Delayed Cord Clamping in Preterm Neonates: A Review of Benefits and Risks

How to improve newborn outcomes in 60 s-delay clamping the umbilical cord

Deferred umbilical cord clamping (DCC) has been employed with wide variation in the United States over the last few decades. This practice has the potential to improve infant health and outcomes at the population health level. Education campaigns and policy interventions can promote DCC use in a safe manner.

Umbilical cord milking and delayed cord clamping for the prevention of neonatal hypoglycaemia: a systematic review and meta-analysis

BACKGROUND

Placental management strategies such as umbilical cord milking and delayed cord clamping may provide a range of benefits for the newborn. The aim of this review was to assess the effectiveness of umbilical cord milking and delayed cord clamping for the prevention of neonatal hypoglycaemia.

METHODS

Three databases and five clinical trial registries were systematically reviewed to identify randomised controlled trials comparing umbilical cord milking or delayed cord clamping with control in term and preterm infants. The primary outcome was neonatal hypoglycaemia (study defined). Two independent reviewers conducted screening, data extraction and quality assessment. Quality of the included studies was assessed using the Cochrane Risk of Bias tool (RoB-2). Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Meta-analysis using a random effect model was done using Review Manager 5.4. The review was registered prospectively on PROSPERO (CRD42022356553).

RESULTS

Data from 71 studies and 14 268 infants were included in this review; 22 (2 537 infants) compared umbilical cord milking with control, and 50 studies (11 731 infants) compared delayed with early cord clamping. For umbilical cord milking there were no data on neonatal hypoglycaemia, and no differences between groups for any of the secondary outcomes. We found no evidence that delayed cord clamping reduced the incidence of hypoglycaemia (6 studies, 444 infants, RR = 0.87, CI: 0.58 to 1.30, p = 0.49, I2 = 0%). Delayed cord clamping was associated with a 27% reduction in neonatal mortality (15 studies, 3 041 infants, RR = 0.73, CI: 0.55 to 0.98, p = 0.03, I2 = 0%). We found no evidence for the effect of delayed cord clamping for any of the other outcomes. The certainty of evidence was low for all outcomes.

CONCLUSION

We found no data for the effectiveness of umbilical cord milking on neonatal hypoglycaemia, and no evidence that delayed cord clamping reduced the incidence of hypoglycaemia, but the certainty of the evidence was low.

Immediate vs delayed cord clamping in preterm infants: A systematic review and meta-analysis

To compare and evaluate the efficacy and safety of immediate cord clamping (ICC) and delayed cord clamping (DCC) in preterm infants. We performed a comprehensive and systematic meta-analysis of randomised controlled trials (RCTs) assessing ICC and DCC in preterm infants by searching PUBMED, EMBASE, Science Direct, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, and Wanfang Database (from inception to 30 September 2020). Summary odds ratios or mean differences with 95% confidence intervals were calculated using a fixed- or random-effect model. A total of 20 RCTs with 1807 preterm infants were included in the study. DCC provided more benefits in increasing the haematocrit and haemoglobin levels at 24 hours of life (%), thus reducing the incidence of anaemia, necrotising enterocolitis, length of hospital stay and mortality than when ICC was performed. No significant differences were found between ICC and DCC in terms of peak bilirubin level; need for blood transfusion, mechanical ventilation (MV) and phototherapy; duration of MV and phototherapy; and incidences of intraventricular haemorrhage, retinopathy of prematurity, patent ductus arteriosus, respiratory distress syndrome, sepsis, jaundice, polycythaemia, periventricular leukomalacia and bronchopulmonary dysplasia. DCC is a safe, beneficial and feasible intervention for preterm infants. However, rigorously designed and large-scale RCTs are necessary to identify the role and ideal timing of DCC.

A Quality Improvement Project to Delay Umbilical Cord Clamping Time

Delayed cord clamping (DCC) has numerous benefits to the neonate, including increased hemoglobin levels, decreased need for red blood cell transfusions, and decreased incidence of necrotizing enterocolitis and intraventricular hemorrhage. A preliminary observational study at our institution demonstrated 12% of the observed deliveries met the DCC standard, defined as umbilical cord clamping at least 30-60 seconds after birth. Therefore, we designed a quality improvement project to increase the percentage of deliveries using DCC.

METHODS

We planned a quality improvement project aiming to increase DCC rates on the university obstetrics service. Our interventions included provider education, installation of timers in the delivery suites, and modification to documentation in the electronic health record. We measured our results through the documented status of cord clamping, either: (1) greater than or equal to 30 seconds or (2) less than 30 seconds. We analyzed the DCC rates weekly and compared those results to the DCC goal of 80% of all deliveries.

RESULTS

Postintervention DCC rates were 96% overall. Rates of DCC met our aim of 80% or greater each of the 6 weeks we collected data.

CONCLUSION

Simple and inexpensive interventions quickly led to improvements in DCC rates on our university obstetrics service. Our interventions including, provider education, installation of timers in delivery suites, and modification to cord clamping documentation in the electronic health record can be easily instituted at other hospitals. Additionally, the simplicity of this system can produce long-term sustainability of DCC.

Impact of a delayed cord clamping protocol on maternal and neonatal outcomes in patients undergoing term cesarean section

OBJECTIVE

Given concerns amongst physicians and other maternity providers for increased maternal blood loss with delayed cord clamping, our objective was to determine the impact of routine delayed clamping with term cesarean section on maternal blood loss metrics.

STUDY DESIGN

A retrospective cohort study evaluated the impact of delayed cord clamping in term cesareans at our tertiary care center following protocol implementation. The pre-protocol group (PRE) ranged 1 October 2015 to 31 March 2016. The post-protocol (POST) group ranged 1 October 2017 to 31 March 2018. The primary outcome was maternal estimated blood loss (EBL) during cesarean section. Secondary outcomes included maternal transfusion, hemorrhage (EBL > 1,000 mL), and changes in hemoglobin (Hgb) and hematocrit (HCT). Neonatal outcomes were APGAR scores at 1 and 5 min.

RESULTS

733 subjects were included, (PRE = 416, POST = 317). Overall 44.7% reported prior cesarean section. Preop differences included only platelets k/µL (222 vs. 211, p = .015), Hgb g/dL (11.7 vs. 11.9, p = .002) and HCT% (36.2 vs. 35.2, p = .027), with Hgb and HCT differences in opposite clinical directions. EBL actually decreased after the delayed cord clamping protocol (p = .04). The median [interquartile range] was the same (700 [600-800]), but the PRE group had higher proportions of EBL 800-1,000 (16% vs. 11%) and EBL > 1,000 (4.3% vs 3.7%) comprising this statistical difference. There was no difference in maternal transfusion (2.2%), hemorrhage (11.1%), or change in Hgb (Δ = -1.6 g/dL) or HCT (Δ = -4.6%), (all p > .05). APGAR scores were slightly lower in the POST group at 1 min (8 [8-9] vs. 9 [8-9], p = .035) but similar by 5 min (9 [9-9], p = .38).

CONCLUSION

Concerns for increased maternal blood loss during cesarean delivery after implementing a routine delayed cord clamping protocol were not supported. While EBL was lower with delayed cord clamping, all differences between groups appear to lack clinical significance. This offers reassuring evidence there is no negative impact on maternal hematologic characteristics including blood loss from the delayed cord clamping protocol.

Influence of delayed umbilical cord clamping on pain during suture of perineal tears: A randomised controlled study

OBJECTIVE

This study investigated whether the delayed umbilical cord clamping can influence the pain during suturing perineal tears.

DESIGN

This randomised controlled study applied the Consolidated Standards of Reporting Trials statement.

METHODS

The sample comprised 288 pregnant women who gave birth through vaginal delivery in our hospital from November 2019 to December 2019. They were randomly divided into 2 groups-early umbilical cord clamping (n = 147) and delayed umbilical cord clamping (n = 141)-without severe pregnancy complications. There was no intrauterine infection, neonatal asphyxia or premature birth in the 288 newborns. The pain scores of the Numerical Rating Scale, Visual Analogue Scale, Verbal Rating Scale and Faces Pain Scale-Revised were used as indicators to evaluate the mothers' pain. The Mann-Whitney U test was used, and the statistical significance was set to p < .05.

RESULT

All indicators suggest that perineal suture pain of delayed umbilical cord clamping was lower than that of the control group. For the experience group, the perception of pain for the mothers who received analgesia was less than that for those who did not. For the control group, the Verbal Rating Scale suggests a statistical difference in suturing pain between acceptable and unacceptable labour analgesia. The degree of cooperation of the experience group was higher than that of the control group, but labour analgesia did not affect cooperation degree in both groups.

CONCLUSION

Delayed umbilical cord clamping can alleviate maternal pain when suturing perineal tears and improve the delivery experience. Labour analgesia can enhance the pain relief effect. Trial registration was performed on www.chictr.org.cn (ChiCTR1900026797).

RELEVANCE TO CLINICAL PRACTICE

As a part of perinatal nursing, delayed umbilical cord clamping can help alleviate the pain of perineal suture and improve the experience of parturient. The method is simple and can be used as a routine nursing operation.

Review of the evidence for interventions to reduce perinatal mortality in low- and middle-income countries

Low- and middle-income countries contribute to the overwhelming majority of the global perinatal and neonatal mortality. There is a growing amount of literature focused on interventions aimed at reducing the healthcare gaps and thereby reducing perinatal and neonatal mortality in low- and middle-income countries. The current review synthesizes available evidence for interventions that have shown to improve perinatal and neonatal outcomes. Reduction in important gaps in the availability and utilization of perinatal care practices is needed to end preventable deaths of newborns.

Dealing with neonatal emergencies in low-resource settings

We describe the development and delivery of neonatal care including trends and impacts of major interventions on neonatal mortality particularly in low-resource settings. Low- and middle-income countries continue to be major contributors to neonatal mortality. Although there has been progress in reducing neonatal mortality, neonatal deaths are contributing an increasing percentage of childhood mortality. Several interventions targeting neonatal care such as neonatal resuscitation and essential newborn care have contributed to improved outcomes. However, there are still many neonatal deaths that are preventable with known effective interventions. This review addresses interventions proven effective in reducing neonatal mortality, challenges to implement them, and future directions of implementing these interventions in low- and middle-income countries.

National Program for RMNCH + A: Newer Strategies for Improving the Newborn Health in India

RMNCH+A is a platform for delivering adolescent, maternal, newborn and child health in an integrated manner using a life cycle approach. The new initiatives under this strategy that would impact newborn health include antenatal corticosteroids in preterm labor, delayed clamping of cord at birth, skin-to-skin contact at birth and Kangaroo mother care, Family participatory care, Lactation management centers and care beyond newborn survival under the Rashtriya Bal Swasthya Karyakram. Even though the coverage of many of the existing initiatives has been moderately high, there are concerns about the quality of delivery of these interventions and slow progress in the roll out of the newer interventions. Quality assurance initiative such as Dakshata and LaQshaya will also contribute to improved newborn health as we proceed towards the Sustainable development goals (SDG) 2030 targets for newborn and child survival.

Neuroprotective Care of Extremely Preterm Infants in the First 72 Hours After Birth

Birth at extremely low gestational ages presents a significant threat to infants' survival, health, development, and future well-being. After birth, a critical period of brain development must continue outside the womb. Neuro-supportive and neuroprotective family centered developmental care for and standardized care practices for extremely preterm infants have been shown to improve outcomes. Neuroprotective interventions must include a focus on the emotional connections of infants and their families. Being in skin-to-skin contact with the mother is the developmentally expected environment for all mammals and is especially important for supporting physiologic stability and neurodevelopment of preterm infants.

Effect and safety of timing of cord clamping on neonatal hematocrit values and clinical outcomes in term infants: A randomized controlled trial

OBJECTIVE

To evaluate the effect and safety of different umbilical cord clamping (UCC) timing.

STUDY DESIGN

This was a randomized trial of 720 term mothers/infants from the Tianjin Central Hospital of Obstetrics and Gynecology delivered from December 2014 to May 2015 and randomized to immediate cord clamping (ICC) within 15 s, delayed cord clamping (DCC) by 30, 60, 90, 120, 150, or 180 s, or when the umbilical cord pulsation ceased.

RESULTS

24 h after delivery, the mean infant hematocrit levels were 56.5, 57.3, 58.8, 59.7, 59.5, 59.7, 60.3, and 61.0% in the ICC, 30, 60, 90, 120, 150, and 180-second DCC, and no pulsation groups, respectively (P = 0.021, 0.001, 0.003, 0.001, <0.001, and <0.001, respectively; standard deviations ranging 5.4-8.7%). There was no significant difference between the 30-second DCC and ICC groups. No significant differences were found in other neonatal and maternal outcomes among these groups.

CONCLUSION

For term infants, DCC increases the hematocrit values, without apparent harmful effects on the infants and their mothers.

Pathophysiology, screening and treatment of ROP: A multi-disciplinary perspective

The population of infants at risk for retinopathy of prematurity (ROP) varies by world region; in countries with well developed neonatal intensive care services, the highest risk infants are those born at less than 28 weeks gestational age (GA) and less than 1 kg at birth, while, in regions where many aspects of neonatal intensive and ophthalmological care are not routinely available, more mature infants up to 2000 g at birth and 37 weeks GA are also at risk for severe ROP. Treatment options for both groups of patients include standard retinal laser photocoagulation or, more recently, intravitreal anti-VEGF drugs. In addition to detection and treatment of ROP, this review highlights new opportunities created by telemedicine, where screening and diagnosis of ROP in remote locations can be undertaken by non-ophthalmologists using digital fundus cameras. The ophthalmological care of the ROP infant is undertaken in the wider context of neonatal care and general wellbeing of the infant. Because of this context, this review takes a multi-disciplinary perspective with contributions from retinal vascular biologists, pediatric ophthalmologists, an epidemiologist and a neonatologist. This review highlights the latest insights regarding cellular and molecular mechanisms in the formation of the retinal vasculature in the human infant, pathogenesis of ROP, detection and treatment of severe ROP, the risks and benefits of anti-VEGF therapy, the identification of new therapies over the horizon, and the optimal neonatal care regimen for best ROP outcomes, and the benefits and pitfalls of telemedicine in the remote screening and diagnosis of ROP, all of which have the potential to improve ROP outcomes.