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Research and references

The practice of clamping the umbilical cord almost immediately following delivery can probably be traced to the introduction of oxytocics to reduce post-partum haemorrhage in the mother and fears of increased incidence of hyperbilirubinaemia in the baby. However changes in drugs available and more recent research 1-5 have rendered the approach of early cord clamping of no benefit in either respect.

 

There is a growing body of evidence showing that there are a number of very significant advantages for the newborn baby if clamping of the umbilical cord is delayed for three minutes or more following delivery 1-9. Delayed or deferred cord clamping (DCC) allows the baby to benefit from the continued supply of oxygenated blood from the placenta until spontaneous breathing is established 3,7, which can be of particular importance in the preterm neonate. It has been shown that if respiration starts before the cord is clamped then the risk of bradycardia is reduced10.

 

Following delivery, provided the umbilical cord is not clamped, there is a process of blood transfer from the placenta to the baby, known as placental transfusion. Research has shown that during the three minutes immediately after birth this transfusion can account for over 30% of the newborn’s blood volume 1-4,6. If deprived of this volume the consequences can be critical, with hypovolaemia and reduced cardiac output1,3,4,8, which can be of particular importance in babies with compromised cardiorespiratory function.

 

In pre-term babies lower blood volume in the baby increases the risk of intra-ventricular haemorrhage and a need for blood transfusion in the early stages, and late onset sepsis 1,2,4,8,9,11. In all babies there are also a number of longer term effects, such as anaemia and iron deficiency, lasting as long as 6 months 2-5. The deprivation of a significant volume of stem cells may also have implications on organ development and the spontaneous repair of any intra-partum injury 2. In addition to the shorter term benefits of delayed or deferred cord clamping, studies suggest that there are significant long-term effects, including a reduction in cognitive and behavioural problems 2,4.

 

An increasing number of national and international guidelines now recommend delayed or deferred cord clamping 10-12. However cardiorespiratory resuscitation and good early thermal management often remain a priority and thus prevent the practice of DCC in sick babies who are not considered suitable for “skin-to-skin” care. Preterm babies are likely to benefit most if clamping of the umbilical cord is delayed, yet these are the patients most likely to need resuscitation, making the provision of facilities to allow both these goals to be achieved together an important clinical need.

 

In summary, there are very significant benefits for the newborn if delayed or defered cord clamping is practised, particularly in pre-term babies, with an ideal delay of at least 3 minutes, and the advantages extend well beyond the immediate post-delivery period. It has been established that there is no disadvantage for the mother in this approach which in reality exactly matches nature’s own way.

 

Dr Alan Greene talks about the ticctocc campaign for optimal cord clamping. Click here to see the video.

 

References:

 

1.    Hutchon DJR. Immediate or early cord clamping vs delayed clamping. Journal of Obstetrics and Gynaecology, November 2012; 32: 724-729

 

2.    Mercer JS, Erickson-Owens DA; Rethinking placental transfusion and cord clamping issues. J Perinat Neonat Nurs. 2012; 26; 3; 202-217.

 

3.    Van Rheenen P. Delayed cord clamping and improved infant outcomes. BMJ. 2011; 343:d7127

 

4.    Pan American Health Organization. Beyond survival: Integrated delivery care practices for long-term maternal and infant nutrition, health and development. World Health Organization. 2007.

 

5.    Andersson O et al   Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. BMJ. 2011;343:d7157

 

6.    Farrar D, et al. Measuring placental transfusion for term births: weighing babies with cord intact. BJOG. 2011; 118:70–75.

 

7.    Wiberg N, Källén K, Olofsson P. Delayed umbilical cord clamping at birth has effects on arterial and venous blood gases and lactate concentrations. BJOG. 2008; 115: 697–703.

 

8.    Rabe H, Reynolds G, Diaz-Rossello J. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database of Systematic Reviews.2004, Issue 4. Art. No.: CD003248. DOI: 10.1002/14651858. CD003248.pub2.

 

9.    Mercer JS, et al. Seven-month developmental outcomes of very low birth weight infants enrolled in a randomized controlled trial of delayed versus immediate cord clamping. J Perinatology. 2010; 30; 11-16.

 

10. Richmond S, Wyllie J. European Resuscitation Council guidelines for resuscitation  2010. Resuscitation 81; 2010; 1389-1399.

 

11.  Royal College of Obstetricians and Gynaecologists, UK. Clamping of the umbilical cord and placental transfusion. 2009. Scientific Advisory Committee Opinion Paper 14.

 

12. World Health Organisation. Guidelines on basic newborn resuscitation 2012. ISBN 978 92 4 150369 3.

 

13. Ceriani Cernadas JM, et al. The effect of early and delayed umbilical cord clamping on ferritin levels in term infants at six months of life: a randomized, controlled trial. Arch Argent Pediatr. 2010; 108(3); 201-208.

Other references for optimal cord clamping/ cord milking & resus with an intact cord

AAP. (2013). Timing of Umbilical Cord Clamping After Birth. PEDIATRICS, 131(4), e1323-e1323. http://dx.doi.org/10.1542/peds.2013-0191

AAP. (2013). Timing of Umbilical Cord Clamping After Birth. PEDIATRICS, 131(4), e1323-e1323. http://dx.doi.org/10.1542/peds.2013-0191

ACOG. (2017). Delayed Umbilical Cord Clamping After Birth; No 684 (1st ed.). Washington: The American College of Obstetricians and Gynaecologists. Retrieved from https://www.acog.org/-/media/Committee-Opinions/Committee-on-Obstetric-Practice/co684.pdf?dmc=1&ts=20170126T1339592817

Agarwal, S., Jaiswal, V., Singh, D., Jaiswal, P., Garg, A., & Upadhyay, A. (2016). Randomised control trial showed that delayed cord clamping and milking resulted in no significant differences in iron stores and physical growth parameters at one year of age. Acta Paediatrica, 105(11), e526-e530. http://dx.doi.org/10.1111/apa.13559

Alwan, N., Cade, J., McArdle, H., Greenwood, D., Hayes, H., & Simpson, N. (2015). Maternal iron status in early pregnancy and birth outcomes: insights from the Baby's Vascular health and Iron in Pregnancy study. British Journal Of Nutrition, 113(12), 1985-1992. http://dx.doi.org/10.1017/s0007114515001166

Al-Wassia, H., & Shah, P. (2015). Efficacy and Safety of Umbilical Cord Milking at Birth. JAMA Pediatrics, 169(1), 18. http://dx.doi.org/10.1001/jamapediatrics.2014.1906

Andersson, O., Hellstrom-Westas, L., Andersson, D., & 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), d7157-d7157. http://dx.doi.org/10.1136/bmj.d7157

Andersson, O., Hellström-Westas, L., Andersson, D., Clausen, J., & Domellöf, M. (2012). Effects of delayed compared with early umbilical cord clamping on maternal postpartum hemorrhage and cord blood gas sampling: a randomized trial. Acta Obstetricia Et Gynecologica Scandinavica, 92(5), 567-574. http://dx.doi.org/10.1111/j.1600-0412.2012.01530.x

Andersson, O., Hellström-Westas, L., & Domellöf, M. (2016). Elective caesarean: does delay in cord clamping for 30 s ensure sufficient iron stores at 4 months of age? A historical cohort control study. BMJ Open, 6(11), e012995. http://dx.doi.org/10.1136/bmjopen-2016-012995

Awonusonu, F., Pauly, T., & Hutchison, A. (2002). Maternal Smoking and Partial Exchange Transfusion for Neonatal Polycythemia. Am J Perinatol, 19(7), 349-354. http://dx.doi.org/10.1055/s-2002-35615

Backes, C., Huang, H., Iams, J., Bauer, J., & Giannone, P. (2015). Timing of umbilical cord clamping among infants born at 22 through 27 weeks’ gestation. J Perinatol. http://dx.doi.org/10.1038/jp.2015.117

Baker, R., & Greer, F. (2010). Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0-3 Years of Age). PEDIATRICS, 126(5), 1040-1050. http://dx.doi.org/10.1542/peds.2010-2576

Batey, N., Yoxall, C., Fawke, J., Duley, L., & Dorling, J. (2017). Fifteen-minute consultation: stabilisation of the high-risk newborn infant beside the mother. Archives Of Disease In Childhood - Education & Practice Edition, 102(5), 235-238. http://dx.doi.org/10.1136/archdischild-2016-312276

Benoist, B., McLean, E., Egli, I., & Cogswell, M. (2008). Worldwide prevalence of anaemia 1993–2005 (1st ed.). Genneva: World Health Organisation. Retrieved from http://apps.who.int/iris/bitstream/10665/43894/1/9789241596657_eng.pdf

Bhatt, S., Alison, B., Wallace, E., Crossley, K., Gill, A., & Kluckow, M. et al. (2013). Delaying cord clamping until ventilation onset improves cardiovascular function at birth in preterm lambs. The Journal Of Physiology, 591(8), 2113-2126. http://dx.doi.org/10.1113/jphysiol.2012.250084

Bora, R., Akhtar, S., Venkatasubramaniam, A., Wolfson, J., & Rao, R. (2015). Effect of 40-cm segment umbilical cord milking on hemoglobin and serum ferritin at 6 months of age in full-term infants of anemic and non-anemic mothers. Journal Of Perinatology, 35(10), 832-836. http://dx.doi.org/10.1038/jp.2015.92

Burleigh, A., & Tizard, H. (2015). Latest recommendations on timing of clamping the umbilical cord | RCM. Rcm.org.uk. Retrieved 1 July 2015, from https://www.rcm.org.uk/news-views-and-analysis/views/latest-recommendations-on-timing-of-clamping-the-umbilical-cord

Burleigh, A., Tizard, H., & Munro, D. (2015). Optimal Cord Clamping (pp. 23(6): 55). Midwifery Matters. Retrieved from https://www.inmo.ie/tempDocs/55.%20MidwiferyMattersCord%20Jul%20Aug%2015.pdf

Canterbury District Health Board. (2014). Umbilical Cord Clamping for Term Infants >37 Weeks. Te Poarii Hauora O Waitaha: CDHB.

Ceriani Cernadas, J. (2006). The Effect of Timing of Cord Clamping on Neonatal Venous Hematocrit Values and Clinical Outcome at Term: A Randomized, Controlled Trial. PEDIATRICS, 117(4), e779-e786. http://dx.doi.org/10.1542/peds.2005-1156

Ceriani Cernadas, J., Carroli, G., Pellegrini, L., Otaño, L., Ferreira, M., & Ricci, c. et al. (2006). The Effect of Timing of Cord Clamping on Neonatal Venous Hematocrit Values and Clinical Outcome at Term: A Randomized, Controlled Trial. PEDIATRICS, 117(4), e779-e786. http://dx.doi.org/10.1542/peds.2005-1156

Cernadas, J., Carroli, G., Pellegrini, L., Otao, L., Ferreira, M., & Ricci, C. et al. (2006). The Effect of Timing of Cord Clamping on Neonatal Venous Hematocrit Values and Clinical Outcome at Term: A Randomized, Controlled Trial. Obstetrical & Gynecological Survey, 61(9), 564-565. http://dx.doi.org/10.1097/01.ogx.0000234630.19396.b6

Chantry, C. Delayed Umbilical Cord Clamping - C-section Pilot. California: University of California. Retrieved from https://clinicaltrials.gov/ct2/show/study/NCT02229162

Chaparro, C., Neufeld, L., Alavez, G., Cedillo, R., & Dewey, K. (2006). Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomised controlled trial. Dx.doi.org. Retrieved 21 April 2017, from http://dx.doi.org/10.1016/S0140-6736(06)68889-2

Chiruvolu, A., Tolia, V., Qin, H., Stone, G., Rich, D., Conant, R., & Inzer, R. (2015). Effect of delayed cord clamping on very preterm infants. American Journal Of Obstetrics And Gynecology. http://dx.doi.org/10.1016/j.ajog.2015.07.016

Christensen, R., Baer, V., Gerday, E., Sheffield, M., Richards, D., & Shepherd, J. et al. (2013). Whole-blood viscosity in the neonate: effects of gestational age, hematocrit, mean corpuscular volume and umbilical cord milking. J Perinatol, 34(1), 16-21. http://dx.doi.org/10.1038/jp.2013.112

Clamping of the Umbilical Cord and Placental Transfusion (Scientific Impact Paper No. 14). (2015). Royal College of Obstetricians and Gynaecologists. Retrieved 16 June 2015, from https://www.rcog.org.uk/en/guidelines-research-services/guidelines/sip14

Colozzi, A. (1954). Clamping of the Umbilical Cord. New England Journal Of Medicine, 250(15), 629-632. http://dx.doi.org/10.1056/nejm195404152501502

Committee Opinion No.543. (2012). Obstetrics & Gynecology, 120(6), 1522-1526. http://dx.doi.org/10.1097/01.aog.0000423817.47165.48

Di Tommaso, M., Seravalli, V., Martini, I., La Torre, P., & Dani, C. (2014). Blood gas values in clamped and unclamped umbilical cord at birth. Early Human Development, 90(9), 523-525. http://dx.doi.org/10.1016/j.earlhumdev.2014.03.010

Daly, M., & Bock, R. (2015). Umbilical cord ‘milking’ improves blood flow in preterm infants. National Institutes of Health (NIH). Retrieved 3 April 2017, from https://www.nih.gov/news-events/news-releases/umbilical-cord-milking-improves-blood-flow-preterm-infants

Drukker, L., Hants, Y., Farkash, R., Ruchlemer, R., Samueloff, A., & Grisaru-Granovsky, S. (2015). Iron deficiency anemia at admission for labor and delivery is associated with an increased risk for Cesarean section and adverse maternal and neonatal outcomes. Transfusion, 55(12), 2799-2806. http://dx.doi.org/10.1111/trf.13252

Effect of Timing of Umbilical Cord Clamping on Iron Status in Mexican Infants: A Randomised Controlled Trial. (2006). Obstetric Anesthesia Digest, 26(4), 187-188. http://dx.doi.org/10.1097/00132582-200612000-00026

Enhamed, M., VanRheenen, P., & Brabin, B. (2004). early effects of delayed cord clamping in term babies born to libyan mothers.

European Resuscitation Council. Guidelines for resuscitation. (2010). Erc.edu. Retrieved 9 April 2015, from https://www.erc.edu/index.php/doclibrary/en/209/1/

Erickson-Owens, D. (2009). Milking the umbilical cord at term Cesarean section: Effect on hemoglobin levels in the first 48 hours of life (DOCTOR OF PHILOSOPHY). University of Rhode Island.

Erickson-Owens, D., Mercer, J., & Oh, W. (2011). Umbilical cord milking in term infants delivered by cesarean section: a randomized controlled trial. Journal Of Perinatology, 32(8), 580-584. http://dx.doi.org/10.1038/jp.2011.159

Fanaroff, A., Martin, R., & Walsh, M. (2006). Fanaroff and Martin's neonatal-perinatal medicine. Philadelphia, Pa: Mosby, Elsevier.

Farrar, D., Airey, R., Law, G., Tuffnell, D., Cattle, B., & Duley, L. (2010). Measuring placental transfusion for term births: weighing babies with cord intact. BJOG: An International Journal Of Obstetrics & Gynaecology, 118(1), 70-75. http://dx.doi.org/10.1111/j.1471-0528.2010.02781.x

Finn, D., Roehr, C., Ryan, C., & Dempsey, E. (2017). Optimising Intravenous Volume Resuscitation of the Newborn in the Delivery Room: Practical Considerations and Gaps in Knowledge. Neonatology, 112(2), 163-171. http://dx.doi.org/10.1159/000475456

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Gordon, E. (2003). Polycythemia and Hyperviscosity of the Newborn. The Journal Of Perinatal & Neonatal Nursing, 17(3), 209-221. http://dx.doi.org/10.1097/00005237-200307000-00006

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Grajeda, R., Pérez-Escamilla, R., & Dewey, K. (1997). Delayed clamping of the umbilical cord improves hematologic status of Guatemalan infants at 2 mo of age. American Journal Of Clinical Nutritian. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/9022526

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