Compilation of additional Research in Delayed verses Immediate
Clamping and Cutting of Babies’ Umbilical Cords.
Parents and health providers all wish for the same thing, optimal
health, intelligence and longevity for the mothers and babies in their
care. The following is a review of the more current research on the
effects of delayed verses immediate clamping and cutting of babies’
umbilical cords.
BMJ 2011;343:d7157 doi: 10.1136/bmj.d7157 (Published 15 November 2011) Page 1 of 12
Research
RESEARCH
Effect of delayed versus early umbilical cord clamping on neonatal
outcomes and iron status at 4 months: a randomised controlled trial
12
Ola Andersson consultant in neonatology , Lena Hellströ m-Westas professor of perinatal
2
1
medicine , Dan Andersson head of departments of paediatrics, obstetrics and gynaecology ,
3
Magnus Domellö f associate professor, head of paediatrics
1
Department of Paediatrics, Hospital of Halland, Halmstad, SE-301 85 Halmstad, Sweden; 2Department of Women’s and
Children’s Health, Uppsala University, SE-751 85 Uppsala, Sweden; 3Department of Clinical Sciences, Paediatrics, Umeå
University, SE-901 85 Umeå , Sweden
Conclusions and policy implications
We conclude that delayed cord clamping, in this randomised controlled trial, resulted in improved ferritin levels
and reduced the prevalence of iron deficiency at 4 months of age. Delayed clamping also reduced the prevalence
of neonatal anaemia at 2 days of age without increasing the rate of respiratory symptoms or need for
phototherapy in this sample of 382 full term infants born in a high income country. Two meta-analyses of
clamping studies performed in low or middle income countries with a high general prevalence of anaemia found
similar effects on ferritin as we did and concluded that this effect is clinically relevant and should lead to a
change in practice.16 22 Iron deficiency even without anaemia has been associated with impaired development
among infants. Our results suggest that delayed cord clamping also benefits infant health in regions with a
relatively low prevalence of iron deficiency and should be considered as standard care for full term deliveries
after uncomplicated pregnancies. Further studies are needed to explore long term health effects of delayed and
early cord clamping.
…Our results therefore strongly suggest that delayed cord clamping is not associated with any increase in the
need of phototherapy in term infants, in agreement with the recent meta-analysis in JAMA.22
22 Hutton EK, Hassan ES. Late vs early clamping of the umbilical cord in full-term neonates: systematic review and meta-analysis of controlled trials. JAMA
2007;297:1241-52.
Timing of umbilical cord-clamping and infant anaemia: the role of
maternal anaemia
Brittany Blouin1,2, Mary E. Penny4, Mathieu Maheu-Giroux2, Mart ́ın
Casap ́ıa5, Eder Aguilar6, Herma ́nn Silva6, Hilary M. Creed-Kanashiro4,
Serene A. Joseph1,2, Anita Gagnon3, Elham Rahme2, Theresa W.
Gyorkos1,2
1
Department of Epidemiology, Biostatistics and Occupational Health, McGill University
Paediatrics and International Child Health 2013 VOL. 33 NO. 2 79
1
Results: The prevalence of maternal anaemia (Hb ,11.0 g/dl) at delivery was 22%. Infant
haemoglobin levels at 4 and 8 months of age were 10.4 g/dl and 10.3 g/dl, respectively. Infant
haemoglobin levels did not differ significantly between infants born to anaemic mothers and those
born to non-anaemic mothers at either 4 or 8 months of age. However, the association between the
timing of cord-clamping and infant anaemia was modified by the mother’s anaemia status. Significant
benefits of delayed cord-clamping in preventing anaemia were found in infants born to anaemic
mothers at both 4 months (aOR50.59, 95% CI 0.36–0.99) and 8 months (aOR50.38, 95% CI 0.19–
0.76) of age.
Conclusion: The study contributes additional evidence in support of delayed cord-clamping. This
intervention is likely to have most public health impact in areas with a high prevalence of anaemia
during pregnancy.
Effect of timing of umbilical cord clamping of term infants
on maternal and neonatal outcomes (Review)
McDonald SJ, Middleton P, Dowswell T, Morris PS
Editorial group: Cochrane Pregnancy and Childbirth Group.
Publication status and date: New search for studies and content updated (conclusions changed), published in
Issue 7, 2013. Review content assessed as up-to-date: 14 March 2013.
Neonatal outcomes: There were no significant differences between early and late clamping for the primary
outcome of neonatal mortality (RR 0.37, 95% CI 0.04 to 3.41, two trials, 381 infants with a LCER of ~1%), or for
most other neonatal morbidity outcomes, such as Apgar score less than seven at five minutes or admission to
the special care nursery or neonatal intensive care unit. Mean birthweight was significantly higher in the late,
compared with early, cord clamping (101 g increase 95% CI 45 to 157, random-effects model, 12 trials, 3139
infants, I2 62%). Fewer infants in the early cord clamping group required phototherapy for jaundice than in the
late cord clamping group (RR 0.62, 95% CI 0.41 to 0.96, data from seven trials, 2324 infants with a LCER of
4.36%, I2 0%). Haemoglobin concentration in infants at 24 to 48 hours was significantly lower in the early cord
clamping group (MD -1.49 g/dL, 95% CI -1.78 to -1.21; 884 infants, I2 59%). This difference in haemoglobin
concentration was not seen at subsequent assessments. However, improvement in iron stores appeared to
persist, with infants in the early cord clamping over twice as likely to be iron deficient at three to six months
compared with infants whose cord clamping was delayed (RR 2.65 95% CI 1.04 to 6.73, five trials, 1152 infants,
I2 82%). In the only trial to report longer-term neurodevelopmental outcomes so far, no overall differences
between early and late clamping were seen for Ages and Stages Questionnaire scores.
Authors’ conclusions
A more liberal approach to delaying clamping of the umbilical cord in healthy term infants appears to be
warranted, particularly in light of growing evidence that delayed cord clamping increases early haemoglobin
concentrations and iron stores in infants. Delayed cord clamping is likely to be beneficial as long as access to
treatment for jaundice requiring phototherapy is available.
PLAIN LANGUAGE SUMMARY
Effect of timing of umbilical cord clamping of term infants on mother and baby outcomes
At the time of birth, the infant is still attached to the mother via the umbilical cord, which is part of the placenta.
The infant is usually separated from the placenta by clamping the cord. This clamping is one part of the third
stage of labour (the time from birth of the baby until delivery of the placenta) and the timing can vary according
to clinical policy and practice. Although early cord clamping has been thought to reduce the risk of bleeding after
birth (postpartum haemorrhage), this review of 15 randomised trials involving a total of 3911 women and
infant pairs showed no significant difference in postpartum haemorrhage rates when early and late cord
clamping (generally between one and three minutes) were compared. There were, however, some potentially
important advantages of delayed cord clamping in healthy term infants, such as higher birthweight, early
haemoglobin concentration, and increased iron reserves up to six months after birth. These need to be balanced
against a small additional risk of jaundice in newborns that requires phototherapy.
DISCUSSION
2
The importance of delayed cord clamping for *Aboriginal babies: A life§
enhancing advantage
Rosemary Weckert a, Heather Hancock b,*
a
Clinical Midwifery, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
University of South Australia, School of Nursing and Midwifery, GPO Box 2471, Adelaide, South Australia 5001, Australia
Received 10 July 2008; received in revised form 3 September 2008; accepted 4 September 2008
b
Summary Third stage management has typically focused on women and postpartum haemor- rhage. Clamping and cutting the
umbilical cord following the birth of the baby has continued to be a routine part of this focus. Active versus physiological
management of third stage is generally accepted as an evidence-based plan for women to avoid excessive blood loss. Other
considera- tions around this decision are rarely considered, including the baby’s perspective. This paper provides a review of
the literature regarding timing of clamping and cutting of the umbilical cord and related issues, and discusses the
consequences for babies and in particular *Aboriginal babies. Iron stores in babies are improved (among other important
advantages) if the cord is left to stop pulsating for 3 min before being clamped. Such a simple measure of patience and
informed practice can make a long lasting difference to a baby’s health and for Aboriginal babies this advantage can be critical
in the short and the long term for their development and wellbeing. To achieve much needed reductions in infancy anaemia
and essential increases in infant survival, delayed cord clamping and cutting is recommended for all Aboriginal babies.
# 2008 Australian College of Midwives. Published by Elsevier Australia (a division of Reed International Books Australia Pty
Ltd). All rights reserved.
Conclusion
Clamping and cutting of the umbilical cord at 3 min following birth (including the need for resuscitation which
can be conducted with the baby between the mother’s legs while the cord is still patent and attached) is a safe
option for optimal placental transfusion regardless of the baby’s weight. This practice is completely cost
effective (in the immediate and longer term) non-intervening and not harmful for mother or baby. An oxytocic
could be administered if necessary to decrease maternal blood loss without needing to clamp and cut the cord.
Every baby, and most importantly every Aboriginal baby, regardless of their gestation should have the right and
significant advantages of their cord being clamped and cut 3 min after their birth to achieve much needed
reductions in infancy anaemia and essential increases in infant survival. Such a simple measure of patience and
informed practice with such life enhancing advantages for all babies, especially Aboriginal babies, is vital.
Keeping the cord patent and extending the time before cord clamping and cutting for at least several minutes
after the birth of the baby, or preferably until cord pulsations cease, is recommended for all Aboriginal babies as
an effective primary health strategy by midwives and doctors.
CLINICAL ROUNDS
Delayed Clamping of the Umbilical Cord: A Review With
Implications for Practice
Gina Eichenbaum-Pikser, CNM, MSN and Joanna S. Zasloff, CNM, MSN
POTENTIAL ADVERSE EFFECTS OF DELAYED CORD CLAMPING
It has been postulated that delayed cord clamping may increase rates of hyperbilirubinemia,
polycythemia, and transient tachypnea in the newborn or maternal hemor- rhage. However, delayed
cord clamping has never been proven to increase the rate of neonatal symptomatic disease or
3,6,9
maternal blood loss.
POTENTIAL ADVERSE EFFECTS OF DELAYED CORD CLAMPING
It has been postulated that delayed cord clamping may increase rates of hyperbilirubinemia,
polycythemia, and transient tachypnea in the newborn or maternal hemor- rhage. However, delayed
cord clamping has never been proven to increase the rate of neonatal symptomatic disease or
3,6,9
maternal blood loss.
Hyperbilirubinemia
The potential for developing hyperbilirubinemia is another issue of concern. In their systematic
2
review, using data from 1009 infants, Hutton and Hassan found no signifi- cant difference in mean
serum bilirubin levels nor an increased risk of neonatal jaundice within the first 24 hours of life
associated with late clamping (RR, 1.35; 95% CI, 1.00–1.81). One of their included studies reported a
mean bilirubin level of 192.8 mmol/L in the late clamp- ing group versus 175.7 mmol/L in the early
clamping group. Another trial found a mean bilirubin of 99.18 mmol/L in the late clamping group and
3
2
104.31 mmol/L in the early clamping group. They also report no signifi- cant difference between the
groups in risk of jaundice at 3 to 14 days after birth nor in the percentage of infants with bilirubin
levels exceeding 256.5 mmol/L (15 g/dL) requiring phototherapy (RR, 1.27; 95% CI, 0.76–2.10; 1
2
trial; n = 332). Furthermore, using 3 RCTs (n = 111), Rabe et al. found that none of the neonates with
6
elevated bilirubin levels required phototherapy treatment or exchange transfusions.
3
McDonald and Middleton’s Cochrane metaanalysis found that the difference between early and late
cord clamping for clinical jaundice did not reach statistical significance (RR, 0.83; 95% CI, 0.65–1.06;
n = 1828). However, significantly fewer infants in the early cord clamping group required
phototherapy for jaundice than in the late clamping group (RR, 0.59; 95% CI, 0.38–0.92; n = 1762).
They report that 3% of infants in the early group and 5% of infants in the late group required
3
therapy, a risk difference of 2%.
SPECIAL CONSIDERATIONS
Delayed Cord Clamping for Preterm Infants
Delayed cord clamping has been shown to be especially beneficial for preterm infants. In
industrialized countries, 60% to 80% of preterm infants born before 32 weeks of gestation require
6
blood transfusions. Increases in Hgb levels and RBC volume are associated with a reduction in the
6,8
need for blood transfusion, either for anemia or low blood pressure, in the first 6 weeks of life. In
addi-tion, the risk of intraventricular hemorrhage, a significant cause of neonatal morbidity and
6
mortality in premature in- fants, is reduced with the use of delayed cord clamping. In an RCT of 37
12
premature infants at 34 to 37 weeks of ges- tation, Ultee et al. found that infants with delayed cord
clamping had significantly higher Hgb levels than those with immediate cord clamping (13.4 mmol/l
[1.9], n = 19 versus 11.1 mmol/l [1.7], n = 18) at 1 hour postpartum and continued to have higher
12
Hgb levels up to 10 weeks of age (6.7 mmol/l [0.75], n = 19 versus 6.0 mmol/l [0.65], n = 18).
12
Interestingly, there was no difference between the groups in ferritin levels at 10 weeks. Ultee et al.
found no difference between the delayed and immediate groups in terms of mean glucose levels and
the number of infants born with a blood glucose of < 2.0 mmol/l.
324
Volume 54, No. 4, July/August 2009
13
Strauss et al. found that circulating RBC volume/mass increased after delayed cord clamping (74.4
mL/kg) ver- sus immediate cord clamping (62.7 mL/kg) in preterm infants. Interestingly, the
increase in RBC volume/mass was not observed immediately in the neonates with delayed cord
clamping, but it lead to significantly higher Hct levels by day 7 that continued throughout the first 28
days of life.
Delayed Cord Clamping in Developing Countries
Delayed cord clamping may be particularly beneficial to newborns in developing countries and
8
resource-poor envi- ronments because it is a safe and inexpensive way to pre- vent infant anemia.
Particularly in countries where severe anemia of the mother and newborn is common, and in
countries where blood transfusions are not readily avail- able, delayed cord clamping should be
considered for all infants regardless of gestational age. Perhaps in these settings, using gravity for
added blood transfusion after the cord has stopped pulsing would be particularly benefi- cial in order
to ensure the maximum amount of placental blood is reaching the newborn.
Lotus Birth
Lotus birth or ‘‘umbilical nonseverance’’ is a practice where the umbilical cord is never cut from the
placenta. Many cultures around the world view the placenta with high spiritual regard, and the
practice is based on the belief that allowing the baby to stay attached to the placenta is both
14
nonviolent and allows for an easier transition into life for the newborn. The placenta is cleaned and
covered with a mixture of salts and herbs and wrapped in a cloth until it naturally disintegrates in
14
about 3 to 7 days. It is more difficult to pass the baby around, therefore decreas- ing exposure to
infection. We could find no scientific stud- ies evaluating the benefits of this practice.
Cord Blood Banking
Cord blood banking may conflict with practicing delayed cord clamping because blood banking
10
facilities require a substantial amount of umbilical blood to ensure proper stem cell harvesting. In a
4
conversation with two reputable cord blood banking companies, Viacord and CBR, no recommendations were given concerning the number of units of cord blood needed for adequate
15
banking. In order to collect 100 million stem cells, which is the minimum amount of cells needed for
transplant, both Viacord and CBR recommend that practitioners immediately clamp the cord. Neither
company was opposed to delayed cord clamping but explained that delayed cord clamping may
lower the stem cell count leaving it unusable (personal com- munication; Fred Foster at Viacord and
Fred Ganzales at CBR, October 27, 2008). Because immediate cord clamping will decrease the
amount of blood transfused to the newborn, increasing the baby’s chances of developing anemia, it is
important that midwives and parents evaluate the needs of the newborn when deciding to bank cord
10
blood.
IMPLICATIONS FOR CLINICAL PRACTICE
The practice of delayed cord clamping has shown many benefits to the newborn with no
documentation of signifi- cant risk. As such, it is incumbent upon clinicians to edu- cate their clients
about the physiologic impact of the practice of delayed cord clamping and to involve women in this
decision, as we do in so many other clinical scenar- ios.
BMJ. 2011 Nov 15;343:d7157. doi: 10.1136/bmj.d7157.
Effect of delayed versus early umbilical cord clamping on
neonatal outcomes and iron status at 4 months: a
randomised controlled trial.
Andersson O, Hellström-Westas L, Andersson D, Domellöf M.
Source
Department of Paediatrics, Hospital of Halland, Halmstad, SE-301 85 Halmstad, Sweden.
ola.k.andersson@regionhalland.se
Abstract
OBJECTIVE:
To investigate the effects of delayed umbilical cord clamping, compared with early clamping, on infant iron status at 4 months of
age in a European setting.
DESIGN:
Randomised controlled trial.
SETTING:
Swedish county hospital.
PARTICIPANTS:
400 full term infants born after a low risk pregnancy.
INTERVENTION:
Infants were randomised to delayed umbilical cord clamping (≥ 180 seconds after delivery) or early clamping (≤ 10 seconds after
delivery).
MAIN OUTCOME MEASURES:
Haemoglobin and iron status at 4 months of age with the power estimate based on serum ferritin levels. Secondary outcomes
included neonatal anaemia, early respiratory symptoms, polycythaemia, and need for phototherapy.
RESULTS:
At 4 months of age, infants showed no significant differences in haemoglobin concentration between the groups, but infants
subjected to delayed cord clamping had 45% (95% confidence interval 23% to 71%) higher mean ferritin concentration (117 μg/L
v 81 μg/L, P < 0.001) and a lower prevalence of iron deficiency (1 (0.6%) v 10 (5.7%), P = 0.01, relative risk reduction 0.90;
number needed to treat = 20 (17 to 67)). As for secondary outcomes, the delayed cord clamping group had lower prevalence of
neonatal anaemia at 2 days of age (2 (1.2%) v 10 (6.3%), P = 0.02, relative risk reduction 0.80, number needed to treat 20 (15 to
111)). There were no significant differences between groups in postnatal respiratory symptoms, polycythaemia, or
hyperbilirubinaemia requiring phototherapy.
CONCLUSIONS:
Delayed cord clamping, compared with early clamping, resulted in improved iron status and reduced prevalence of iron deficiency
at 4 months of age, and reduced prevalence of neonatal anaemia, without demonstrable adverse effects. As iron deficiency in
infants even without anaemia has been associated with impaired development, delayed cord clamping seems to benefit full term
infants even in regions with a relatively low prevalence of iron deficiency anaemia. Trial registration Clinical Trials NCT01245296.
5
J Pediatr. 2007 Nov;151(5):506-12. Epub 2007 Sep 17.
Early umbilical cord clamping contributes to elevated blood
lead levels among infants with higher lead exposure.
Chaparro CM, Fornes R, Neufeld LM, Tena Alavez G, Eguía-Líz Cedillo
R, Dewey KG.
Source
Department of Nutrition, Program in International and Community Nutrition, University of
California, Davis, California 95616-8669, USA.
Abstract
OBJECTIVE:
To investigate whether infant iron status, modified by umbilical cord clamping time and infant feeding mode, affected infant blood
lead concentration at 6 months of age.
STUDY DESIGN:
Participants were a subset of women and their infants randomized to receive early (10 seconds) or delayed (2 minutes) umbilical
cord clamping and were monitored to 6 months postpartum in Mexico City. Iron and lead status was analyzed in maternal,
placental, and 6-month infant blood samples. Baseline maternal lead exposure data and infant feeding data at 2, 4, and 6 months
were collected.
RESULTS:
In the total sample, maternal blood lead concentration, infant ferritin, and breast-feeding practices predicted infant blood lead
concentration. Among infants with higher placental blood lead concentration and breast-fed infants not receiving any iron-fortified
formula or milk at 6 months, early clamping increased infant blood lead concentration, an effect mediated in part via decreased
infant iron status.
CONCLUSIONS:
Early cord clamping, by decreasing infant iron status, contributes to higher blood lead concentrations at 6 months of age among
infants at high risk.
Indian Pediatr. 2002 Feb;39(2):130-5.
Effect of delayed cord clamping on iron stores in infants
born to anemic mothers: a randomized controlled trial.
Gupta R, Ramji S.
Source
Neonatal Division, Department of Pediatrics, Maulana Azad Medical College, New Delhi 110 002,
India.
Abstract
OBJECTIVE:
To study the effects of cord clamping on iron stores of infants born to anemic mothers at 3 months of age.
DESIGN:
Randomized controlled trial.
SETTING:
Teaching hospital.
METHODS:
Infants born to mothers with hemoglobin (Hb)<100 g/L were randomized at delivery to either immediate cord clamping (early
group) or cord clamping delayed till descent of placenta into vagina (delayed group). The outcome measures were infant's
hemoglobin and serum ferritin 3 months after delivery.
RESULTS:
There were 102 neonates randomized to early (n = 43) or delayed cord clamping (n = 59). The groups were comparable for
maternal age, parity, weight and supplemental iron intake, infant s birth weight, gestation and sex. The mean infant ferritin and Hb
6
at 3 months were significantly higher in the delayed clamping group (118.4 microg/L and 99 g/L) than in the early clamping group
(73 microg/L and 88 g/L). The mean decrease in Hb (g/L) at 3 months adjusted for co-variates was significantly less in the delayed
clamping group compared to the early clamping group (-1.09, 95% CI-1.58 to -0.62, p >0.001). The odds for anemia (<100 g/L) at
3 months was 7.7 (95% CI 1.84-34.9) times higher in the early compared to the delayed clamping group.
CONCLUSION:
Iron stores and Hb in infancy can be improved in neonates born to anemic mothers by delaying cord clamping at birth.
Acta Obstet Gynecol Scand. 2013 May;92(5):567-74. doi: 10.1111/j.1600-0412.2012.01530.x.
Epub 2012 Oct 17.
Effects of delayed compared with early umbilical cord
clamping on maternal postpartum hemorrhage and cord
blood gas sampling: a randomized trial.
Andersson O, Hellström-Westas L, Andersson D, Clausen J, Domellöf M.
Source
Department of Pediatrics, Hospital of Halland, Halmstad Department of Women's and Children's
Health, Uppsala University, Uppsala, Sweden. ola.k.andersson@regionhalland.se
Abstract
OBJECTIVE:
To investigate the effect of delayed cord clamping (DCC) compared with early cord clamping (ECC) on maternal postpartum
hemorrhage (PPH) and umbilical cord blood gas sampling.
DESIGN:
Secondary analysis of a parallel-group, single-center, randomized controlled trial.
SETTING:
Swedish county hospital.
POPULATION:
382 term deliveries after a low-risk pregnancy.
METHODS:
Deliveries were randomized to DCC (≥180 seconds, n = 193) or ECC (≤10 seconds, n = 189). Maternal blood loss was estimated
by the midwife. Samples for blood gas analysis were taken from one umbilical artery and the umbilical vein, from the pulsating
unclamped cord in the DCC group and from the double-clamped cord in the ECC group. Samples were classified as valid when
the arterial-venous difference was -0.02 or less for pH and 0.5 kPa or more for pCO2 . Main outcome measures. PPH and
proportion of valid blood gas samples.
RESULTS:
The differences between the DCC and ECC groups with regard to PPH (1.2%, p = 0.8) and severe PPH (-2.7%, p = 0.3) were
small and non-significant. The proportion of valid blood gas samples was similar between the DCC (67%, n = 130) and ECC
(74%, n = 139) groups, with 6% (95% confidence interval: -4%-16%, p = 0.2) fewer valid samples after DCC.
CONCLUSIONS:
Delayed cord clamping, compared with early, did not have a significant effect on maternal postpartum hemorrhage or on the
proportion of valid blood gas samples. We conclude that delayed cord clamping is a feasible method from an obstetric
perspective.
Trop Med Int Health. 2007 May;12(5):603-16.
Delayed cord clamping and haemoglobin levels in infancy: a
randomised controlled trial in term babies.
van Rheenen P, de Moor L, Eschbach S, de Grooth H, Brabin B.
7
Source
Department of Paediatrics, Paediatric Gastroenterology, University Medical Centre, Groningen,
The Netherlands. p.f.vanrheenen@gmail.com
Abstract
OBJECTIVES:
This study was carried out to assess whether delaying umbilical cord clamping is effective in improving the haematological status
of term infants living in a malaria-endemic area, and whether this is associated with complications in infants and mothers.
METHODS:
We randomly assigned women delivering term babies in Mpongwe Mission Hospital, Zambia, to delayed cord clamping (DCC, n =
46) or immediate cord clamping (controls, n = 45) and followed their infants on a bi-monthly basis until the age of 6 months. We
compared the haemoglobin (Hb) change from cord values and the proportion of anaemic infants. Secondary outcomes related to
infant and maternal safety.
RESULTS:
Throughout the observation period infant Hb levels in both groups declined, but more rapidly in controls than in the DCC group
[difference in Hb change from baseline at 4 months 1.1 g/dl, 95% confidence interval (CI) 0.2; 2.1]. By 6 months, this difference
had disappeared (0.0 g/dl, 95% CI -0.9; 0.8). The odds ratio for iron deficiency anaemia in the DCC group at 4 months was 0.3
(95% CI 0.1; 1.0), but no differences were found between the groups at 6 months. No adverse events were seen in infants and
mothers.
CONCLUSION:
Our findings indicate that DCC could help improve the haematological status of term infants living in a malaria-endemic region at 4
months of age. However, the beneficial haematological effect disappeared by 6 months. This simple, free and safe delivery
procedure might offer a strategy to reduce early infant anaemia risk, when other interventions are not yet feasible.
Cochrane Database Syst Rev. 2012 Aug 15;8:CD003248. doi:
10.1002/14651858.CD003248.pub3.
Effect of timing of umbilical cord clamping and other
strategies to influence placental transfusion at preterm birth
on maternal and infant outcomes.
Rabe H, Diaz-Rossello JL, Duley L, Dowswell T.
Source
BSMS Academic Department of Paediatrics, Brighton and Sussex University Hospitals, Royal
Sussex Country Hospital, UK. heike.rabe@bsuh.nhs.uk
Abstract
BACKGROUND:
Optimal timing for clamping the umbilical cord at preterm birth is unclear. Early clamping allows for immediate transfer of the infant
to the neonatologist. Delaying clamping allows blood flow between the placenta, the umbilical cord and the baby to continue. The
blood which transfers to the baby between birth and cord clamping is called placental transfusion. Placental transfusion may
improve circulating volume at birth, which may in turn improve outcome for preterm infants.
OBJECTIVES:
To assess the short- and long-term effects of early rather than delaying clamping or milking of the umbilical cord for infants born at
less than 37 completed weeks' gestation, and their mothers.
SEARCH METHODS:
We searched the Cochrane Pregnancy and Childbirth Group Trials Register (31 May 2011). We updated this search on 26 June
2012 and added the results to the awaiting classification section.
SELECTION CRITERIA:
Randomised controlled trials comparing early with delayed clamping of the umbilical cord and other strategies to influence
placental transfusion for births before 37 completed weeks' gestation.
DATA COLLECTION AND ANALYSIS:
Three review authors assessed eligibility and trial quality.
MAIN RESULTS:
Fifteen studies (738 infants) were eligible for inclusion. Participants were between 24 and 36 weeks' gestation at birth. The
maximum delay in cord clamping was 180 seconds. Delaying cord clamping was associated with fewer infants requiring
8
transfusions for anaemia (seven trials, 392 infants; risk ratio (RR) 0.61, 95% confidence interval (CI) 0.46 to 0.81), less
intraventricular haemorrhage (ultrasound diagnosis all grades) 10 trials, 539 infants (RR 0.59, 95% CI 0.41 to 0.85) and lower risk
for necrotising enterocolitis (five trials, 241 infants, RR 0.62, 95% CI 0.43 to 0.90) compared with immediate clamping. However,
the peak bilirubin concentration was higher for infants allocated to delayed cord clamping compared with immediate clamping
(seven trials, 320 infants, mean difference 15.01 mmol/L, 95% CI 5.62 to 24.40). For most other outcomes (including the primary
outcomes infant death, severe (grade three to four) intraventricular haemorrhage and periventricular leukomalacia) there were no
clear differences identified between groups; but for many there was incomplete reporting and wide CIs. Outcome after discharge
from hospital was reported for one small study; there were no significant differences between the groups in mean Bayley II scores
at age seven months (corrected for gestation at birth (58 children)).No studies reported outcomes for the women.
AUTHORS' CONCLUSIONS:
Providing additional placental blood to the preterm baby by either delaying cord clamping for 30 to 120 seconds, rather than early
clamping, seems to be associated with less need for transfusion, better circulatory stability, less intraventricular haemorrhage (all
grades) and lower risk for necrotising enterocolitis. However, there were insufficient data for reliable conclusions about the
comparative effects on any of the primary outcomes for this review.
Pediatrics. 2006 Apr;117(4):e779-86. Epub 2006 Mar 27.
The effect of timing of cord clamping on neonatal venous
hematocrit values and clinical outcome at term: a
randomized, controlled trial.
Ceriani Cernadas JM, Carroli G, Pellegrini L, Otaño L, Ferreira M, Ricci C, Casas
O, Giordano D, Lardizábal J.
Source
Division of Neonatology, Department of Pediatrics, Hospital Italiano de Buenos Aires, Buenos
Aires, Argentina.
Abstract
BACKGROUND:
The umbilical cord is usually clamped immediately after birth. There is no sound evidence to support this approach, which might
deprive the newborn of some benefits such as an increase in iron storage.
OBJECTIVES:
We sought to determine the effect of timing of cord clamping on neonatal venous hematocrit and clinical outcome in term
newborns and maternal postpartum hemorrhage.
METHODS:
This was a randomized, controlled trial performed in 2 obstetrical units in Argentina on neonates born at term without
complications to mothers with uneventful pregnancies. After written parental consents were obtained, newborns were randomly
assigned to cord clamping within the first 15 seconds (group 1), at 1 minute (group 2), or at 3 minutes (group 3) after birth. The
infants' venous hematocrit value was measured 6 hours after birth.
RESULTS:
Two hundred seventy-six newborns were recruited. Mean venous hematocrit values at 6 hours of life were 53.5% (group 1),
57.0% (group 2), and 59.4% (group 3). Statistical analyses were performed, and results were equivalent among groups because
the hematocrit increase in neonates with late clamping was within the prespecified physiologic range. The prevalence of
hematocrit at <45% (anemia) was significantly lower in groups 2 and 3 than in group 1. The prevalence of hematocrit at >65% was
similar in groups 1 and 2 (4.4% and 5.9%, respectively) but significantly higher in group 3 (14.1%) versus group 1 (4.4%). There
were no significant differences in other neonatal outcomes and in maternal postpartum hemorrhage.
CONCLUSIONS:
Delayed 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.
JAMA. 2007 Mar 21;297(11):1241-52.
9
Late vs early clamping of the umbilical cord in full-term
neonates: systematic review and meta-analysis of
controlled trials.
Hutton EK, Hassan ES.
Source
Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario.
huttone@mcmaster.ca
Abstract
CONTEXT:
With few exceptions, the umbilical cord of every newborn is clamped and cut at birth, yet the optimal timing for this intervention
remains controversial.
OBJECTIVE:
To compare the potential benefits and harms of late vs early cord clamping in term infants.
DATA SOURCES:
Search of 6 electronic databases (on November 15, 2006, starting from the beginning of each): the Cochrane Pregnancy and
Childbirth Group trials register, the Cochrane Neonatal Group trials register, the Cochrane library, MEDLINE, EMBASE, and
CINHAL; hand search of secondary references in relevant studies; and contact of investigators about relevant published research.
STUDY SELECTION:
Controlled trials comparing late vs early cord clamping following birth in infants born at 37 or more weeks' gestation.
DATA EXTRACTION:
Two reviewers independently assessed eligibility and quality of trials and extracted data for outcomes of interest: infant
hematologic status; iron status; and risk of adverse events such as jaundice, polycythemia, and respiratory distress.
DATA SYNTHESIS:
The meta-analysis included 15 controlled trials (1912 newborns). Late cord clamping was delayed for at least 2 minutes (n = 1001
newborns), while early clamping in most trials (n = 911 newborns) was performed immediately after birth. Benefits over ages 2 to
6 months associated with late cord clamping include improved hematologic status measured as hematocrit (weighted mean
difference [WMD], 3.70%; 95% confidence interval [CI], 2.00%-5.40%); iron status as measured by ferritin concentration (WMD,
17.89; 95% CI, 16.58-19.21) and stored iron (WMD, 19.90; 95% CI, 7.67-32.13); and a clinically important reduction in the risk of
anemia (relative risk (RR), 0.53; 95% CI, 0.40-0.70). Neonates with late clamping were at increased risk of experiencing
asymptomatic polycythemia (7 studies [403 neonates]: RR, 3.82; 95% CI, 1.11-13.21; 2 high-quality studies only [281 infants]: RR,
3.91; 95% CI, 1.00-15.36).
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.
Physiological Parameters
Mean Hematocrit. Mean neonatal hematocrit measured in capillary or venous blood samples
collected from the newborns at around 6 hours after birth was higher for those allocated to late vs
early cord clamping (2 trials, 494 infants)32,37 (WMD, 4.16%; 95% CI, 0.83% to 7.49%) (Figure
1). Similarly, 4 trials evaluating 341 infants37,38,45,48 found significantly higher levels of
neonatal hematocrit at 24 to 48 hours after the time of delivery with late clamping (WMD,
10.01%; 95% CI, 4.10% to 15.92%). This significant effect was further demonstrated at age 5 days
(4 trials, 120 infants)44,45,47,48 (WMD, 11.97%; 95% CI, 8.50% to 15.45%) and at age 2 months
(1 trial, 47 infants)46 (WMD, 3.70%; 95% CI, 2.00% to 5.40%). However, no significant
differences were found in hematocrit at age 6 months (1 trial, 305 infants)32 (WMD, 0.10%; 95%
CI, −0.62% to 0.82%). A sensitivity analysis for hematocrit at 24 to 48 hours after delivery
comparing high-quality studies with all studies showed no substantial changes in the observed
differences (2 trials, 279 infants)37,38 (WMD, 4.54%; 95% CI, 2.98% to 6.10%).
Mean Hemoglobin Level. At ≈7 hours after birth, the mean neonatal hemoglobin level
measured in capillary blood was higher in newborns with late cord clamping (1 trial, 354
infants)32 (WMD, 0.60 g/dL; 95% CI, 0.11 to 1.09). No significant differences in mean levels were
found at ages 2 to 3 months (3 trials, 209 infants)39,42,46 (WMD, 0.47 g/dL; 95% CI, −0.48 to
1.42) (Figure 1) or 6 months (1 trial, 356 infants)32 (WMD, 0.00 g/dL; 95% CI, −0.21 to 0.21). Of
10
the 3 trials assessing hemoglobin levels at 2 to 3 months, only 1 was of high quality.39 In this
small trial of 58 infants, levels were higher in newborns who had late clamping (WMD, 1.10 g/dL;
95% CI, 0.66 to 1.54).
Blood Volume and Plasma and Blood Viscosity. Blood volume during the first 2 to 4 hours
of life was higher in infants who had late cord clamping (2 trials, 60 infants)43,48 (WMD, 9.07
mL/kg; 95% CI, 5.81 to 12.32). Three trials (90 neonates)45,47,48 found no significant
differences with respect to values of plasma viscosity at 24 hours after birth (WMD, 0.01 mPa.s;
95% CI, −0.03 to 0.05) and at age 5 days in the same population (WMD, −0.02 mPa.s; 95% CI,
−0.07 to 0.02). Three trials (90 infants)44,45,47 reported that values of blood viscosity during the
first 2 to 4 hours of life and again at age 5 days were significantly higher in neonates allocated to
late clamping (2-4 hours: WMD, 1.39 mPa.s; 95% CI, 1.19 to 1.59; 5 days: WMD, 0.94 mPa.s; 95%
CI, 0.72 to 1.16) (Figure 2).
Bilirubin Level. As shown in Figure 3, there was no significant difference in mean serum
bilirubin levels within the first 24 hours of life (2 trials, 163 infants)38,41 (WMD, 3.81 mmol/L;
95% CI, −17.55 to 25.18). Similarly, no significant differences in levels were noted between late
and early cord clamping at or after 72 hours following birth (2 trials, 91 infants)41,43 (WMD,
18.27 mmol/L; 95% CI, −2.47 to 39.00).
Iron Status. Iron status was assessed in terms of mean ferritin level and stored iron level.
Ferritin levels at ages 2 to 3 months were higher for infants allocated to late vs early cord
clamping (2 trials, 144 infants)42,46 (WMD, 17.89 μg/L; 95% CI, 16.58 to 19.21) (Figure 4). Two
trials that included a total of 165 infants39,42 compared the effects of late vs early clamping on
having ferritin levels less than 50 μg/L at age 3 months as an indicator for deficient iron stores.
Fewer infants allocated to late clamping had ferritin levels less than 50 μg/L (RR, 0.67; 95% CI,
0.47 to 0.96). At age 6 months, ferritin levels were also higher with late clamping (1 trial, 315
infants)32 (WMD, 11.80 μg/L; 95% CI, 4.07 to 19.53).
One trial (315 infants)32 that evaluated stored iron at age 6 months found that infants with late
cord clamping at birth had higher levels of stored iron vs those with early clamping (WMD, 19.90
mg; 95% CI, 7.67 to 32.13).
Clinical Outcomes
Risk of Anemia. Compared with early cord clamping, the risk of anemia was decreased with late
clamping at 24 to 48 hours after birth (1 study, 179 infants)37 (RR, 0.20; 95% CI, 0.06 to 0.66)
and at ages 2 to 3 months (2 trials, 119 infants)39,46 (RR, 0.53; 95% CI, 0.40 to 0.70) (Figure 5).
At 6 months, similar proportions of infants in the late- and early-clamping groups were anemic (1
trial, 356 infants)32 (RR, 0.85; 95% CI, 0.51 to 1.43). However, in the same trial, 315 infants were
evaluated for risk of iron deficiency anemia at age 6 months by considering their levels of ferritin
as well. None in the late-clamping group (n = 161) vs 6 in the early-clamping group (n = 154) were
diagnosed with the deficiency (RR, 0.07; 95% CI, 0.00 to 1.30).
11
Risk of Clinical Jaundice and Use of Phototherapy. A pooled analysis of data from 8 trials
(1009 infants)37,38,40,41,44,45,47,48 did not show an increased risk of developing neonatal
jaundice within the first 24 to 48 hours of life associated with late cord clamping (RR, 1.35; 95%
CI, 1.00 to 1.81) (Figure 6). When low-quality trials were excluded, findings still showed no
significant difference between groups in the risk of jaundice (4 trials, 889 infants)37,38,40,41 (RR
1.16; 95% CI, 0.85 to 1.58). Similarly, no significant differences were noted between late and early
clamping in risk of jaundice at 3 to 14 days after birth (1 trial, 332 infants)32 (RR, 1.27; 95% CI,
0.76 to 2.10). In addition, no significant differences were found between groups in the
proportions of infants who had elevated bilirubin levels (>256.5 mmo/L [15 g/dL]) that
necessitated use of phototherapy (3 trials, 699 infants)38,40,41 (RR, 1.78; 95% CI, 0.71 to 4.46)
(Figure 6).
Risk of Polycythemia. Risk of polycythemia after birth was more common in neonates
allocated to late rather than early cord clamping at 7 hours (2 trials, 236 neonates)32,37 (RR,
3.44; 95% CI, 1.25 to 9.52) and at 24 to 48 hours (7 trials, 403 neonates)37,38,42,44,46- 48 (RR,
3.82; 95% CI, 1.11 to 13.21) (Figure 7). A sensitivity analysis that included only high-quality
studies provided a similar estimate for risk of polycythemia at 24 to 48 hours (2 studies, 281
infants)37,38 (RR, 3.91; 95% CI, 1.00 to 15.36), although statistical significance was lost (Figure
7).
Risk of Tachypnea or Respiratory Grunting. No significant difference was observed
between late and early cord clamping in terms of the risk of developing either tachypnea or
respiratory grunting (3 trials, 296 infants)19,37,40 (RR, 2.48; 95% CI, 0.34 to 17.89) (Figure 8).
The estimate for risk remained non significant when the single low-quality trial was removed
from the analysis (2 trials, 239 infants)37,40 (RR, 1.24; 95 CI, 0.49 to 1.37).
Perhaps the most important finding was that the beneficial effects of late cord clamping appear to
extend beyond the early neonatal period. Our meta-analysis estimated a significant 47% reduction
in risk of anemia and 33% reduction in risk of having deficient iron stores at ages 2 to 3 months
with late clamping. Although the risk estimate of anemia at ages 2 to 3 months was pooled from 2
small studies39,46 and the loss to follow-up in 1 of these was 40%,39 this finding agrees with the
results of a large, well-designed and well-executed randomized trial with respect to the sustained
effect of late clamping on other indicators of infant hematologic status at age 6 months: iron
stores and ferritin concentrations.32
Late clamping of the umbilical cord is a physiological and inexpensive means of enhancing
hematologic status, preventing anemia over the first 3 months of life and enriching iron stores
and ferritin levels for as long as 6 months. Although this is of particular importance for
developing countries in which anemia during infancy and childhood is highly prevalent, it is likely
to have an important impact on all newborns, regardless of birth setting. Additional research may
be helpful in refining the timing of clamping by determining the minimum time required to
12
provide maximum benefit associated with placental transfusion. Questions remain about whether
the optimal time for clamping is affected by the use of oxytocic drugs before the delivery of the
placenta or by milking of the umbilical cord. We believe that this meta-analysis supports
incorporating into clinical practice a minimum delay of 2 minutes before clamping the umbilical
cord following birth for all full-term newborns.
Neonatology. 2008;93(2):138-44. Epub 2007 Sep 21.
A systematic review and meta-analysis of a brief delay in
clamping the umbilical cord of preterm infants.
Rabe H, Reynolds G, Diaz-Rossello J.
Source
Department of Neonatology, Brighton and Sussex University Hospitals, Brighton, UK.
Heike.Rabe@bsuh.nhs.uk
Abstract
BACKGROUND:
The optimal timing of clamping the umbilical cord in preterm infants at birth is the subject of continuing debate. Objective: To
investigate the effects of a brief delay in cord clamping on the outcome of babies born prematurely.
METHODS:
A retrospective meta-analysis of randomised trials in preterm infants was conducted. Data were collected from published studies
identified by a structured literature search in EMBASE, PubMed, CINAHL and the Cochrane Library. All infants born below 37
weeks gestation and enrolled into a randomised study of delayed cord clamping (30 s or more) versus immediate cord clamping
(less than 20 s) after birth were included. Systematic search and analysis of the data were done according to the methodology of
the Cochrane collaboration.
RESULTS:
Ten studies describing a total of 454 preterm infants were identified which met the inclusion and assessment criteria. Major
benefits of the intervention were higher circulating blood volume during the first 24 h of life, less need for blood transfusions (p =
0.004) and less incidence of intraventricular hemorrhage (p = 0.002).
CONCLUSIONS:
The procedure of a delayed cord clamping time of at least 30 s is safe to use and does not compromise the preterm infant in the
initial post-partum adaptation phase.
Pediatrics. 2012 Mar;129(3):e667-72. doi: 10.1542/peds.2011-2550. Epub 2012 Feb 13.
Hemodynamic effects of delayed cord clamping in
premature infants.
Sommers R, Stonestreet BS, Oh W, Laptook A, Yanowitz TD, Raker C, Mercer J.
Source
Department of Neonatology, Women & Infants Hospital of Rhode Island & Alpert Medical School
of Brown University, Providence, RI 02905, USA. drsommers@gmail.com
Abstract
BACKGROUND AND OBJECTIVE:
Delayed cord clamping (DCC) has been advocated during preterm delivery to improve hemodynamic stability during the early
neonatal period. The hemodynamic effects of DCC in premature infants after birth have not been previously examined. Our
objective was to compare the hemodynamic differences between premature infants randomized to either DCC or immediate cord
clamping (ICC).
13
METHODS:
This prospective study was conducted on a subset of infants who were enrolled in a randomized controlled trial to evaluate the
effects of DCC versus ICC. Entry criteria included gestational ages of 24(0) to 31(6) weeks. Twins and infants of mothers with
substance abuse were excluded. Serial Doppler studies were performed at 6 ± 2, 24 ± 4, 48 ± 6, and 108 ± 12 hours of life.
Measurements included superior vena cava blood flow, right ventricle output, middle cerebral artery blood flow velocity (BFV),
superior mesenteric artery BFV, left ventricle shortening fraction, and presence of a persistent ductus arteriosus.
RESULTS:
Twenty-five infants were enrolled in the DCC group and 26 in the ICC group. Gestational age, birth weight, and male gender were
similar. Admission laboratory and clinical events were also similar. DCC resulted in significantly higher superior vena cava blood
flow over the study period, as well as greater right ventricle output and right ventricular stroke volumes at 48 hours. No differences
were noted in middle cerebral artery BFV, mean superior mesenteric artery BFV, shortening fraction, or the incidence of a
persistent ductus arteriosus.
CONCLUSIONS:
DCC in premature infants is associated with potentially beneficial hemodynamic changes over the first days of life.
(just to emphasize the importance of avoiding anemia)
Nutr Rev. 2011 Nov;69 Suppl 1:S43-8. doi: 10.1111/j.1753-4887.2011.00432.x.
Long-term brain and behavioral consequences of early iron
deficiency.
Georgieff MK.
Source
Center for Neurobehavioral Development, University of Minnesota School of Medicine and
College of Education and Human Development, Minneapolis, Minnesota 55455, USA.
georg001@umn.edu
Abstract
Early iron deficiency not only affects brain and behavioral function during the period of iron deficiency, it persists long after
treatment. The mechanisms include long-term alterations in dopamine metabolism, myelination, and hippocampal structure and
function. Recent studies have demonstrated long-term genomic changes, which suggests the regulation of brain function is
fundamentally altered.
Pediatrics. 2010 Nov;126(5):1040-50. doi: 10.1542/peds.2010-2576. Epub 2010 Oct 5.
Diagnosis and prevention of iron deficiency and irondeficiency anemia in infants and young children (0-3 years
of age).
Baker RD, Greer FR; Committee on Nutrition American Academy of Pediatrics.
Collaborators (13)
Abstract
This clinical report covers diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants (both breastfed and
formula fed) and toddlers from birth through 3 years of age. Results of recent basic research support the concerns that irondeficiency anemia and iron deficiency without anemia during infancy and childhood can have long-lasting detrimental effects on
neurodevelopment. Therefore, pediatricians and other health care providers should strive to eliminate iron deficiency and irondeficiency anemia. Appropriate iron intakes for infants and toddlers as well as methods for screening for iron deficiency and irondeficiency anemia are presented.
14
Delayed cord clamping and haemoglobin levels in infancy: a
randomised controlled trial in term babies
Patrick van Rheenen1, Lette de Moor2, Sanne Eschbach2, Hannah de Grooth3 and Bernard Brabin4,5,6
1.
2.
3.
4.
5.
6.
1 Department of Paediatrics, Paediatric Gastroenterology, University Medical Centre, Groningen, The Netherlands
2 University of Amsterdam, Amsterdam, The Netherlands
3 Mpongwe Mission Hospital, Zambia
4 Emma Children’s Hospital – Academic Medical Centre, Amsterdam, The Netherlands
5 Child and Reproductive Health Group, Liverpool School of Tropical Medicine, Liverpool, UK
6 Royal Liverpool Children’s Hospital, NHS Trust, Alder Hey, Liverpool, UK
objectives This study was carried out to assess whether delaying umbilical cord clamping is effective in
improving the haematological status of term infants living in a malaria-endemic area, and whether this is
associated with complications in infants and mothers.
methods We randomly assigned women delivering term babies in Mpongwe Mission Hospital, Zambia, to
delayed cord clamping (DCC, n 1⁄4 46) or immediate cord clamping (controls, n 1⁄4 45) and followed their
infants on a bi-monthly basis until the age of 6 months. We compared the haemoglobin (Hb) change from cord
values and the proportion of anaemic infants. Secondary outcomes related to infant and maternal safety.
results Throughout the observation period infant Hb levels in both groups declined, but more rapidly in controls
than in the DCC group [difference in Hb change from baseline at 4 months 1.1 g/dl, 95% confidence interval (CI)
0.2; 2.1]. By 6 months, this difference had disappeared (0.0 g/dl, 95% CI )0.9; 0.8). The odds ratio for iron
deficiency anaemia in the DCC group at 4 months was 0.3 (95% CI 0.1; 1.0), but no differences were found
between the groups at 6 months. No adverse events were seen in infants and mothers.
conclusion Our findings indicate that DCC could help improve the haematological status of term infants living in
a malaria-endemic region at 4 months of age. However, the beneficial haematological effect disappeared by 6
months. This simple, free and safe delivery procedure might offer a strategy to reduce early infant anaemia risk,
when other interventions are not yet feasible.
Delayed Umbilical Cord Clamping in Premature Neonates
Joseph W. Kaempf, MD, Mark W. Tomlinson, MD, Andrew J. Kaempf, BS, YingXing Wu, MD,
Lian Wang, MS, Nicole Tipping, RN, and Gary Grunkemeier, PhD
RESULTS: In VLBW neonates (77 delayed umbilical cord clamping, birth weight [mean�standard
deviation] 1,099�266 g; 77 early umbilical cord clamping 1,058�289 g), delayed umbilical cord clamping
was associated with less delivery room resuscitation, higher Apgar scores at 1 minute, and higher hematocrit.
Delayed umbilical cord clamping was not associated with significant differences in the overall transfusion
rate, peak bilirubin, any of the principle Vermont Oxford Network outcomes, or mortality. In LBW neonates
(172 delayed umbilical cord clamping, birth weight [mean�standard deviation] 2,159�384 g; 172 early
umbilical cord clamping 2,203�447 g), delayed um- bilical cord clamping was associated with higher hematocrit and was not associated with a change in delivery
From the Departments of Neonatology and Obstetrics, Providence St. Vincent Medical Center, Portland, Oregon.
Supported by the Vollum Family Foundation and Northwest Newborn Special- ists PC.
15
Corresponding author: Joseph W. Kaempf, MD, Providence St Vincent Medical Center, Departments of Neonatology and Obstetrics,
9205 SW Barnes Road Portland, OR 97225; e-mail: joe@nnspc.com.
Financial Disclosure
The authors did not report any potential conflicts of interest.
© 2012 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins.
ISSN: 0029-7844/12
room resuscitation or Apgar scores or with changes in the transfusion rate or peak bilirubin. Regression
analysis showed increasing gestational age and birth weight and delayed umbilical cord clamping were the
best predictors of higher hematocrit and less delivery room resuscitation.
CONCLUSION: Delayed umbilical cord clamping can safely be performed in singleton premature neonates
and is associated with a higher hematocrit, less delivery room resuscitation, and no significant changes in
neonatal morbidities.
(Obstet Gynecol 2012;120:325–30) DOI: 10.1097/AOG.0b013e31825f269f
Journal of Perinatology (2012) 32, 580–584 r 2012 Nature America, Inc. All rights reserved. 0743-8346/12
www.nature.com/jp
ORIGINAL ARTICLE
Umbilical cord milking in term infants delivered by cesarean section: a
randomized controlled trial
DA Erickson-Owens1, JS Mercer1 and W Oh2
1
University of Rhode Island, College of Nursing, Kingston, RI, USA and 2Warren Alpert
Medical School of Brown University, Providence, RI, USA
Objective: The study’s objective was to compare hematocrit (Hct) levels at 36 to 48 h of age in term infants
delivered by cesarean section exposed to immediate cord clamping or umbilical cord milking (UCM).
Umbilical cord milking (UCM) can be used as a proxy for delayed cord clamping (DCC), as
the benefits of UCM are similar to those associated with DCC and include improved blood
and red cell volume, red blood cell counts and hemoglobin (Hb) and hematocrit (Hct) levels.
Conclusion: UCM results in placental transfusion in term infants at the time of elective cesarean section with
higher Hct levels at 36 to 48 h of age. Journal of Perinatology (2012) 32, 580–584; doi:10.1038/jp.2011.159;
published online 17 November 2011
The timing of the clamping and cutting of the umbilical cord has a significant impact on the
infant’s blood and red cell volume and early iron stores.1 – 2,5 In utero, at term gestation,
one-third of the fetus’s blood volume is in the placenta at any one time. At the time of birth,
a major shift occurs in the cardiac output to the lungsFchanging from 8 to 10% in fetal life to
50% in neonatal life. This shift requires a rapid increase of blood volume to fill the capillary
beds surrounding each alveolus to assist with lung tissue recruitment and expansion.19 The
placenta serves as the blood reservoir designed to meet this immediate demand for
increased blood volume. A delay in cord clamping or milking the cord supports placental
transfusion and results in a 20 to 30% increase in whole blood and a 50 to 60% increase in
red blood cell volume.1 When the cord is cut immediately, the infant does not receive the
additional blood volume from placental transfusion, representing a loss of 25mgkg–1 of iron
or 33% less body iron.2 This loss can affect iron stores and may place the infant at risk for
iron deficiency and anemia during infancy.1 – 5
Although delaying the clamping and cutting of the cord at birth optimizes placental
transfusion, it is not always feasible at the time of cesarean section. Waiting up to two or
three minutes (or until pulsations cease) before clamping the cord can seem like a long time
16
during a cesarean section. Cord milking appears to be a viable alternative to DCC when
timing is critical. In our study, we found that milking the cord took <20 s, yet resulted in less
PRBV and demonstrated significantly higher Hct levels at 36–48h of age when compared
with infants with ICC. These findings suggest that cord milking is easy to implement and
takes only a few seconds to improve an infant’s hematologic status.
The greatest barrier to the clinical application of placental transfusion is the long held belief
that overtransfusion can lead to symptomatic polycythemia and hyperbilirubinemia. In a
meta- analysis involving 1912 infants, Hutton and Hassan15 reported a slightly higher rate
of asymptomatic polycythemia at 24 to 48 h of age with delayed clamping, but treatment
was unnecessary and not associated with higher levels of jaundice and hyperbilirubinemia.
Cord milking is a low-cost intervention that accelerates placental transfusion at the time of
cesarean section. Placental transfusion appears to have an important role in enriching early
infancy iron stores and assists in availability of iron for the developing brain. Although DCC
is the preferred method of transferring iron-rich blood from the placenta to the infant in the
first few minutes after birth, it is not always feasible at the time of cesarean section. UCM is
a viable alternative.
JOURNAL OF TROPICAL PEDIATRICS, VOL. 58, NO. 6, 2012
A Hospital Policy Change Toward Delayed Cord Clamping is
Effective in Improving Hemoglobin Levels and Anemia Status
of 8-month-old Peruvian Infants
by Theresa W. Gyorkos,1,2 Mathieu Maheu-Giroux,2,3 Brittany Blouin,1,2 Hilary Creed-Kanashiro,4 Martı ́n Casapı ́a,5 Eder
Aguilar,6 Herma ́ nn Silva,6 Serene A. Joseph,1,2 and Mary E. Penny4
1
Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, 1020 Pine Avenue West, Montre ́al,
QC, Canada H3A 1A2
2
Division of Clinical Epidemiology, Research Institute of the McGill University Health Centre, Royal Victoria Hospital – V
Building, 687 Pine Avenue W., Montre á l, QC, Canada H3A 1A1
3
Department of Global Health and Population, Harvard School of Public Health, 677 Huntington Avenue, Boston,
MA 02115, USA
4
Instituto de Investigacio ́n Nutricional, Av. La Molina 1885 – La Molina, Lima, Peru ́ 5Asociacio ́n Civil Selva Amazo ́nica, Urb.
Jardı ́n No. 27, Fanning 4ta. Cuadra, Iquitos, Peru ́ 6Hospital Iquitos ‘‘Ce ś ar Garayar Garcı á ’’, Av. Cornejo Portugal 1710,
Iquitos, Peru ́
Correspondence: Dr Theresa W. Gyorkos, Division of Clinical Epidemiology, McGill University Health Centre, Royal Victoria
Hospital Campus (V Building), 687 Pine Avenue West, Montreal, QC, Canada H3A 1A1. Tel.: þ514-934-1934 ext 44721, Fax:
514-934-8293, E-mail: <theresa.gyorkos@mcgill.ca>.
Summary
Objective: To assess the effectiveness of a hospital policy change toward delayed cord clamping on infant
hemoglobin (Hb) levels and anemia status at 4 and 8 months of age.
Methods: A cohort of Peruvian mothers and infants, originating from a pre/post study investigating a change in
hospital policy from early to delayed cord clamping, was followed until 8 months postpartum. Infant hemoglobin
levels and anemia status were measured at 4 and 8 months postpartum.
Results: Following the hospital policy change, adjusted mean infant Hb levels improved by 0.89 gdl�1 [95%
confidence interval (95% CI) 0.57–1.22] and anemia was significantly reduced (aOR 1⁄4 0.38; 95% CI 0.19–
0.78) at 8 months postpartum.
Conclusions: A hospital policy change toward delayed cord clamping is effective in improving Hb levels and the
anemia status of 8-month-old infants. Prior to scaling-up this intervention, issues related to training, monitoring,
safety, additional long-term benefits and specific local conditions should be investigated.
To our knowledge, this is the first study to assess the effectiveness of delayed cord clamping. It pro- vides crucial
empirical evidence that implementing this intervention in a real-life hospital setting, where compliance will not
be perfect, will still yield benefits to the infants that are of public health significance. Our results support the
implementation of delayed cord clamping in other settings as we estimate that a 22% reduction of infant anemia
at 8 months of age is associated with this cost-free intervention. Future research should further investigate for
how long the benefits of delayed cord clamping extend into late infancy/early childhood.
17
Timing of umbilical cord clamping and neonatal haematological
status
Riffat Jaleel, Farah Deeba, Ayesha Khan
Department of Obstetrics and Gynecology, Unit-V, Dow Medical College and Lyari General Hospital, Karachi.
Abstract
Objectives: To determine the effect of delayed umbilical cord clamping on Hb (haemoglobin) and bilirubin
levels of neonates and to identify newborn babies with anaemia and refer them for treatment.
Methods: This Randomized Controlled Trial was conducted in the Department of Obstetrics and
Gynaecology, Unit V, Dow Medical College and Lyari General Hospital and Department of Pathology, Lyari
General Hospital, between 1st November, 2006 and 15th July, 2007. Patients admitted to labour ward were
selected according to inclusion criteria of the study. They were randomly allocated to 2 groups. Group A
included women in whom umbilical cord was clamped immediately after birth. In Group B, clamping was
delayed until cessation of pulsations in the cord. After cutting the cord, sample of blood was collected from
the cut end of cord of the newborn for Hb and bilirubin. After 6 hours of birth, another sample of blood was
drawn from antecubital vein for serum bilirubin. Samples were sent to laboratory for analysis. All data were
entered and analyzed using SPSS version 11. Results: Two hundred women were studied, 100 in each of
the 2 groups. Mean maternal Hb was 9.75 g/dl in Group A and 9.95 g/dl in Group B. The average neonatal
Hb was 14.1 g/dl in Group A and 15.2 g/dl in Group B ( p=0.008 ). In all 49% neonates in Group A and 37%
in Group B had Hb < 14 g/dl. Serum bilirubin values at birth and at 6 hours of birth were 1.8 mg/dl and 2.5
mg/dl for Group A and 1.9 mg/dl and 2.7 mg/dl for Group B, respectively. The difference in bilirubin after 6
hours in the 2 groups was insignificant (p=0.186).
Conclusion: Delayed umbilical cord clamping at birth seems to be safe and can be expected to reduce the
prevalence of anaemic newborn babies in our community (JPMA 59:468; 2009).
Conclusion
In term newborn babies, delayed cord clamping results in an increase in Hb, without causing unacceptable
side effects. It can be used as a simple and cost free intervention for reducing prevalence of anaemia in
infants in developing countries.
Continuing Education
J Perinat Neonat Nurs r Vo 2012
Rethinking Placental Transfusion and
Cord Clamping Issues
Judith S. Mercer, PhD, CNM, FACNM, Debra A. Erickson-Owens, PhD, CNM
PHYSIOLOGIC EFFECTS OF PLACENTAL TRANSFUSION ON THE INFANT
When cord clamping is delayed at birth or the cord is milked, infants experience placental transfusion as whole
blood is transferred (or transfused) from the pla- centa to the infant during the first few minutes of life. This
blood contains not only volume and red blood cells but also millions of stem cells important in re- pairing
tissue and building immunocompetence. The red blood cells are a major source of iron during the first few
months of life.3 When the cord is cut rapidly, the infant has no access to approximately 30 mL/kg (of birth
weight) of blood—about 30% of the fetal-placental blood volume. Placental transfusion facilitates an in- crease
in the circulatory bed at the same time that the infant’s various organs (lung, liver, kidney, etc) assume the many
functions maintained by the placenta during fetal life. This additional blood volume may reduce the
vulnerability of infants to inflammatory processes and provide protection against infection. 4,5
Fetal and neonatal blood volume
Throughout pregnancy, blood flows in a continuous cir- cuit from fetus to placenta (via the 2 umbilical arteries)
and back to fetus (via the 1 umbilical vein). The fe- tal heart is the driver for this process, contracting with
enough force to perfuse the most distant placental villi. The amount of whole blood in the fetal-placental circulation is estimated to be 110 to 115 mL/kg of fetal weight throughout gestation.6 , 7 During fetal life, the blood
flow to the lungs is only 10% of the fetal cardiac output. The placenta is the organ of respiration and it
adequately oxygenates the fetus with more than 50% of the fetal cardiac output circulating through it at any
one time. At birth, the cardiac output to the lungs must rapidly change from 10% to 45%–55% to adapt to air
respiration in the newborn lungs. Delayed cord clamping delivers the volume of blood needed for this
18
adaptation. The cir- culation in the cord continues for several minutes after birth and placental transfusion
results in approximately 30% more blood volume compared with infants with ICC. 8
Table 1. Effects of delayed cord clamping in term infants (from randomized controlled
trials) Abbreviations: Hb, hemoglobin; Hct, hematocrit.
Newborn Period
↑ Hct and Hb levels at 2 days of age31,34,36 ↓ Anemia32,36
No symptomatic polycythemia14,34,36,37
No difference in clinical jaundice14,37
At 3-6 Months of Age
↑ Ferritin levels31,33,35,36,38
↑ Total body iron stores35
↓ Anemia14,38
↓ Lead levels in infants exposed to lead40
RISKS FROM PLACENTAL TRANSFUSION
A widely held belief, often unreferenced in obstet- rical and neonatal textbooks, is that there is a link between
DCC, hyperbilirubinemia, and symptomatic polycythemia. Clinicians are concerned that babies will be
“overtransfused.” This belief is unsubstanti- ated by the current research. Recent evidence suggests DCC is a
harmless practice. The issues of hyperbiliru- binemia and polycythemia are more likely related to underlying
pathologic events occurring within the fe- tus and/or newborn. Hyperbilirubinemia has been as- sociated with
preterm birth, hypoxia, hypoglycemia, polycythemia, poor feeding habits or feeding intoler65
ance, and delayed passage of meconium. Symptomatic
polycythemia is associated with a poor intrauterine en- vironment resulting in an increased fetal production
of erythrocytes (erythropoiesis).66 Known factors that cause erythropoiesis during pregnancy, resulting in
polycythemia, include maternal diabetes, hypertension, cigarette smoking, postmaturity, newborn congenital
anomalies, twin-to-twin transfusion, and intrauterine growth restriction.66−70
None of the randomized controlled trials pub- lished since 1980 have supported a link be- tween DCC and
hyperbilirubinemia or symptomatic polycythemia.14 , 31 − 38 , 71 − 74 Results of studies reporting the incidence of
jaundice and polycythemia in full-term in- fants are summarized in Appendix 2. A systematic review published
by McDonald and Middleton29 suggested that there was a significantly higher rate of jaundice requir- ing
phototherapy in DCC infants.29 However, this finding surfaced only with the weighted results of an unpublished 1996 dissertation by McDonald. This thesis did not report bilirubin levels or masking of pediatricians
and has not been peer reviewed. A 2007 systematic re- view by Hutton and Hassan,28 looking at similar studies
did not identify any differences in rates of clinical jaun- dice or jaundice requiring treatment. Although a slight
increase in asymptomatic polycythemia did occur as a result of DCC, it appeared to be benign. 28
POTENTIAL BENEFITS FROM PLACENTAL TRANSFUSION
In light of the recent findings of improved iron stores and increased knowledge about stem cells, it is probable
that DCC at birth or milking the cord offers significant benefits to the newborn and may play a
neuroprotective role related to increased iron stores.
Cord blood collection
Blood banks designed to save the infant’s stem cells for the future are aggressively marketed to parents and
providers and have been established without any long- term research on the safety or impact. Immediately
clamping and cutting the umbilical cord usually yields a high volume of blood (preferred by blood banks) compared with collection after DCC, which may yield 30 to 60 mL of cord blood. Current stem cell transfusion
tech- nology is beginning to combine cord blood donations to obtain enough cells for a transfusion thus
support- ing idea of the collection of smaller samples. Immediate cord clamping prevents the infant from
receiving a full allotment of stem cells at birth. The authors recommend against ICC, which results in large
collections and ques- tions the ethics of using the newborn as a blood donor. An adult donates no more than
10% of his or her blood volume at one time. For infants, ICC can result in a do- nation of up to 30% of the
fetal-placental blood. A child is not allowed to be a blood donor in this country. This should also include all
infants. The practice of collect- ing a large amount of placental blood from an infant at birth needs
reexamination. There have been no studies looking at long-term consequences of this practice. It is time to
19
rethink large quantities of infant blood donation at the time of birth. Collection of stem cells at birth ver- sus
placental transfusion is a topic about which parents should be fully informed in the prenatal period. 112
Recommendations for practice
At a normal birth, the provider can place the infant skin- to-skin, dry and cover the infant with a warm blanket,
and leave the umbilical cord intact until the placenta is
ready to deliver. When perfusion is complete, the cord will become pale, white, and flat and look obviously
emptied. One caveat is that only infants with good tone should go immediately onto the maternal abdomen.
When an infant has poor tone or is “slow to start,” the infant can be placed on a clean pad at the perineum or
held below the level of the placenta. The heart rate should be assessed. The rate is generally normal even
though the infant may not be breathing. As long as the heart rate is normal, then resuscitation, as
recommended by the NRP, can proceed but at the perineum (with an intact cord), rather than on the warmer.
Once the infant is breathing and tone is regained, the infant can be placed skin-to-skin.
If the heart rate is low, the cord can be milked several times toward the infant to accelerate transfer of blood
volume. The heart rate should be checked again and if not improved, all the usual resuscitation maneuvers can
be instituted at the perineum without detaching the infant. This method of resuscitation has been practiced for
many years in out-of-hospital settings.91
SUMMARY
This article offers high quality evidence that shows that receiving a placental transfusion at birth protects the
infant from low iron stores and anemia during the first 6 months of life—a time of maximum brain growth.
Iron deficiency is associated with hypomyelination and less favorable developmental outcomes but long-term
effects related to placental transfusion have not been studied. Techniques to facilitate placental transfusion at
the time of normal birth as well as in complex practice situations needs the support of informed change agents
to foster the introduction of practice change into all labor and birthing units. It is time to rethink the
management of the umbilical cord during the critical time of fetal to neonatal transition.
Timing of umbilical cord clamping after birth for optimizing placental
transfusion
Tonse N.K. Raju
Volume 25 � Number 2 � April 2013
As most healthy infants cry soon after birth, establishing pulmonary ventilation quickly, pulmonary
arterial flow into the lungs increases, as does pulmonary venous flow (oxygenated blood) back into
the left heart. Therefore, in such infants, postnatal circulatory status transitions smoothly, despite
early cord clamping.
However, if the cord is clamped soon after birth and pulmonary ventilation is inadequate, depending upon the severity of the latter, the consequences could be serious. Inadequate ventilation
prevents the postnatal drop in pulmonary vascular resistance, preventing the normal increase of
pulmonary blood flow, and reducing the return of oxygenated blood into the left side of the heart.
Consequent drop in left ventricular output in an asphyxiated infant manifests as hypovolemic shock,
often prompting the caregivers to administer fluid boluses in rapid sequence. Rapid volume
expansion in a comprom- ised preterm infant with maximally dilated cerebral blood vessels (because
of asphyxia), with super- imposed immature cerebral autoregulatory controls, could lead to
intraventricular hemorrhage [19,20]. Some experts therefore argue that, especially in compromised
infants, a delay in cord clamping that improves the infant’s blood volume, which may be
physiologically, would be beneficial [8].
In a small group of healthy term infants, Zaramella et al. [21] reported that delayed cord clamping up
to 4min resulted in a larger end- diastolic left ventricular diameter on day 3 of age, indicating
improved venous return and left ventri- cular function. Such studies have not been reported in
asphyxiated term or preterm infants.
(
benefits: term infants
1. (a) higher hemoglobin and hematocrit in the
early neonatal period;
2. (b) higher total body iron stores, 2 – 4 months of
20
age;
(c) highercirculatingferritinlevel,2–4months
of age;
4. (d) lower incidence of iron-deficiency anemia,
around 4 months of age;
benefits: preterm infants
1. (a) higher hematocrit and hemoglobin during the early neonatal period;
2. (b) higher systemic blood pressure between 4 and 24h of age;
3. (c) increased blood volume;
4. (d) reduced need for inotropic medications;
5. (e) increasedurineoutputduringthefirst48h;
6. (f) reduced need for blood transfusions for
anemia;
7. (g) reduced incidence of intraventricular hemorrhage (all grades);
8. (h) improved myocardial function (systolic
time intervals and cardiac output);
9. (i) improved cerebral oxygenation;
10. (j) higher transfer of autologous stem cells;
adverse infant outcomes in delayed cord clamping groups:
(a) increased peak bilirubin values during the
first week in preterm infants;
(b) increased need for phototherapy in both preterm and term infants;
(refuted in other studies added by Lim)
unchanged maternal and neonatal outcomes compared with early clamping:
1. (a) any or severe postpartum hemorrhage;
2. (b) incidence of retained placenta;
3. (c) incidenceofotherobstetricoutcomes,such
as need for maternal blood transfusions,
operative delivery, episiotomy, etc.;
4. (d) infant Apgar scores, need for resuscitation,
or umbilical cord pH values;
5. (e) frequency of respiratory distress in the
newborn;
6. (f) severe intraventricular hemorrhage or periventricular leukomalacia;
7. (g) incidence of polycythemia;
8. (h) requirement of exchange transfusions;
9. (i) BayleyIIScaleofDevelopmentat7months
of age.
3.
RECOMMENDATIONS AND OPINIONS FROM PROFESSIONAL GROUPS
The World Health Organization was the first to recommend delayed cord clamping as a standard
for all infants at birth [31 ]. Since then, many organizations, professional societies and their committees have followed suit (Table 4) [32–34,35 ]. Although some variations exist in the language of
the guidelines, all entities recommend that whenever feasible one ought to consider delaying cord
clamping, at least for 30s after birth, as the resultant increase in placental transfusion offers clinically
important, measurable benefits to the infant.
&&
&&
Labor Management: Current Commentary
Time to Implement Delayed Cord Clamping Ryan M. McAdams, MD
OBSTETRICS & GYNECOLOGY VOL. 123, NO. 3, MARCH 2014
21
Immediate umbilical cord clamping after delivery is routine in the United States despite little evidence to
support this practice. Numerous trials in both term and preterm neonates have demonstrated the safety and
benefit of delayed cord clamping. In premature neo- nates, delayed cord clamping has been shown to stabilize
transitional circulation, lessening needs for inotropic medications and reducing blood transfusions, necrotiz- ing
enterocolitis, and intraventricular hemorrhage. In term neonates, delayed cord clamping has been associ- ated
with decreased iron-deficient anemia and increased iron stores with potential valuable effects that extend
beyond the newborn period, including improvements in long-term neurodevelopment. The failure to more
broadly implement delayed cord clamping in neonates ignores published benefits of increased placental blood
transfusion at birth and may represent an unnecessary harm for vulnerable neonates.
(Obstet Gynecol 2014;123:549–52) DOI: 10.1097/AOG.0000000000000122
Commentary
Less iron deficiency anaemia after delayed cord-clamping
Patrick van Rheenen
University Medical Center, Groningen, The Netherlands
Invited Commentary on ‘Timing of umbilical cord- clamping and infant anaemia: the role of maternal
anaemia’, Blouin et al.
Umbilical cord-clamping and cutting, by far the most frequently performed intervention in humans,
takes place in the third stage of labour, which is defined as the period from expulsion of the fetus to
expulsion of the placenta. The best timing of cord- clamping in term infants has long been debated,
and, until recently, research has been equivocal. Early clamping is some time between 10 and 60
seconds after birth, while delayed clamping is between 2 minutes and cessation of cord pulsations.
Late clamping is mainly seen in traditional African home deliveries, where the cord is cut after
placental descent into the vagina.
Immediately after the birth of a baby, placental blood continues to flow in the direction of the child.
The total fetoplacental blood volume is about 120 ml/ kg of fetal weight, and the distribution of blood
between fetus and placenta is roughly in a ratio of 2:1. This distribution remains unchanged if the
cord is clamped early. Allowing placental transfusion to occur for at least 3 minutes results in greater
infant blood volume (ratio 5:1). The rate of placental transfusion is influenced by the position of the
delivered infant. From 10 cm above the level of the placenta (on the abdomen of the mother) to 10
cm below the level of the placenta (on the birthing bed), infants receive the maximum possible
amount of blood for at least 3 minutes after birth. Keeping the infant 40 cm below the placenta
hastens placental transfusion to near completion within 1 minute. 1
Until the turn of the new millennium, early cord- clamping was considered to be standard good care.
Obstetricians believed that early clamping (next to the administration of oxytocics and controlled
cord traction) was essential to reduce maternal blood loss in the third stage of labour. However, early
clamping
Correspondence to: P van Rheenen, Faculty of Medical Sciences, University of Groningen – University Medical Center Groningen, 9700 RB
Groningen, The Netherlands. Email: p.f.van.rheenen@umcg.nl
ß W. S. Maney & Son Ltd 2013
DOI 10.1179/2046905513Y.0000000059
has been accepted in obstetrical practice without much consideration. A Cochrane review published
in 2008 studied the effects of different cord-clamping times on maternal blood loss and found that
delay- ed clamping poses no additional threat to women.2 The World Health Organization, the
International Federation of Gynecology and Obstetrics and the International Confederation of
Midwives have now removed the early clamping practice from their guide- lines. Neonatologists and
paediatricians frequently cautioned about polycythaemia, hyperviscosity syn- drome and
hyperbilirubinaemia as adverse effects of placental transfusion, and therefore also advocated early
clamping. Meta-analyses in 2006 and 2007, however, independently showed that delayed clamping
causes no danger to the newborn, and actually improves the haematological and iron status of the
infant.1,3 A Mexican trial showed that the beneficial effect of delayed cord-clamping on infant iron
status could be detected even 6 months after birth.4
Although scientific evidence had demonstrated that the benefits of delayed cord-clamping outweigh
the risks to mother and child, as yet, implementation of delayed clamping has not been very
successful. Changing the practice of cord-clamping poses unique challenges because, although
paediatricians are responsible for the long-term wellbeing of newborns, the umbilical clamp is
22
applied by midwives and obstetricians. This challenge may explain why there are no countries in
which a policy of delayed cord- clamping has been successfully implemented. The only paper
reporting an approach to implement- ing change was from a hospital in Peru.5 After introduction of a
national statement supporting delay of cord-clamping, a 3-day workshop was organised involving all
midwives at the hospital. Following this, the mean cord-clamping time increased from 57 seconds
before the educational intervention to 170 seconds thereafter.
In this issue of Paediatrics and International Child Health the same group reports on progress in the
practice of cord-clamping.6 On the basis of earlier published studies on the timing of cord-clamping,
the authors suspected that maternal anaemia during pregnancy possibly modifies the beneficial
effect of delayed cord-clamping on infant haemoglobin status. To test this hypothesis, they analyzed
maternal haemoglobin levels before delivery, and infant hae- moglobin levels at 4 and 8 months.
Mother–infant
Paediatrics and International Child Health 2013 VOL. 33 NO. 2 57
Published by Maney Publishing (c) W. S. Maney & Son Limited
van Rheenen Commentary
pairs before the change of practice were compared with those who underwent delayed clamping. The
authors concluded that even 8 months after delivery the beneficial effect of delayed clamping is
greater in infants born to anaemic mothers.
From a pathophysiological viewpoint, it is difficult to understand how the haematological benefits of
delayed cord-clamping extend so far into infancy. Earlier work on cord-clamping has shown that by
the age of approximately 6 months the infant outgrows its fetal iron reserves. 4,7 From that age
onwards, the infant becomes dependent on exogeneous iron sources, including iron-enriched infant
formulae and weaning foods. Intercurrent infections, especially those of the gastro-intestinal tract,
disturb iron absorption and might even increase iron loss from the gut. There is a risk that overfitting
the logistic regression model has led the authors to over-estimate the effect of cord clamping in their
population.
Nevertheless, the authors of this Peruvian study should be complimen- ted for their succesfull
implementation of delayed cord-clamping and for closely monitoring their patients after the
intervention.6 They have had the courage to change an inappropriate technique (early
clamping) that had been established in their obstetrical practice. I recommend that other institutions in
resource-poor settings follow their example.
References
1 van Rheenen PF, Brabin BJ. A practical approach to timing cord clamping in resource poor settings. Br Med J. 2006;333:954–
84.
2 McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes.
Cochrane Database Syst Rev. 2008;2:CD004074.
3 Hutton EK, Hassan ES. Late vs early clamping of the umbilical cord in full-term neonates: systematic review and metaanalysis of controlled trials. JAMA. 2007;297:1241–52.
4 Chaparro CM, Neufeld LM, Tena AG, Eguia-Liz CR, Dewey KG. Effect of timing of umbilical cord clamping on iron status in
Mexican infants: a randomised controlled trial. Lancet. 2006;367:1997–2004.
5 Blouin B, Penny ME, Casapia M, Aguilar E, Silva H, Joseph SA, et al. Effect of a two-component intervention to change hospital
practice from early to delayed umbilical cord clamping in the Peruvian Amazon. Rev Panam Salud Publica. 2011;29:322–8.
6 Blouin B, Penny ME, Maheu-Giroux M, Casap ı́ a M, Aguilar E, Silva H, et al. Timing of umbilical cord-clamping and infant
anaemia: the role of maternal anaemia. Paediatr Int Child Health. 2013;33:79–85.
7 van Rheenen P, de Moor L, Eschbach S, de Grooth H, Brabin B. Delayed cord clamping and haemoglobin levels in infancy: a
randomised controlled trial in term babies. Trop Med Int Health. 2007;12:603–16.
Umbilical cord clamping after birth
Better not to rush
Andrew Weeks senior lecturer in obstetrics
School of Reproductive and Developmental Medicine, University of Liverpool, Liverpool L8 7SS
aweeks@liv.ac.uk Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
BMJ 2007;335:312-3
doi: 10.1136/bmj.39282.440787.80
So what is the evidence behind cord clamping? For the mother, trials show that early cord clamping has no effect
on the risk of retained placenta or postpar- tum haemorrhage.3 4 Evidence from a Cochrane review supports this
23
result—prophylactic oxytocin reduces the risk of postpartum haemorrhage whether the rest of the active
management package is adopted or not.5
But what about the baby? Initially, the cord blood continues to flow, sending oxygenated blood back to the fetus
while respiration becomes established, ensuring a good handover between the respiratory systems. At the time
of the first fetal breath, however, the reduction in intrathoracic pressure draws blood into the lungs from the
umbilical vein. So long as the cord is unclamped the average transfusion to the newborn is 19 ml/kg birth
weight, equivalent to 21% of the neonate’s final blood volume (figure).6 The final amount is unaffected by the
use of oxytocics or the position of the baby relative to the placenta.6 7 Three quarters of the transfusion occurs in
the first minute after birth. The rate of transfer can be increased by the use of intravenous uterotonics (to 89%),
or by holding the newborn 40 cm below the level of the placenta.6 8
For the term baby, the main effect of this large autotransfusion is to increase iron status and shift the normal
curve of the neonatal haematocrit to the right. This may be life saving in areas where anaemia is endemic. Here,
late cord clamping increases the average haemoglobin concentration by 11 g/l at four months. 9 In the developed
world, however, there have been concerns that it could increase the risk of neonatal polycythaemia and
hyperbilirubinaemia. Trials show this is not the case. Delayed cord clamp- ing seems to drive up mean
haematocrit values and serum concentrations of bilirubin, without increasing the number of infants needing
treatment for jaundice or polycythaemia.7
For preterm babies the beneficial effects of delayed cord clamping may be greater. Although the studies are
smaller, delayed clamping is consistently associated with reductions in anaemia, intraventricular haemor- rhage,
and the need for transfusion for hypovolaemia and anaemia.10 The one exception may be growth restricted
babies who are already at risk of hypoxia induced polycythaemia.11
How should we approach cord clamping in prac- tice? In normal deliveries, delaying cord clamping for three
minutes with the baby on the mother’s abdomen should not be too difficult. The situation is a little more
complex for babies born by caesarean section or for those who need support soon after birth. Neverthe- less, it is
these babies who may benefit most from a delay in cord clamping. For them, a policy of “wait a minute” would be
pragmatic.11 Indeed, this first minute is already largely spent on neonatal assessment. This could be done in
warmed towels on the birthing bed or the mother’s abdomen after vaginal delivery, or on the mother’s legs at
caesarean section. Cord clamping need only take place when transfer to the resuscitation trolley is required. For
medicolegal purposes it will be important to document the time at which the cord was clamped, as delayed
clamping reduces pH values in umbilical artery blood samples.12
There is now considerable evidence that early cord clamping does not benefit mothers or babies and may even
be harmful. Both the World Health Organization and the International Federation of Gynecology and Obstetrics
(FIGO) have dropped the practice from their guidelines. It is time for others to follow their lead and find
practical ways of incorporating delayed cord clamp- ing into delivery routines. In these days of advanced
technology, it is surely not beyond us to find a way of keeping the cord intact during the first minute of neonatal resuscitation.
http://www.who.int/elena/titles/cord_clamping/en/
world health organization:
Optimal timing of cord clamping for the prevention of iron
deficiency anaemia in infants
At the time of birth, an infant is still attached to the mother via the umbilical cord, which is
part of the placenta. The infant is usually separated from the placenta by clamping the
umbilical cord.s
Early cord clamping is generally carried out in the first 60 seconds after birth, whereas
later cord clamping is carried out greater than one minute after the birth or when cord
pulsation has ceased.
Delaying cord clamping allows blood flow between the placenta and neonate to
continue, which may improve iron status in the infant for up to six months after birth. This
may be particularly relevant for infants living in low-resource settings with less access to
iron-rich foods.
24
WHO recommendations
Late cord clamping approximately (one to three minutes after birth) is recommended for
all births while initiating simultaneous essential newborn care.
Early cord clamping (less than one minute after birth) is not recommended unless the
neonate is asphyxiated and needs to be moved immediately for resuscitation.
The Blood Volume of the Newborn Infant and Placental
Transfusion
http://onlinelibrary.wiley.com/doi/10.1111/j.16512227.1963.tb03809.x/abstract
ROBERT USHER†, MICHAEL SHEPHARD‡ and JOHN LIND
Acta Paediatrica
Volume 52, Issue 5, pages 497–512, September 1963
SUMMARY
Serial blood volume measurements were made in 27 normal full-term newborn
infants using iodinated human albumin. At the moment of birth the newborn infant
was estimated to have a blood volume of 78 ml/kg (X 3.5kg = 273 ml) with a
venous hematocrit of 48 %. When the cord-clamping was delayed for 5 minutes
the blood volume increased by 61 % to 126 ml/kg (X 3.5 kg = 441 ml) . This
placental transfusion amounted to 166 ml for a 3500 g infant, one-quarter of
which occurred in the first 15 seconds, and one-half within 60 seconds of birth.
Stripping of the umbilical cord 10 times during the 5 minutes did not increase the
volume of the transfusion.
When the placental transfusion was prevented by immediate clamping of the
cord, the blood volume did not change appreciably during the first 4 hours of life.
On the other hand, there was a marked decrease in blood volume from 126 to 89
ml/kg during the first 4 hours in infants who had received a placental transfusion.
This decrease was brought about by the transudation of one-half of the original
plasma volume, so that the venous hematocrit rose from 48 % at birth to 64 % by
4 hours.
In all but three of the infants studied there was an increase in blood volume
between 4 and 24 hours of age which was due to an increase in plasma volume
averaging 22 ml per infant. There was no appreciable change in blood volume
between 24 and 72 hours of age.
The red cell volume remained stable during the first three days of life in each of
the infants; those who had received a placental transfusion maintained a red cell
volume about 60 % larger than those who had not.
At 72 hours of age the blood volume had stabilized after the plasma shifts of the
first day of life, and the range of values extended from 75 to 107 ml/kg. This
variation between individuals was due in large part to differences in hematocrit
25
which ranged from 39 % to 67 %, and these in turn were related to the volume of
placental transfusion.
Average values at 72 hours for infants who had received no placental transfusion
were 82 ml/kg blood volume, 31 ml/kg red blood cell volume, 51 ml/kg plasma
volume, and 44 % venous hematocrit. For infants who had received a placental
transfusion they were 93 ml/kg blood volume, 49 ml/kg red blood cell volume, 44
ml/kg plasma volume, and 60 % venous hematocrit.
From:
http://www.gentlebirth.org/archives/cordIssues.html#Delayed
Delayed Cord Clamping Should Be Standard Practice in Obstetrics
from Academic OB/GYN Blogcast
The UK makes it official!
Midwives told to drop ‘30-second rule’ on cutting umbilical cord after
delaying longer shown to benefit babies [8/18/12] - Longer connection
to mother's blood supply thought to protect babies against anaemia.
Evidence-based practices for the fetal to newborn transition - Many
common care practices during labor, birth, and the immediate
postpartum period impact the fetal to neonatal transition, including
medication used during labor, suctioning protocols, strategies to
prevent heat loss, umbilical cord clamping, and use of 100%
oxygen for resuscitation. Many of the care practices used to
assess and manage a newborn immediately after birth have not
proven efficacious.
Immediate Cord Clamping: the Primary Injury - Immediate clamping
of the umbilical cord before the child has breathed has been
condemned in obstetrical literature for over 200 years.
Blood simple - A small change in how babies are delivered might
abolish infantile anaemia [11/26/11] - Even the Economist is knows
26
about this . . . when will OBs learn?!?
Childbirth: Benefits Seen in Clamping the Cord Later [11/28/11] - And
now even the New York Times is in on it.
Waiting three minutes or longer before clamping a newborn’s
umbilical cord reduces the prevalence of iron deficiency at four
months, a large trial has found.
Swedish researchers studied 334 infants, randomly assigning
half to have their cords clamped within 10 seconds of birth and
the rest to clamping after three minutes or longer. The two
groups were statistically identical in gestational age, head
circumference, health and age of the mother, and other
characteristics.
In blood tests at two days after birth, there were no significant
differences in iron status. But when researchers analyzed blood
taken at four months, they found iron concentrations were 45
percent higher in the delayed clamping group, and iron
deficiency was significantly more prevalent in those who were
clamped early.
Dr. Ola Andersson, the lead author and a pediatrician at the
Hospital of Halland in Halmstad, Sweden, pointed out that there
were no adverse effects to delayed clamping.
“Many obstetricians worry about jaundice, and most believe that
delayed clamping causes it,” he said. But he and his colleagues
found no difference in rates of jaundice.
The study, published this month in the journal BMJ, is one of the
largest randomized trials of delayed cord clamping and the first
to assess iron status beyond the neonatal period in a highincome country.
Delayed Cutting of the Umbilical Cord--Robin Lim, C.P.M - learn
about "wisdom birthing". As her interviewer says, "There's actually
no reason to cut the cord, and every reason not to." [Ed: There's a
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point where Robin uses the term "stillborn" in a way that I'm pretty
sure she meant "unconscious", i.e. needing resuscitation.]
Neonatal Resuscitation: Life that Failed by George Malcolm Morley,
MB ChB FACOG - a great article about leaving the cord intact,
ESPECIALLY for distressed babies!
Effect of timing of umbilical cord clamping on iron status in Mexican
infants: a randomised controlled trial Camila M Chaparro a,
Lynnette M Neufeld b, Gilberto Tena Alavez c, Raúl Eguia-Líz
Cedillo c and Kathryn G Dewey a Summary The Lancet 2006;
367:1997-2004
Delay in cord clamping of 2 minutes could help prevent iron
deficiency from developing before 6 months of age, when ironfortified complementary foods could be introduced.
Current best evidence: a review of the literature on umbilical cord
clamping. Mercer JS. J Midwifery Womens Health. 2001 NovDec;46(6):402-14.
Delayed cord clamping increases infants' iron stores. Mercer J,
Erickson-Owens D. Lancet. 2006 Jun 17;367(9527):1956-8.
Neonatal transitional physiology: a new paradigm. Mercer JS,
Skovgaard RL. J Perinat Neonatal Nurs 2002 Mar;15(4):56-75
"Early clamping of the umbilical cord at birth, a practice developed
without adequate evidence, causes neonatal blood volume to vary
25% to 40%. Such a massive change occurs at no other time in one's
life without serious consequences, even death. Early cord clamping
may impede a successful transition and contribute to hypovolemic
and hypoxic damage in vulnerable newborns. The authors present a
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model for neonatal transition based on and driven by adequate blood
volume rather than by respiratory effort to demonstrate how neonatal
transition most likely occurs at a normal physiologic birth."
This unnecessary episode of transient hypoxia may contribute to
anorexia in later life:
Obstetric complications predict anorexia onset Source: Archives of
General Psychiatry 2006; 63: 82-8
Perinatal factors and the risk of developing anorexia nervosa and
bulimia nervosa. Favaro A, Tenconi E, Santonastaso P. Arch Gen
Psychiatry. 2006 Jan;63(1):82-8.
Favaro A1, Tenconi E, Santonastaso P.
Author information
Abstract
CONTEXT:
Few prospective studies to date have investigated the role of obstetric
complications in anorexia nervosa, and no study to our knowledge exists
for this in bulimia nervosa.
OBJECTIVE:
To explore the role of obstetric complications in the development of eating
disorders.
DESIGN:
A blind analysis of the obstetric records of a sample of subjects with
anorexia nervosa, with bulimia nervosa, and normal subjects was
performed. All of the subjects included in the study belong to the same
population birth cohort and were born in the 2 obstetric wards of Padua
Hospital, Padua, Italy, between January 17, 1971, and December 30,
1979.
SETTINGS AND PARTICIPANTS:
Part of the sample of subjects with eating disorders and all of the controls
took part in a prevalence study carried out in 2 randomly selected areas of
Padua. In addition, all of the subjects with anorexia nervosa and bulimia
nervosa of the same birth cohort who were referred to an outpatient
specialist unit were included. The final sample comprised 114 subjects with
anorexia nervosa, 73 with bulimia nervosa, and 554 control subjects.
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RESULTS:
Several complications, such as maternal anemia (P = .03), diabetes
mellitus (P = .04), preeclampsia (P = .02), placental infarction (P = .001),
neonatal cardiac problems (P = .007), and hyporeactivity (P = .03), were
significant independent predictors of the development of anorexia nervosa.
The risk of developing anorexia nervosa increased with the total number of
obstetric complications. In addition, an increasing number of complications
significantly anticipated the age at onset of anorexia nervosa (P = .03). The
obstetric complications significantly associated with bulimia nervosa were
the following: placental infarction (P = .10), neonatal hyporeactivity (P =
.005), early eating difficulties (P = .02), and a low birth weight for
gestational age (P = .009). Being shorter for gestational age significantly
differentiated subjects with bulimia nervosa from both those with anorexia
nervosa (P = .04) and control subjects (P = .05).
CONCLUSIONS:
A significantly higher risk of eating disorders was found for subjects with
specific types of obstetric complications. An impairment in
neurodevelopment could be implicated in the pathogenesis of eating
disorders.
Early clamping of the umbilical cord may interrupt humankind's first
'natural stem cell transplant'
Early Clamping Of The Umbilical Cord May Interrupt Humankind's First 'Natural Stem Cell
Transplant'
The USF review is published in a recent issue of the Journal of
Cellular and Molecular Medicine (14:3).
"Several clinical studies have shown that delaying clamping the umbilical
cord not only allows more blood to be transferred but helps prevent anemia
as well," said the paper's lead author Dr. Paul Sanberg, director of the
Center. "Cord blood also contains many valuable stem cells, making this
transfer of stem cells a process that might be considered 'the original stem
cell transplant'."
… Another potential benefit of delayed cord clamping is to ensure that the
baby can receive the complete retinue of clotting factors.
Yet, there is debate and disagreement on early versus later clamping. The
side favoring delayed clamping, the authors noted, cite the value of the
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infant's receiving umbilical cord blood (UCB)-derived stem cells, known to
be pluripotent.
"The virtue of the unique and immature features of cord blood, including
their ability to differentiate, are well known," added Dr. Sanberg.
The researchers concluded that many common disorders in newborns related
to the immaturity of organ systems may receive benefits from delayed
clamping. These may include: respiratory distress; anemia; sepsis;
intraventricular haemorrhage; and periventricular leukomalacia. They also
speculate that other health problems, such as chronic lung disease,
prematurity apneas and retinopathy of prematurity, may also be affected by a
delay in cord blood clamping.
http://www.cordclamp.org
G. M. Morley, MD FACOG
obgmmorley@aol.com
Birth Injuries Related to
Umbilical Cord Clamping:
Autism, cerebral palsy, anemia, hypovolemia, hypotension, ischemia, shock, shock lung,
respiratory distress, oliguria, hypoglycemia, ischemic encephalopathy, mental
retardation; neural, behavioral and developmental disorders.
The clinical origins of these birth injuries are meticulously recorded on the
birth certificate worksheet of every child born in the USA.
“Another thing very injurious to the child, is the tying and cutting of the navel
string too soon; which should always be left till the child has not only repeatedly
breathed but till all pulsation in the cord ceases. As otherwise the child is much weaker
than it ought to be, a portion of the blood being left in the placenta, which ought to have
been in the child.”
Erasmus Darwin, Zoonomia, 1801
“Immediately after delivery of the neonate, a segment of the umbilical cord should be
doubly clamped ...”
ACOG Practice Bulletins #127, #216, #348, 1989 – 2006
*The “MOST IMPORTANT FINDING was that delayed cord clamping
resulted in a 47% reduction of risk of infant anemia.” [1]
*“For each decrement in hemoglobin, [infant anemia] the risk of
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mental retardation [in grade school] increased by 1.28.” [2, 3]
How many obstetricians / neonatologists understand that when a
pulsating cord is clamped, and enough blood volume is removed to cause
anemia in infancy, the child’s IQ will be lowered for the rest of its life,
possibly to the extent of perpetual dependency?
EARLY CORD CLAMPING –> ANEMIA –> MENTAL RETARDATION
The practice of Immediate Cord Clamping (ICC) became widespread after 1980 with the
introduction of neonatal intensive care units and two new medical specialties,
neonatology and perinatology. The mandated routine care of the “at risk” birth entails
ICC and immediate removal to a resuscitation table for immediate ventilation /
oxygenation.
These “ICC” neonates, mainly preemies, C-section deliveries and “fetal distress /
asphyxia” births, are thus routinely hypovolemic - , “a portion of the blood [volume]
being left in the placenta”; many “normal” births are also subjected to ICC. The degree
of blood loss determines the degree of eventual anemia and the scale of other injuries that
are recorded on birth certificate worksheets. For thirty years, perinatal academia has
promoted an injurious practice that violates the basic principles of birth physiology.
Permanent Neural Injuries
Autism, (autistic spectrum disorder ASD) is the most common cord clamp injury. It is
a learning disorder of sound memory and speech. Inability to remember and form
sounds (words) impairs mental ability; the severity of ASD is measured by the
child’s IQ. The ICC and Cesarean section epidemics parallel the autism epidemic.
Cerebral Palsy follows neonatal (ischemic) encephalopathy and occurs in neonates that
are born already compromised by hypovolemia and hypovolemic shock, and are
resuscitated by ICC and ventilation.
________________________________________________________________________
_______
References:
1. Hutton EK, Hassan ES. Late vs Early Clamping of the Umbilical Cord in Full-term
Neonates. JAMA, March 21, 2007—Vol 297, No. 11 1241-1252
2. Lozoff B, Beard J, Long-lasting neural and behavioral effects of iron deficiency in
infancy Nut. Rev 2006 May 64 (5 PT 2): S34-S43
3. Hurtado EK et al. Early childhood anemia and mild to moderate mental
retardation. Am J Clin Nut. 1999; 69(1): 115-9.
The following thesis defines the extent of the perinatal professions’ errors and fallacies,
and illustrates how a small group of professional midwives have avoided this tragic
travesty of modern obstetrical practice:
Birth Brain Injury
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