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BMJ. 2007 March 31; 334(7595): 651.
PMCID: PMC1839226
Cord Clamping

NICE is encouraging artificial intervention

David J R Hutchon, consultant obstetrician

As well as seeming to discourage the detection of postpartum depression,1 the National Institute for Health and Clinical Excellence (NICE) is also encouraging the artificial intervention of immediate cord clamping.2

The NICE guideline for caesarean section includes a section on cord clamping. It states a number of “suggested” benefits and a number of “possible” harms. The reference is a review paper in a midwifery journal.3 This review clearly provides evidence for the benefits, not simply a “suggestion,” and clearly disputes any evidence of harm from polycythemia, hyperviscosity, or hyperbilirubinaemia..

The NICE draft guideline on intrapartum care never mentions cord clamping (www.nice.org.uk/page.aspx?o=334322). The authors recognise that the major rapid physiological changes that take place enable the baby to adapt to life outside the womb. How rapidly should we expect these changes to take place? Is it reasonable to expect these physiological changes to occur within a few seconds and at the whim of a bystander? Active management of the third stage is considered to be an established part of good intrapartum care, and early cord clamping an integral part of it.4

How precise does the practice need to be? The timing of the oxytocic agent varies among the studies and in different parts of the world. There is no real logic for incorporating early cord clamping in a strategy to reduce post-partum haemorrhage. Removing the clamp and draining the residual placental blood seems to shorten the third stage.3 This is recommended practice in rhesus negative women, in an effort to reduce the risk of fetomaternal haemorrhage.5 It is therefore totally illogical to recommend immediate cord clamping and cutting, followed by drainage of the residual placental blood. This is blood that is physiogically required by the newborn baby. It would be better to “drain the placenta” into the newborn baby or at least provide the baby with the amount of blood that it requires. Any residual blood at that stage can be allowed to drain away.

Notes

Competing interests: None declared.

References

1. Coyne JC, Mitchell AJ. NICE may be discouraging detection of postpartum depression. BMJ 2007;334:550-a. (17 March.) doi:10.1136/bmj.39150.424896.BE.
2. Kent A What's new in the other journals? BJOG 2007. 114:379-80.
3. Mercer JS. Current best evidence: a review of the literature on umbilical cord clamping. J Midwifery Women's Health 2001;46:402–14. [PubMed]
4. Soltani H, Dickinson F, Symonds I. Placental cord drainage after spontaneous vaginal delivery as part of the management of the third stage of labour. Cochrane Database Syst Rev 2005. (4): CD004665.
5. Prendiville W, Elbourne D. Care during the third stage of labour. In: Chalmers I, Enkin M, Keirse MJNC, eds. Effective care in pregnancy and childbirth Oxford: Oxford University Press, 1989:1145-69.

Articles from The BMJ are provided here courtesy of BMJ Publishing Group