Delayed Umbilical Cord Clamping

This is an interesting topic that is being studied more and more lately in the premature infant.  Delayed cord clamping in the term infant has been a practice, particularly amongst nurse mid-wives for some time.  While this has not been well-studied, there are a few studies particular to the term newborn.  Recently, this has been of interest in the premature infant for different reasons.

One of the earlier studies regarding delayed cord clamping in preterm infants (24 to 32 weeks gestation) looked at the effect on lung health as measured by days on oxygen, days on ventilator and if the infant was discharged on oxygen.¹  The cord clamping was immediate (5-10 seconds) or delayed (30-45 seconds).  This group was able to show that delayed cord clamping resulted in significantly fewer days on oxygen and ventilation as well as fewer infants being sent home on oxygen, overall, resulting in better lung health.

Other, more recent studies, have compared delayed cord clamping, varying from 30 seconds to 2 minutes as the definition of “delayed.”  One study compared traditional or immediate cord clamping to cord milking.  These studies all included infants less than 32 to 33 weeks gestation.  They did not study term infants as the outcomes studied are not usually issues in term infants.  The outcomes found in these studies included less blood transfusions and higher hematocrit upon admission, less intraventricular hemorrhage, less use of vasopressors and volume administration and one study (the one that studied cord milking) showed less late onset sepsis (Mercer, 2006; Cochrane review, 2010; Bell, CPQCC, 2011;  Rabe, 2011).  This was thought to be related to the infusion of stem cells into the infant and therefore, better immunity.⁴

With all of this evidence to support delayed cord clamping or cord milking, many see the benefit of this practice and believe there is sufficient evidence in the preterm infant to support its use (Obstetrics & Gynecology, 2012, Committee opinion #543).  This presents a couple of clinical challenges and an obvious need for collaboration with our obstetric colleagues.  How often have you awaited the delivery of a preterm infant in distress, impatient to begin resuscitation?  This impatience is often transmitted to the obstetric team leading, perhaps, to a more rapid clamping of the cord in an infant who would benefit more than most from the extra 30 to 60 seconds prior to clamping.  In addition, our obstetric colleagues must understand as well, the benefit transmitted to the infant from the proper delay or milking procedure.  A delay in cord clamping with the infant held above the introitus results in less blood to the infant.   Most studies have placed the infant at or slightly below the introitus for the specified duration.

Additionally, as with any new protocol, following our own outcomes and ensuring the protocol is followed as intended is important.  Just putting the practice on a piece of paper or even educating clinicians well about the practice doesn’t ensure it will happen.  Sometimes there are unanticipated obstacles in one environment vs another that must be addressed.  As quoted by those more learned than I, “all quality improvement is local.”  The same answers don’t always fit every institution or patient.  Only by auditing our own practices and outcomes can we be certain that our patients are better because of us and not in spite of us!

References:

1. Mercer, J. S., McGrath, M. M., Hensman, A., Silver, H., & Oh, W. (2003). Immediate and delayed cord clamping in infants born between 24 and 32 weeks: a pilot randomized controlled trial. Journal of perinatology, 23(6), 466-472.

2. Mercer, J. S., Vohr, B. R., McGrath, M. M., Padbury, J. F., Wallach, M., & Oh, W. (2006). Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial. Pediatrics, 117(4), 1235-1242.

3. Rabe, H., Reynolds, G., & Diaz-Rossello, J. (2004). Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database Syst Rev, 4. (reviewed 2010)

4. Rabe H, Jewison A, Alvarex RF, Crook D, Stilton D, Bradley R, Holden D; Brighton Perinatal Study Group.  (2011).  Milking compared with delayed cord clamping to increase placental transfusion in preterm neonates: a randomized controlled trial.  Obstet Gynecol. 117(2 Pt 1):205-11.