Prof. Dr. med. Richard Berger heads the Department of Obstetrics and Gynecology at Marienhaus Klinikum St. Elisabeth Neuwied and provides comprehensive, state-of-the-art care throughout pregnancy. As an experienced perinatal specialist, he supports patients both during and after childbirth and also possesses in-depth knowledge in the field of oncology. Under his leadership, the department has developed into a recognized institution that provides patients with the highest level of care. Prof. Dr. Berger places particular emphasis on the human aspects of medical care and on the excellent professional expertise of his team. The focus is on individualized patient care and the development of tailored treatment methods.
The clinic offers a wide range of services, from perinatal medicine and obstetrics to gynecological surgery and the treatment of incontinence. Even complex pregnancies are carefully managed thanks to collaboration with specialists and modern diagnostic procedures. The Perinatal Center is renowned far beyond the region and offers the highest standards of care, particularly for high-risk and multiple pregnancies. Prof. Dr. Berger has also founded his own research group dedicated to the prediction and prevention of preterm births and coordinated the guideline “Prevention and Treatment of Preterm Birth” for Germany, Austria, and Switzerland.
His expertise in minimally invasive gynecological surgery enables gentle procedures that promote rapid recovery for patients. In addition to gynecological surgery, he also heads the certified Gynecologic Cancer Center and the Breast Center, both of which are renowned for their first-class diagnostics and treatment. During pregnancy, the umbilical cord plays a crucial role, as it supplies the fetus with vital nutrients and oxygen. During childbirth, it is essential for the newborn’s transition by continuing to supply oxygen until the baby can breathe on its own.
The editorial team at Leading Medicine Guide spoke with Prof. Dr. Berger to learn more about the important topic of umbilical cord management.
Pregnancy is a transformative phase in a woman’s life, marked by biological and emotional changes. The umbilical cord plays a central role in this process, serving as a vital link between mother and child. It not only supplies the fetus with nutrients and oxygen but also supports the newborn’s transition into the world outside the womb. The special significance of the umbilical cord is evident in its essential role in the healthy growth and smooth development of the unborn child. Umbilical cord management encompasses the various medical procedures and decisions regarding the handling of the umbilical cord immediately after a child’s birth. The goal of umbilical cord management is to establish the best possible foundation for the newborn’s health while also taking advantage of any potential medical benefits. The placenta is connected to the fetus via the umbilical cord. The umbilical cord contains one umbilical vein and two umbilical arteries. The umbilical vein supplies oxygen-rich blood, while the two umbilical arteries carry the fetus’s oxygen-poor blood back to the placenta.
The health of the umbilical cord during pregnancy and childbirth is influenced by a variety of factors that encompass both maternal and fetal aspects.
“Little research has been done on the health of the umbilical cord, so there is little to say about it. This is because the umbilical cord has never really been considered in isolation. One aspect that is currently emerging in the discussion is a more intensive focus on the transition phase—from the time in the womb to the first minutes after birth. And to do that, one must first understand how the fetal circulatory system works. This is because it does not function like an adult circulatory system. Nor is the placenta simply an organ that is “switched on.” Oxygen-rich blood from the left ventricle is pumped through the aorta into the fetus’s body to supply the organs and tissues with oxygen and nutrients. The oxygen-poor blood then flows back to the placenta via the umbilical arteries, where the exchange of oxygen and carbon dioxide takes place,” Prof. Dr. Berger begins our conversation and, to provide a better overall understanding, explains the two different circulatory systems in adults:
“In adults, there are two main circulatory systems that work closely together: the systemic circulation and the pulmonary circulation. The systemic circulation begins in the left ventricle of the heart, which pumps oxygen-rich blood through the aorta to the entire body. In the capillaries of the organs, oxygen is released to the cells, and carbon dioxide and other waste products are absorbed. The blood, now low in oxygen, flows back through the vena cavae to the right atrium of the heart. The pulmonary circulation begins in the right ventricle, which pumps oxygen-poor blood through the pulmonary arteries into the lungs. Gas exchange takes place in the alveoli: carbon dioxide is released and oxygen is absorbed. The oxygen-rich blood then flows back through the pulmonary veins into the left atrium of the heart. From there, the blood is pumped back into the systemic circulation. Both circulatory systems work seamlessly together to continuously supply the body with oxygen and remove carbon dioxide. The pumping capacity of the left and right sides of the heart is equal in this process; otherwise, it wouldn’t work, and blood would back up somewhere. It’s different in the fetus. There, the pumping capacity of the right side of the heart is significantly greater than that of the left side because the fetus isn’t breathing. It therefore wouldn’t make much sense to supply the lungs with a high volume of blood. Nature is clever here because it adapts supply to demand,” he adds,
“In the fetal circulatory system, part of the blood pumped from the right ventricle of the heart into the pulmonary artery is routed directly into the aorta via the ductus arteriosus (a temporary connection between the pulmonary artery and the aorta). This bypass is necessary because the fetus’s lungs are not yet ventilated and therefore cannot participate in the blood circulation. The blood is thus routed directly past the left ventricle. Consequently, the pumping capacity of the right side of the heart is greater than that of the left side. The small amount of blood that then flows back from the lungs into the left side of the heart is recirculated back into the systemic circulation. Arteries branch off from the pelvic arteries and enter the placenta, where blood exchange and oxygenation of the blood take place; this oxygen-rich blood is then returned to the right heart, passing by the liver, through the right atrium, through the foramen ovale into the left atrium, then into the left ventricle, and finally, primarily, directly to the brain. This is all quite complex, but that is what makes fetal circulation so special. Because just a few minutes after the child is born, a transition takes place.”
An average of 1,800 children are born each year at the Marienhaus Klinikum St. Elisabeth Neuwied.
Umbilical cord management immediately after birth plays a crucial role in the long-term health of the newborn. An important aspect of this is the timing of cord clamping.
“Studies have shown that delayed cord clamping—in which the umbilical cord is not cut until 1–3 minutes after birth—offers numerous health benefits. The circulation, which after birth still passes through the placenta, should not be interrupted too early. Here’s what happens: If umbilical cord clamps are applied immediately after birth, it’s as if the fetus were still in the uterus and the umbilical cord were compressed, which would trigger an immediate drop in the infant’s heart rate. This is because clamping the umbilical cord causes systemic blood pressure to rise, since the entire downstream circulation beyond the placenta is cut off. This activates the fetus’s baroreceptors (specialized sensors located in the walls of certain blood vessels that monitor blood pressure), which are connected to the vagus nerve (one of the most important nerves in the human body, responsible for a healthy cardiovascular system), and this then leads to fetal bradycardia (a slowed heart rate). Children continue to benefit from delayed cord clamping even months or years later, in part because their iron stores are well-filled. There is also a randomized study by Andersson (Sweden) from 2014 in which children who underwent delayed cord clamping were examined four years after birth. The study demonstrated that these children—especially the boys—exhibited better neuromotor development compared to children whose umbilical cords were clamped immediately. “In this respect, there is already evidence that delayed cord clamping can have positive effects later in life,” explains Prof. Dr. Berger.
In addition to the medical benefits, umbilical cord management also plays a role in the emotional and psychological adjustment of both mother and child. A gentle and well-planned cord-clamping procedure can help ease the transition for both, which can have a positive effect on bonding and breastfeeding.
Current recommendations and guidelines emphasize the benefits of delayed cord clamping after birth.
The World Health Organization (WHO), the American College of Obstetricians and Gynecologists (ACOG), and the International Federation of Gynecology and Obstetrics (FIGO) recommend clamping the umbilical cord at least 1–3 minutes after the baby is born. “The importance of these precious minutes shortly after birth has been known for decades, but it has never really been given proper attention in hospitals. However, this topic has come to the forefront in recent years, particularly in the context of the discussion surrounding preterm births. When dealing with low-birth-weight preterm infants weighing 600–700 grams, two-thirds of whom are delivered by cesarean section, you might think you can’t just let the baby lie there for 2–3 minutes after birth until the umbilical cord has finished pulsating, because the preterm infant could get cold. The instinct is to clamp the cord immediately so the pediatrician can attend to the baby. However, if you let the umbilical cord pulsate out, there is another flow of blood from the placenta to the baby. This increases the newborn’s blood volume by 25–30%. And it’s believed that this blood benefits the baby, making the circulation more stable, improving iron levels, and so on. Then people thought they could apply pressure to the umbilical cord multiple times to deliver even more blood to the fetus. And this was done for years with premature infants. In 2018, a prospective study was launched that compared cord clamping versus allowing the umbilical cord to pulsate in these premature infants, particularly those born before 28 weeks of gestation. It was found that when the umbilical cord was squeezed, the rate of cerebral hemorrhage in these infants increased by a factor of 4 to 5. This is easy to explain. When the cord is swabbed, a large volume of blood is introduced into the infant within a few seconds, which drives up systemic blood pressure. However, these infants have virtually no autoregulation in their cerebral vessels, and the blood volume rushes into the brain—particularly into the germinal matrix, which has fragile blood vessels that then rupture. “That is why the guidelines for preterm births now specify that the umbilical cord must not be clamped in cases of preterm birth before 28 weeks,” explains Prof. Dr. Berger.
Delayed cord clamping refers to waiting at least one minute after birth before applying the umbilical cord clamp, although it is preferable to wait a little longer. Delayed cord clamping should not be performed if the placenta has detached prematurely.
“Even compromised infants may potentially benefit from delayed umbilical cord clamping due to the increased blood supply. We are in the process of fully integrating this practice into our hospital’s protocols. There is certainly still much that needs to be improved and further refined. For example, there is still a lack of prospective randomized studies on infants who require resuscitation after birth. This needs to be discussed further within a scientific framework,” explains Prof. Dr. Berger, and with that, we conclude our conversation.
Thank you very much, Professor Dr. Berger, for this informative conversation!
Related links:
https://register.awmf.org/assets/guidelines/015-083l_S3_Vaginale-Geburt-am-Termin_2021-03.pdf
