DELAYED UMBILICAL

CORD CLAMPING
Morgan T Gilcrest
March 18, 2019
Background
■ Placenta
– Organ attached to the uterus
– Blood Supply
■ Nutrients
■ Gas Exchange
■ Waste
■ Umbilical Cord
– Attaches placenta to fetus
■ Clamping
– Immediate/ICC (5-15 seconds)
– Delayed/DCC (30-75 seconds)
■ Premature https://www.mountnittany.org/articles/healthsheets/6788
– Born before 37 weeks gestation
Clamping
Immediate Delayed
■ Original Standard ■ More time for maternal blood to be
transferred
■ 10-15 seconds after delivery
■ Reduced chance of blood
■ Active management in post-delivery
transfusion
stage
■ Higher levels of hemoglobin and
■ Prompt neonate resuscitation
iron
■ Less Volume overload
■ Effect on social and motor skills
■ No difference from delaying
■ Increase risk of jaundice
 1

Timing of umbilical cord clamping

among infants born at 22 through
27 weeks' gestation.
Backes CH, Huang H, Bauer JA, Giannone PJ
 Methods
■ Randomized, controlled trial
– The Ohio State University Wexner Medical Center
■ Between August 2009 and December 2013

https://www.merckmanuals.com/en-ca/home/women-s-health-
issues/complications-of-pregnancy/placental-abruption

■ Qualifications  Disqualifications
– Singleton pregnancies  Placental Abruption
– Between 22.5 and 27.6 weeks gestation  Placental Previa
 Multiple births
& admitted  Chromosome Abnormalities
■ GA determined by OB/ultrasound  Major Congenital Malformations
– Admitted 3 hours prior to delivery  OB refusal
Methods
■ 2 Groups (40 infants)
– Immediate Cord Clamping (ICC)
■ OB clamped <10 seconds after delivery
– Delayed Cord Clamping (DCC) https://www.smartparenting.com.ph
/pregnancy/labor-and-
■ OB clamped at 30-45 seconds after delivery childbirth/delayed-cord-clamping-
benefits-preemies-full-term-babies-
■ Baby held 10-15 inches below vagina/cesarean incision a00041-20161223

■ Neonatologist
■ Collected prenatal, peripartum data
■ Infant Data collected until discharge
– Recorded maximum serum bilirubin levels
– Incidence of polycythemia (Venous Hematocrit > 65%)
Infant Data Collected
■ Hematocrit (Vaginal Delivery/C-Section)
– Admission
– 72 hours
– 2 weeks
– 4 weeks
– 8 weeks
– Discharge
■ # of blood transfusions at 28 days of life https://www.slideserve.com/creola/hematocrit

■ Phlebotomy loss throughout first 28 days of life

■ Hourly mean arterial blood pressure from umbilical arterial catheters or peripheral
arterial lines
■ Neonate morbidities
– Sepsis
Results
■ No significant differences in markers of infant safety between the ICC and DCC groups.
– Supplemental Oxygen
■ 89% in DCC
■ 91% in ICC
– Intubation
■ 83% / 73%
– Surfactant
■ 78% / 64%
■ 2 ICC + 1 DCC infants received chest
compression at delivery but did not survive
and were excluded from the study
■ Admission Temperature higher in DCC*
■ No infants developed polycythemia
http://ib.bioninja.com.au/standard-
level/topic-6-human-physiology/64-gas-
exchange/pneumocytes.html
Results
■ Hematocrit levels higher in DCC during
first 72 hours
– No different as time progressed
■ # Blood Transfusions in first 28 days
of life higher in ICC
– Total number throughout entire
hospital stay had no difference
■ Similar Phlebotomy losses
■ DCC has higher MABP
– ICC received 4x hypotension tx
■ 45% vs 12%
Conclusion

■ Brief DCC in premature babies born at 22-27 weeks gestation is safe and offers
some hematological and circulatory benefits compared to ICC.
– 30-45 seconds
– Provide better cardiopulmonary transition at birth than ICC
– More blood volume  stabilizes systemic and cerebral blood flow
■ Concern for DCC in <28 week gestation due to delay of resuscitation procedures
– Risk of hypothermia
■ DCC higher temp  due to use of warm sterile towel opposed to open warmer
 2

Duration of cord clamping and

neonatal outcomes in very
preterm infants.
Song D, Jegatheesan P, DeSandre G, Govindaswami B
Methods
■ Observational Study from January 2008 – April 2014
– Santa Clara Valley Medical Center
■ Level 3 Neonatal Intensive Care Unit (NICU)

■ Prior  ICC, 5-10 seconds after birth

■ January 2008  DCC, 30-45 seconds after birth (78%)
■ March 2011  DCC, 60-75 seconds after birth (81%)
– Those not requiring resuscitation

■ Contraindications for DCC: https://www.flickr.com/photos/jian-

– Placental Abruption hua_qiao_md/8487871436

– Placental Previa
– Cord Avulsion
– True knot
– Severely compromised neonate that required immediate resuscitation
Methods
■ Held in polyethylene wrap or sterile towel with warming mattress
– As low as possible without creating cord tension
■ Below vagina or incision
■ Intermittent tactile stimulation prior to clamping
– Gentle back rub
– Oral bulb suction
■ Collected data
– Demographics
– Cord Clamping
– Neonatal Outcomes
■ DCC 30-45s from January 2008 - February 2011
■ DCC 60-75s from March 2011 - February 2014

https://www.fphcare.com/en-
gb/products/neowrap-occlusive-wrap/
Infant Data Collected
■ Demographics
■ Hematocrit Levels
– <2 hours
– 12-36 hours
■ Delivery Room Measures
– APGAR scores at 1 and 5
minutes
– Intubation
– Chest Compressions
– Temperature
– Resuscitation Medications
■ NICU Measures
– Surfactant Administration
– Intubation in first 24 hours of
life
– Intubation and RBC
transfusions during stay
■ Neonate Mortality & Morbidity
– IVH
– Sepsis
– NEC
– CLD
https://www.grepmed.com/images/3423/assessment-
pediatrics-diagnosis-newborns-score-apgar-peds
Results
■ DCC 60-75s had higher hematocrit at <2 hours
– Infants <28 weeks, hematocrit higher for 60-75s for 12-36 hours

■ DCC 60-75s had significant reduction in hypothermia, respiratory interventions, and

RBC transfusions in Delivery Room
■ No differences between Neonatal Mortality and Morbidity between two groups
 Results

Hematocrit Levels
- 12-36 hours of life

Hematocrit Levels
- <2 hours of life
Conclusion

■ Extending DCC to 60-75 seconds may enhance placental transfusion

– Lower hypothermia
– Fewer respiratory interventions
– Fewer RBC transfusions
– No negative impact on mortality and morbidity
– Increased hematocrit by 1.8% at <2 hours
■ 5.8% increase in <28 weeks at 12-36 hours

■ Allows infants to establish respiration and pulmonary circulation while placental

circulation is still intact
 3

Delayed versus immediate cord

clamping in preterm infants.
Tarnow-Mordi W, Morris J, Kirby A, et al.
Methods
■ Randomized control trial
– 25 Centers in 7 countries
■ Looked at effects on hemoglobin concentration 6 hours post-delivery in infants born
before 30 weeks gestation
■ Between December 8, 2010 – January 6, 2017
– DCC (60+ seconds after delivery)
– ICC (within 10 seconds after delivery)
■ Exclusions:
– Fetal Hemolytic Disease
– Hydrops fetalis
– Twin-Twin Transfusion
– Genetic Syndromes
– Potentially Lethal Malformations https://www.cincinnatichildrens.org/service/f/feta
l-care/conditions/twin-twin-transfusion-syndrome
Methods ■ Primary and Secondary Outcomes
– Severe Brain Injury
■ ICC vs DCC
– Severe Retinopathy of
■ Infant held as low as possible below Prematurity
vagina/incision without palpation of – Necrotizing enterocolitis
the cord
– Late Onset Sepsis
■ No cord milking – Chronic Lung Disease
■ Multiples each had random ■ Tertiary Outcomes
assignments individually
– Birth Weight
– # of RBC Transfusions by 36
■ Australian and New Zealand study weeks
■ Looked at mainly death and morbidity – Temperature of Infant at
Admission
– Bilirubin Levels
– Hematocrit Levels
– APGAR
– Duration of Stay
Results
■ 1,566 infants born alive before 30 weeks gestation
– 782 ICC
■ Median time= 5 seconds
– 784 DCC
■ Median time= 60 seconds
■ Of all infants,
– 65.7% were C-sections
– 24.9% Multiple Births
Results
■ Primary & Secondary Outcomes
– No significant differences between DCC (37%) and ICC (37.2%)
– Death by 36 weeks occurred in 6.4% DCC and 9% in ICC

■ Tertiary Outcomes
– No significant difference between median APGAR scores at 1 and 5 minutes
– Mean temperature was 0.1℃ lower in DCC
– Average peak hematocrit was 2.7% points higher in DCC
■ Fewer DCC infants required RBC transfusions (52.1%)
– ICC (60.5%)
Results
Conclusion
■ Found no significant difference in primary outcomes of death between DCC and ICC
■ Did see a 2.7% points higher hematocrit level in DCC
– Due to placental transfer

■ Limitation: Control of DCC

– Some were <60 seconds
– Some were >60 seconds
 4

Efficacy of delayed versus immediate

cord clamping in late preterm
newborns following normal labor: A
randomized control trial.
Salae R, Tanprasertkul C, Somprasit C,
Bhamarapravatana K, Suwannaruk K
Methods
■ Randomized control trial
■ Between May 2000 and June 2001
■ 33 women with gestational age between:
– 24 weeks and 0 days
– 27 weeks and 6 days
■ Singleton Pregnancies
■ Admitted for pre-term labor https://myhealth.alberta.ca/health/AfterCareInformation/pages/
conditions.aspx?HwId=abk5847

■ Two Groups:
– ICC  clamped <10 seconds after delivery (17/33)
– DCC  clamped at 30-45 seconds after delivery (16/33)
■ Infant kept at ~10cm below vagina/incision
Methods
■ Primary Outcomes
– Venous Hematocrit at 4 hours of age
■ Secondary Outcomes
– Delivery Room Management
– Hourly Mean Arterial BP during first 12 hours

■ Capillary Hematocrit
– 2, 4, 6 weeks of age
■ Neonate Morbidity
– Interventricular hemorrhage
– Late Onset Sepsis
– Necrotizing Enterocolitis > Stage 2
– Bronchopulmonary dysplasia
– Retinopathy of Prematurity
Results
■ Delivery Room procedures saw no difference between groups
■ APGAR scores almost identical in each group
■ No differences in mean arterial BP
■ Venous Hematocrit values were higher in DCC
– At 2, 4, and 6 weeks of age, hematocrit in DCC remained higher than ICC
– Indicated an effective placental transfer
■ No neonate morbidity differences
■ More RBC Transfusion in ICC
Results
Results
Conclusion
■ DCC at mean duration of 35 seconds is safe and feasible
– Higher hematocrit levels
– Fewer transfusion
– Lower Incidence of late-onset sepsis and necrotizing enterocolitis
– Higher incidence of intraventricular hemorrhage and retinopathy of prematurity
■ All secondary variables, not statistically significant in the sample size
Sources
Backles, C. H., Huang, H., Iams, J. D., Bauer, J. A., & Giannone, P. J. (2016). Timing of
umbilical cord clamping among infants born at 22 through 27 weeks' gestation. J
Perinatol, 36(1), 35-40. doi:10.1038/jp.2015.117.

Song, D., Jegatheesan, P., DeSandre, G., & Govindaswami, B. (2015). Duration of Cord
Clamping and Neonatal Outcomes in Very Preterm Infants. PLoS One, 10(9).
doi:10.1371/journal.pone.0138829

Tarnow-Mordi, W., Moriss, J., & Kirby, A. (2017). Delayed versus Immediate Cord Clamping in
Preterm Infants. The New England Journal of Medicine,377(25), 2445-2445.
doi:10.1056/NEJMoa1711281

Salae, R., Tanprasertkul, C., Somprasit, C., Bhamarapravatana, K., & Suwannarurk, K.
(2016). Efficacy of Delayed versus Immediate Cord Clamping in Late Preterm Newborns
following Normal Labor: A Randomized Control Trial. Journal of the Medical Association of
Thailand, 99, 159-165. Retrieved March 5, 2019, from
https://www.ncbi.nlm.nih.gov/pubmed/29926695.