The problem
One of the many questions hitting our inbox recently is to do with the practice of delayed cord clamping at caesarean section.
As we move practice further towards the stabilisation and resuscitation of the neonate with an intact umbilical cord, one of the very first issues to be addressed is the lack of or minimal timing of delayed cord clamping in theatre.
We recognise that practice is always going to be slow to change. While we wait for practitioner enrolment and trusts to purchase specialist equipment to enable motherside stabilisation, particularly in theatre, we can't ignore that many babies may, in the meantime, be denied adequate time for placental transfusion.
The reason for concern
We know 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 (Erickson-Owens, Mercer and Oh, 2011). This later improving neurological development, white matter gain and fine motor skills (Mercer et al., 2018; Andersson et al., 2011).
The physiology tells us, 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 lungs—changing 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 (Mercer and Skovgaard, 2002).
Receiving placental blood volume ensures a smoother transition and helps to minimise any hypoxic oxidative stress to the neonate.
The issues at caesarean
Maternal post partum haemorrage (PPH)
Kuo et al., (2017) found no clinically significant difference in rates of PPH rates between ECC and DCC groups in their preterm cesarean section study.
Purisch et al., (2019) report in scheduled term caesarean delivery, DCC is not associated with increased maternal blood loss but does achieve higher neonatal Hgb levels at 24-72 hrs of life.
Ruangkit et al., (2018) study considered the theoretical concerns of increased risk of maternal blood loss secondary to increase time spent performing DCC in multiple pregnancies. They found no significant increase in morbidity was found in terms of estimated blood loss, rate of PPH, diagnosis of other bleeding complication or post-cesarean decreases in maternal haemoglobin and hematocrit, maternal blood transfusion or therapeutic hysterectomy between the immediate cord clamping and DCC groups.
Delayed hysterotomy closure (closing of the maternal uterine wall)
Kuo et al., (2017) found no difference in operating room time or maternal PPH rates, suggesting that the practice of DCC itself represents a minimal interruption during cesarean deliveries.
Ruangkit et al's., (2018) study showed no significant increase in delayed hysterotomy closure, precipitate uterine atony, or operative time in relation to PPH of multiple pregnancies above.
Delayed uterotonic administration
High quality evidence suggests that maternal infectious morbidity is reduced with antibiotics use administered routinely within 60 minutes before the cesarean delivery skin incision. The use of specific antibiotics dependant on whether there are ruptured membranes can confer additional reduction in postoperative infection (Caughey et al., 2018).
In addition, Bollig et al's. (2017) systematic review showed that women who received antibiotics preoperatively were 28% less likely to develop composite infectious morbidities as compared with those who received antibiotics after neonatal cord clamping. They also identified that none of the reviews or guidelines identified disadvantages for the neonates when the prophylaxis is given before cord clamping. However they do comment that additional research in neonatal outcomes are needed to rule out definitively any safety issues related to antepartum antibiotic exposure in infants.
Baby getting cold
Caughey et al. (2018) recommend immediate drying and covering of the infant’s head reduce heat losses while awaiting cord clamping of at least 1 minute in term infants at caesarean section. Use of exothermic heaters or open bed incubators, transwarmer mat- tresses, plastic wraps/bags, and caps all keep preterm infants warmer and lead to higher temperatures on admission to neonatal units and less hypothermia. Body temperature should be measured and maintained at between 36.5C and 37.5C after birth, through admission and stabilisation.
Position of the neonate during delayed cord clamping
In caesarean delivery, Caughey et al. (2018) recommend the neonate can be placed on the maternal abdomen or legs or held by the surgeon or assistant close to the level of the placenta until the umbilical cord is clamped. It is not recommended to lift baby up over the drapes (Lion King pose!) to show the parents during delayed cord clamping as the effect of gravity predisposes blood to flow away from the baby and negates benefits of DCC. A brief explanation for the delay can be offered to parents and baby immediately taken for skin to skin following DCC.
Exceptions
There are some scenarios where it is sensible to perform immediate cord clamping;
severe placental abruption, placenta acareta, fetal hydrops, twin-twin transfusion syndrome, and known fetal anomalies.
A resource solution
In response to some of the challenges to changing practice, three members of the bloodtobaby team collaborated to make a new resource which can be used in clinical practice.
This resource intends to raise awareness of delayed cord clamping at caesarean section, with the aim to influence optimal maternal and neonatal outcomes in theatre. This resource can now be ordered for a minimal charge from the BloodtoBaby Online Store.
References
Andersson, O., Hellstrom-Westas, L., Andersson, D. and Domellof, M. (2011). Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. BMJ, 343(nov15 1), pp.d7157-d7157.
Bollig, C., Nothacker, M., Lehane, C., Motschall, E., Lang, B., Meerpohl, J. and Schmucker, C. (2017). Prophylactic antibiotics before cord clamping in cesarean delivery: a systematic review. Acta Obstetricia et Gynecologica Scandinavica, [online] 97(5), pp.521-535. Available at: https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/aogs.13276
Caughey, A., Wood, S., Macones, G., Wrench, I., Huang, J., Norman, M., Pettersson, K., Fawcett, W., Shalabi, M., Metcalfe, A., Gramlich, L., Nelson, G. and Wilson, R. (2018). Guidelines for intraoperative care in cesarean delivery: Enhanced Recovery After Surgery Society Recommendations (Part 2). American Journal of Obstetrics and Gynecology, [online] 219(6), pp.533-544. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30118692
Erickson-Owens, D., Mercer, J. and Oh, W. (2011). Umbilical cord milking in term infants delivered by cesarean section: a randomized controlled trial. Journal of Perinatology, [online] 32(8), pp.580-584. Available at: https://www.nature.com/articles/jp2011159#ref19
Kuo, K., Gokhale, P., Hackney, D., Ruangkit, C., Bhola, M. and March, M. (2017). Maternal outcomes following the initiation of an institutional delayed cord clamping protocol: an observational case–control study. The Journal of Maternal-Fetal & Neonatal Medicine, [online] 31(2), pp.197-201. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28068852
Mercer, J. and Skovgaard, R. (2002). Neonatal Transitional Physiology. The Journal of Perinatal & Neonatal Nursing, [online] 15(4), pp.56-75. Available at: https://europepmc.org/abstract/med/11911621
Mercer, J., Erickson-Owens, D., Deoni, S., Dean, D., Collins, J., Parker, A., Wang, M., Joelson, S., Mercer, E. and Padbury, J. (2018). Effects of Delayed Cord Clamping on 4-Month Ferritin Levels, Brain Myelin Content, and Neurodevelopment: A Randomized Controlled Trial. The Journal of Pediatrics, [online] 203, pp.266-272.e2. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6259583/.
Purisch, S., Ananth, C., Mauney, L., Arditi, B., Ajemian, B., Heiderich, A., Leone, T. and Gyamfi-Bannerman, C. (2019). 47: Impact of delayed cord clamping on maternal blood loss in term cesareans: a randomized trial. American Journal of Obstetrics and Gynecology, [online] 220(1), pp.S37-S38. Available at: https://www.ajog.org/article/S0002-9378(18)31074-3/fulltext
Ruangkit, C., Leon, M., Hassen, K., Baker, K., Poeltler, D. and Katheria, A. (2018). Maternal bleeding complications following early versus delayed umbilical cord clamping in multiple pregnancies. BMC Pregnancy and Childbirth, [online] 18(1). Available at: https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-018-1781-6
Weeks, A. (2012). Early umbilical cord clamping increases the risk of neonatal anaemia and infant iron deficiency. Evidence-Based Medicine, 17(6), pp.179-180.