it has to separate from that circulation.

[00:02:00] And historically, I was taught as a medical student and then as a junior doctor, as soon as the baby was out, we should clamp and cut the umbilical cord separating the baby from the placenta. It didn't occur to us that that could be a detrimental thing to do. The baby was out. The baby was breathing getting its own oxygen now through its lungs.

The fetal circulation changes at that point. The way the heart pumps the blood is different because it's got to get blood to the lungs in much bigger volumes, and the circulation to the placenta through the umbilical cord starts to shut down. So stopping it and clamping and cutting the cord never seemed like a problem.

It was the logical thing to do. We all did it. If you look at birth in the media, birth happens [00:03:00] maybe outside hospital. There's that traditional thing of finding a shoelace or something to tie and occlude the cord and subsequently cut it. Somehow it became part of our culture to cut and clamp the. . One of the things I love to do is to go on holiday to Wales and me and my family often go in spring.

It's lambing time of year. There's nothing better as an obstetrician than watching these sheep give birth instinctively. But what happens to the sheep? There's no one there to clamp and cut that umbilical cord. What happens in nature is that the cord and the placenta is still attached to the lamb and then snaps off or is [00:04:00] snapped by the mother.

So it's not designed that we should immediately separate. But a few years ago when I started to look at women's experience of maternity care and join. twitter which for me was an unbelievable new network. One of the things I came across was Amanda Burleigh @optimalclamping on Twitter and another hashtag Blood to baby.

And this made me start to question for the first time whether I should be immediately cutting and clamping the umbilical cord after birth. So I started to think about it and the more I started to think about it and read things about it, the more I [00:05:00] started to discover that actually I was potentially doing something quite detrimental.

So when was it that we started immediately cutting and clamping the umbilical cord? , my regular listeners will know I have a 1930s manual of obstetrics. So I looked in that and that says that the practitioner, having noted the hour of birth, should wait for a few minutes before tying the cord if anything is normal.

So clearly we used to do it the right. way . So when did we introduce doing it the wrong way? I wonder if it was to do with active management at the third stage in our eagerness to prevent and control maternal bleeding and giving an injection of syntometrine syntocinon and ergometrine to help the [00:06:00] womb contract and to assist with the birth of the placenta

was it then that we introduced the idea of immediate cord clamping? I think it might have been, so at that point, I think it was around about 2014, 2015, I started to be introduced to the idea of delayed cord clamping. If the baby didn't need to be immediately separated from, its mother that one could leave the cord intact.

Are there any other reasons why we might have been clamping or cutting the umbilical cord? Well, we use some of the cord blood sometimes for useful tests. So if we've done an assisted for vaginal birth or a cesarean birth for fetal distress , we might want to [00:07:00] take blood from the umbilical cord to look at what condition the baby was in at birth, a blood test from the umbilical vein and the umbilical artery.

Give us good information about that baby's pH. Its acidity, how well it was coping with the labor or birth, and that can give valuable information for our pediatric colleagues in how that baby's coping and adapting to life outside the womb. And if a baby's very unwell, this information can be extremely valuable.

The other situation in which that information can be useful is also in medico legal terms when you're trying to establish whether something was related to an event around the birth or not knowing what the baby's cold gases were, what [00:08:00] condition that baby came out in, in the immediate minute of its birth can be helpful in extrapolating and understanding whether something is likely to be birth related or not.

Although it's not an exact science, so we often take cord gases. Cord bloods for. that The other situation in which we take cord blood is if a mother is rhesus negative, and we need to establish whether the baby is rhesus negative or rhesus positive so that we know whether the mother needs anti-D injections after birth.

Taking blood from the umbilical cord in that situation means we contest the baby's blood without inflicting a blood test on the baby , the cord doesn't have any nerve endings. It's not painful for the baby if we take blood from the umbilical cord. [00:09:00] So sometimes we would clamp and cut the umbilical cord and we would double clamp it so that we would save some blood for us to take for tests, whatever tests were required.

So up to that point in my career, I would usually immediately clamp and cut the umbilical cord then what I discovered astonished me that the evidence was there, that actually doing this made a significant impact on the baby's iron stores and even its birth weight. If you turn to the 2016 version of prevention and management of postpartum hemorrhage, Greentop guideline, it details.

It talks about the timing of clamping and cutting the umbilical cord. It defines active management of the third [00:10:00] stage of labor using uterotonics, the syntometrine early clamping of the umbilical cord and controlled cord traction to help deliver the placenta more quickly and reduce blood loss. And it showed that active management

results in a lower birth weight reflecting, a lower blood volume from early cord clamping, and that a systematic review and meta-analysis of controlled trials found delayed cord clamping for at least two minutes is beneficial to the newborn. And what's more, the benefits extend into infancy. So this isn't something that is just affecting the wellbeing of that baby immediately in the hours after birth

this has a longer term impact. So in 2016, the Royal College of Obstetricians and Gynecologists, after I would say [00:11:00] significant pressure from people like Amanda who fought their corner, that actually this evidence should not be ignored, changed their guidance. , so the guidance from NICE the National Institute of Clinical Excellence now recommends that the umbilical cord should not be clamped earlier than one minute from delivery of the baby if there are no concerns over cord integrity or the baby's wellbeing.

Wow. If you look at the evidence on the timing of umbilical cord clamping, there's lots of evidence that. That it's beneficial. And in fact, if you look at the Cochrane evidence, there's no evidence that actually it worsens the outcome for the mother. So we're not seeing increasing hemorrhage rates [00:12:00] or bleeding.

And the Cochrane Review talks about cord clamping between one and three minutes, and although it seems to have made very little difference on bleeding. , there's very little evidence that it makes any difference. There is lots of evidence about important advantages of delayed cord clamping on hemoglobin. That's the molecule in the blood that carries oxygen, hemoglobin concentration, iron reserves, higher birth weight for up to six months.

So this then made me think, why have the pediatricians not been clamoring and asking for us to do later cord clamping or delayed cord clamping? And actually, I don't want to call it delayed [00:13:00] called clamping, because really what we're talking about is what's now being called optimal core clamping . So it's not that you are delaying something, which sounds like you're doing something too slowly, it's you're doing it at a better time for the mother and baby.

So when I started thinking about this and we started to introduce sometime after the birth of the baby at Cesarean birth, I expected. , the pediatricians I worked with really to be congratulating us and to be really pleased that we've made the shift in our practice and that this would be great and that, um, it would be so much more beneficial for them.

These babies would be better looked after and healthier, and we were doing a really positive thing , how naive was I? Not a bit of it. [00:14:00] So initially the pediatricians were actually really unhappy because this later cord clamping, there can be a little bit more jaundice in the neonatal period. And they started to question, why are you doing this?

We are seeing babies with jaundice this isn't a practice we want to encourage and it, we were in this really odd situation where we as obstetricians, were going to conferences and our fellow obstetricians were talking about the importance of optimal core clamping and really how we should all be changing our practice in terms of when we cut and clamp the umbilical cord, and then the very people that should be looking out for the babies were complaining to us

that we were changing our practice and that they weren't happy with it, which just felt [00:15:00] kind of the wrong way around. Very odd. So why is it so important? Well, it's becomes even more important if you are preterm. So if you are a preterm baby, , there is significant evidence that it actually makes a difference in survival.

If you look at the Cochran evidence that delayed cord clamping compared with early cord clamping meant that fewer babies died before discharge. This is preterm babies. , fewer babies had bleeding in the brain and they concluded that delayed cord clamping or optimal cord clamping reduced the risk of [00:16:00] death for babies born preterm and the early cord clamping probably causes harm.

They didn't talk about what length of delay was best, and if you've got a preterm baby, you've got to think really carefully. , you've got to be able to resuscitate the baby, um, and give it the care it needs whilst it's still attached to the mother. But that actually just needs a bit more logistical thinking through and equipment, thoughts, and a team that want to make it work.

But why? Why on earth? Why would we not give preterm babies? the best chance. Why would we immediately clamp and cut the umbilical cord? Because they need resuscitation when we know that makes a difference to their mortality. I mean, it's just mind blowing that we've been doing the wrong thing so [00:17:00] much. So there's a lot to think about here, and if you want to explore it more, there's Hannah Tizard

an amazing student midwife who founded the Blood to Baby Campaign, and she's got a great website, which I'm putting in the program notes and has lots of educational resources and things to think about, and one of the most inspiring people I've heard talk about resuscitation of a preterm baby with the umbilical cord intact is actually by Professor Andrew Weeks.

He gave a fantastic talk a few years ago to conference about this, and indeed he is working with Hannah on the Blood to Baby campaign to try and help medical professionals understand better how to do that resuscitation with the cord intact. [00:18:00] So really useful resources and things to explore. . What about the other uses of blood from the umbilical cord?

If it's not all going to the baby, some of it is left in the placental circulation. You may have heard that there are things that we could do with that. So you may have heard of stem cell collection or stem cell banking. What is that? , the blood within the umbilical cord is unique, so it contains stem cells and stem cells are incredible cells that have the ability to become almost any cell in your baby's body.[00:19:00] 

a few years ago, the thought came about that actually you could use stem cells, you could bank them and keep them frozen, and then if your baby developed some kind of health problem in the future, you could use the stem cells from the umbilical cord to help. That health concern in your child in the future.

Therefore, people started collecting and storing stem cells, and there was quite a lot of concern about this at the time with the Royal College of Midwives and the College of Obstetricians and Gynecologists, because there were concerns that if staff were trying to collect. Or maximize the collection of blood from the placenta that [00:20:00] at the time of birth they would not be caring for and looking after that mother and newborn baby.

That was the first thing. So it was agreed that NHS staff would not collect and help collect and store stem cells. The other reason that this. deemed not something we should be doing was that there was a very theoretical chance that these stem, that these stem cells could be valuable to this baby in the future.

And I must admit, I feel that a lot of these companies that do this, it feels a little bit exploitative. So you're going. Take people that are about to become parents who are already a bit anxious about the wellbeing of their baby, and are they gonna be good enough parents, and is their baby going to have some kind of [00:21:00] future health problem and, and that they have a responsibility to safeguard this.

And then you charge them money for a private company to come and collect that blood and store it for who knows how long. With a view to maybe being able to use it in some potential way in the future. But actually so far over the last, I don't know, 10, 20 years, it's not been obvious that that's actually been achieved.

So it feels like quite a difficult topic, and I must admit, if parents do ask my opinion about stem cell storage, privately I do express my view that I, I don't think it's relevant or a good idea. If you are interested in banking stem cells, [00:22:00] then actually it's much better that you have a little look at the NHS cord blood donation options because it's possible that your baby's cord blood

could be of value to someone, a child or adult with an existing disease. So it is true that stem cells and use of cord blood stem cells could be of potential benefit and can be of actual benefit to certain people with certain illnesses. And there's lots more to explore on the NHS cord blood banking website if you are interested.

But please note it does say that if you're going to do delayed cord clamping or what I would prefer to call optimal cord clamping, then this may reduce the ability of you to donate blood from the cord [00:23:00] and from the placenta and explains they need a minimum of 60 milliliters, and they usually get somewhere between 60 and 150 milliliters of cord blood

if you think about that volume, I tend to think about volumes and weights as food. That's just the way my brain works. So to me, 150 milliliters is pretty much a small tub of cream. So if I'm buying some double cream to do some cooking or pour on a dessert, the one I reach for is 150 milli. So that means that potentially we are leaving a small pot of cream worth of blood in the umbilical cord and placenta that could be in the baby.[00:24:00] 

So immediately, if you think about it like that, rather than thinking about the blood all spread out down the umbilical cord and through the placenta, . If you think about it in that little container, then immediately you can see that that's actually quite a significant volume of blood belonging to that baby.

So this brings me to my zesty bit. If you are a health professional, there is absolutely no excuse at the moment not to be doing optimal cord clamping a minimum of a minute, but. Considerably longer if you're clinically able to, for example, at a straightforward vaginal birth, there's absolutely no need to clamp and cut the umbilical cord until it's white.

The so-called wait for white, there's no need. If the baby's crying, the mum's enjoying skin to skin with her baby, she's not bleeding. [00:25:00] Absolutely no need to. . And likewise, if we're doing an assisted vaginal birth and the baby's in good condition and everything's gone well, equally the same, and still I find myself having to put my hand out to stop junior doctors or midwives picking up the clamps to clamp the umbilical cord and saying, wait, you don't need to do that.

Don't need to do that yet. There's no need. We're still very programmed into cutting and clamping, and I would say we've moved from cutting and clamping immediately. That is early to doing it after a minute. And the minute thing has come from doing optimal core clamping or delayed core clamping at cesarean birth, and that's cesarean.

A minute may be more [00:26:00] appropriate because the womb is open and while the womb is open, the woman will be losing blood, and therefore we don't necessarily want to delay closing the womb by having the baby attached for many minutes. So we've settled at a minute as kind of standard, but don't then extrapolate that minute to vaginal birth where the womb isn't open.

That isn't the case. That risk isn't there

and even at cesarean birth, sometimes in that minute, if the baby's in good condition and everything's going well, I will either clamp the blood vessels to prevent bleeding and we can wait longer. Or sometimes in that time, the placenta will separate and I can literally hand the whole placenta with the cord intact, still attached to the baby, to the midwife, and.

the woman can do whatever she wants. She can wait for white if she wants to. [00:27:00] So as health professionals, we must stop clamping and cutting the umbilical cord as an automatic thing. . And we really need to work hard now with our neonatal colleagues to think about how we do that for preterm babies, how we enable that early resuscitation of a preterm baby with the umbilical cord intact, because it will save lives literally.

And remember I said our pediatricians were skeptical. us doing optimal cord clamping and the effects this was having on babies and the their worries about jaundice. Well, we tried to talk to them about preterm resuscitation with an intact umbilical cord, and they were reluctant. And now a year or two later, they're coming to us saying, how can we do this?

Can we facilitate this? [00:28:00] So it's something that just has to happen if you are a woman giving birth or a parent whose partner is giving birth, make it clear to people in your birth plan what you want to happen and that it's important to you. If it is not to immediately clamp and cut the umbilical cord and understand what the pros and cons.

of private stem cell banking, and I would suggest don't do it because that blood, rather than being in a freezer somewhere stored for your baby at some potential point in the future that might never be used, could be in your baby's body immediately after birth. And for the first six months of its life doing what it's actually designed to.

and if you are [00:29:00] very altruistic and you want to think about donating your cord blood, then feel free. But actually the best place for the cord blood to be is within your baby.