Increment in Phototherapy After Adopting Delayed Cord Clamping Practice

The foetus is connected to the placenta via the umbilical cord, which enters through the abdomen at the umbilicus. A venous catheter for infusion and medication may be inserted via the umbilical vein, as it is directly related to the central circulation. Since delayed cord clamping increases iron storage after birth, it may help prevent anaemia in later infancy. This randomized controlled trial was conducted in the Department of Obstetrics and Gynaecology at Aziz Bhatti Shaheed Teaching Hospital, Pakistan, over a period of six months, from August 2021 to January 2022. A total of 70 females were enrolled. The neonates were randomly divided into two groups using the lottery method. In group 1, neonates underwent early cord clamping, while in group 2, neonates underwent delayed cord clamping after delivery. Haemoglobin levels were noted and analysed using IBM SPSS Statistics for Windows, Version 20 (Released 2011; IBM Corp., Armonk, New York). The mean age of patients in the early cord clamping group was 26.80±7.59 years, and in the delayed cord clamping group, it was 28.14±6.12 years. The mean haemoglobin level in the early cord clamping group was 13.84±1.74, while in the delayed cord clamping group, it was 16.34±1.90 (p-value=0.001). In neonates born at term, the mean haemoglobin level in the delayed cord clamping group was significantly higher than that in the early cord clamping group.

Background: The optimal timing of umbilical cord clamping has been debated in the scientific literature for over a century. Early clamping of the umbilical cord is widely practised as part of the management of labour. Early clamping of the cord was one of the first routine medical interventions in labour. Its place in modern births was guaranteed by its incorporation into the triad of interventions that make up the active management of the third stage of labour. Babies who have immediate cord clamping have also been shown to be more likely to be anaemic, have decreased fine motor skills, and have decreased social skills during their first few years of age. Delayed umbilical cord clamping appears to have clear benefit for term infants. Delayed umbilical cord clamping increases hemoglobin levels at birth and improves iron stores in the first few months of life, which improve the developmental outcomes. There is growing evidence that delayed cord clamping is beneficial and can improve the infant’s iron status for up to 6 months after birth. For the first few minutes after birth, there is still circulation from the placenta to the infant. Waiting to clamp the umbilical cord for 2 - 3 min, or until cord pulsations cease, allows a physiological transfer of placental blood to the infant (placental transfusion), the majority of which occurs within 3 min. This placental transfusion provides sufficient iron reserves for the first 6 - 8 months of life, preventing or delaying the development of iron deficiency until other interventions. WHO’s findings suggest that late cord clamping (one to three minutes after delivery or longer) is recommended for all births. Aim of the study: 1) To evaluate the benefit of delayed cord clamping on the infant’s health status. 2) To assess hemoglobin, iron and ferritin at birth and at 4 months of age in infants who underwent early cord clamping (at 30 seconds) as compared with infants who underwent delayed cord clamping (at 60 seconds). Methods: A randomized controlled trial was conducted in Benghazi Medical Center and Elmgharif Hospital at Ejdabia. Study population was 256 women. The participants were randomized to delayed cord clamping or early cord clamping study groups. The data were checked manually for completeness, coded and analyzed by using Statistical Package for Social Sciences (SPSS). The incidence, relative risk, risk reduction, frequency percentage, mean, and standard deviation were used. Also t-test and chi sequare test (to test difference between means and proportions respectively) were used to compare between early and late cord clamping groups. Results: Two hundred forty seven participants completed the study (the attrition rate was 3.5%); 121 (49%) were control group (early cord clamping) and 126 (51%) were study group (delayed cord clamping) group. At birth no significant difference between two groups regarding the level of hemoglobin, iron and ferritin. At 4th month of age delayed cord clamping was associated with improved hemoglobin, iron and ferritin and that the incidence of anemia among infants who exposed to delayed cord clamping was 0.07, while the incidence of anemia among the infants who exposed to early cord clamping was 0.5. Conclusion: There was strong association between delayed umbilical cord clamping and improvement of iron indices and developmental mile stones in infants at 4th month of age.

We aimed to demonstrate non-inferiority of delayed cord clamping (DCC) and cord milking (CM) in comparison to early cord clamping (ECC) in the incidence of hyperbilirubinemia requiring phototherapy. 467 of maternal-foetal dyads were screened for eligibility. 389 term infants, of breastfeeding, non-smoking mothers were randomized to receive ECC ( < 40 s), DCC (1-2 min) or CM (4 times towards the neonate). The primary outcome was defined as hyperbilirubinemia requiring phototherapy. 307 patients were included in the analysis. CM did not increase the risk of phototherapy RR 11.27 95% CI (0.80; 2.04). Similar results were achieved when comparing DCC and ECC, RR 1.29 95% CI (0.82; 2.05). This was also true for CM vs DCC, RR 0.99 95% CI (0.64; 1.52). The prevalence of total serum bilirubin (TSB) at 24-48 hours was 10.8 mg/dL; 10.33 mg/dL and 11.39 in ECC, CM and DCC group respectively. Transcutaneous bilirubin (TcB) levels at 24-48 h were 7.58 mg/dL, 7.89 mg/dL and 7.60 mg/dL in the ECC, CM and DCC respectively. None of the neonates met exchange transfusion criteria or symptomatic polycythaemia. Our study suggests that placental transfusion is not associated with hyperbilirubinemia requiring phototherapy or exchange transfusion.

Timing of umbilical cord clamping and neonatal jaundice in singleton term pregnancy

To compare the effect of delayed cord clamping on cord blood gas values in vaginally delivered, healthy, term singletons. We used MEDLINE, CINAHL, CENTRAL, EMBASE, and ClinicalTrials.gov databases. Eligible studies included randomized controlled trials (RCTs) comparing cord blood gas values obtained from early compared with delayed cord clamping groups and observational studies using serial cord blood gas from the same umbilical cord. We described the difference in means of cord blood gas parameters and comparative descriptive statistics when a difference in means was not available. We used a domain-based risk bias tool to extract methodologic details and assess potential risk of bias. This review included two RCTs and three observational studies. These studies included a total of 234 newborns with early cord clamping and 218 newborns with delayed cord clamping. The observational studies showed that 45-90 seconds delayed cord clamping was associated with mean decreases in umbilical arterial pH (0.02-0.03), HCO3 (0.3-0.8 mmol/L) and increases in base deficit (0.3-1.3 mmol/L) compared with early cord clamping. One observational study showed that delayed cord clamping was associated with decreases in umbilical venous pH (0.01) and HCO3 (0.2 mmol/L) and increase in venous base deficit (0.1-0.3 mmol/L) compared with early cord clamping. These changes were not observed in the two RCTs. Delayed cord clamping up to 120 seconds has either no effect or only a small effect on cord blood acid-base balance; overall, the magnitude of these changes is not clinically significant in vaginally delivered, healthy, term singletons. PROSPERO, CRD42019135779.

Delayed cord clamping (DCC) may be beneficial in very-preterm and very-low-birth-weight infants. This study was a randomized unmasked controlled trial. It was performed at three centers of the NICHD (National Institute of Child Health and Human Development) Neonatal Research Network. DCC in very-preterm and very-low-birth-weight infants will result in an increase in hematocrit levels at 4 h of age. Infants with a gestational age of 24 to 28 weeks were randomized to either early cord clamping (<10 s) or DCC (30 to 45 s). The primary outcome was venous hematocrit at 4 h of age. Secondary outcomes included delivery room management, selected neonatal morbidities and the need for blood transfusion during the infants' hospital stay. A total of 33 infants were randomized: 17 to the immediate cord clamping group (cord clamped at 7.9±5.2 s, mean±s.d.) and 16 to the DCC (cord clamped at 35.2±10.1 s) group. Hematocrit was higher in the DCC group (45±8% vs 40±5%, P<0.05). The frequency of events during delivery room resuscitation was almost identical between the two groups. There was no difference in the hourly mean arterial blood pressure during the first 12 h of life; there was a trend in the difference in the incidence of selected neonatal morbidities, hematocrit at 2, 4 and 6 weeks, as well as the need for transfusion, but none of the differences was statistically significant. A higher hematocrit is achieved by DCC in very-low-birth-weight infants, suggesting effective placental transfusion.

Delayed cord clamping (DCC) occurs in most preterm births. Evaluate the association of DCC with acute kidney injury (AKI) and two-year kidney outcomes. Secondary analysis of the Preterm Erythropoietin Neuroprotection Trial of neonates born 240/7 to 276/7 weeks gestation. AKI and two year kidney outcomes were compared in neonates with DCC ( ≥ 30 s after delivery) to those with early cord clamping (ECC) (<30 s after delivery). The incidence and severity of AKI did not differ between the DCC and ECC groups (aOR 1.17 [95%CI 0.76-1.80]). At two years corrected age, DCC was associated with a 4.5-fold increased adjusted odds of estimated glomerular filtration rate (eGFR) <90 mL/min/1.73m2. No significant associations were noted between DCC and albuminuria or elevatedblood pressure. DCC was not associated with decreased neonatal AKI, but was associated with higher adjusted odds of eGFR <90 mL/min/1.73m2 at two years.

Background:Delayed cord clamping (DCC) occurs in most preterm births.Objective:Evaluate the association of DCC with acute kidney injury (AKI) and two-year kidney outcomes.Methods:Secondary analysis of the Preterm Erythropoietin Neuroprotection Trial of neonates born 240/7 to 276/7 weeks’ gestation. AKI and two year kidney outcomes were compared in neonates with DCC (≥30 seconds after delivery) to those with early cord clamping (ECC) (<30 seconds after delivery).Results:The incidence and severity of AKI did not differ between the DCC and ECC groups (aOR 1.17 [95%CI 0.76–1.80]). At two years corrected age, DCC was associated with a 4.5-fold times increased adjusted odds of eGFR <90 mL/min/1.73m2. No significant associations were noted between DCC and albuminuria or elevated BP.Conclusions:DCC was not associated with decreased neonatal AKI, but was associated with higher adjusted odds of eGFR <90 mL/min/1.73m2 at two years.

Background: Preterm infants are at a great risk for both cognitive and motor delay. Hypovolemia secondary to immediate cord clamping, may be disruptive to the developing brain resulting in subsequent motor delay. Objective: The aim of this work is to compare early versus delayed cord clamping in cases of preterm birth. Patients and Methods: This is a prospective randomized controlled study which was performed at Al-Azhar University Maternity Hospital from July 2018 to February 2019. It included 100 pregnant patients. They were divided into two equal groups: Group I with early cord clamping (ECC). Group II with delayed cord clamping (DCC). Results: In our study the hematocrit on day 1 was also significantly higher in the DCC group (5.2%+50.8 ±vs. 58.5 ±5.1 %, p value 0.00). The DCC group required significantly longer duration of phototherapy (55.3±40.0 h vs. 36.7±32.6 h, p value 0.016) and had a trend towards higher risk of polycythemia probably due to the higher hemoglobin and bilirubin pool in those babies, however the incidence of significant jaundice was not different. In this study, there was no statistically significant difference in blood pressure between neonates of both groups of ECC and DCC. Our study found that 24% of the group underwent delayed cord clamping needed blood transfusion versus 70% of infants of the group of the immediate cord clamping. Conclusion: Delayed cord clamping (DCC) (more than 30 seconds) in preterm births is associated with higher Hb, hematocrit and less need for blood transfusion compared to immediate cord clamping.

INTRODUCTION: In the term infant, there is evidence of delayed cord clamping (DCC) resulting in decreased anemia and improved cardiopulmonary adaptation. Despite the benefits, there are concerns regarding maternal safety, especially postpartum hemorrhage. This study evaluated the maternal safety outcomes following the departmental wide implementation of DCC. METHODS: A retrospective chart review was conducted of infants delivering between gestational age 34+0 weeks to 42+6 weeks. Outcomes were evaluated between the DCC and Immediate cord clamping (ICC) groups. Primary outcomes included estimated maternal blood loss (EBL) and hematocrit (Hct) decline following delivery. RESULTS: Of 817 deliveries, 763 (93%) underwent DCC. EBL for ICC group was 950 mL vs 300 mL in DCC group (<0.01 U); Hct decline was 6.2 vs 4.2 respectively (<0.01 t). 53% of the deliveries for the ICC were cesareans, while only 27% for the DCC. After controlling for mode of delivery, EBL in the vaginal delivery ICC group was 300 mL vs 300 mL in the DCC (P=.38); Hct decline was 3.1 and 3.7 (P=.76). In those undergoing cesareans, ICC EBL was 900 mL vs 1,000 mL (P=.93) for DCC; Hct decline 5.1 and 5.2 (0.92%). No blood transfusions in the vaginal delivery group. For those undergoing cesareans one (3.5%) transfusion was provided in the ICC group and 2 (1%) (P=.33) in the DCC group. CONCLUSION: Once controlling for mode of delivery there was no difference in primary maternal safety measures between the two groups. It is encouraged for Obstetricians to consider implementing universal DCC for all infants.

To evaluate safety and haematological effects of delayed cord clamping (DCC) in infants with expected low birthweight born in a resource-poor setting. Randomised controlled trial involving pregnant women in early labour ≥18 years with intrapartum symphysal-fundal height ≤32 cm. Mothers were randomised for either early cord clamping (ECC, <30 s) or DCC (2-3 min after birth). We included 104 vigorous infants born by vaginal delivery, of whom 39% had a birthweight <2500 g. Infant haemoglobin (Hb) levels 24 h after birth were significantly higher in the DCC group (18.0 g/dl vs. 16.8 g/dl, P = 0.006). Despite successful placental transfusion, hyperbilirubinemia and hyperviscosity were not observed. Two months after birth, there were no differences in Hb between groups (9.9 g/dl vs. 9.8 g/dl, P = 0.60), but the infants in the DCC group had better weight gain from baseline than those with ECC (2.2 kg vs. 1.9 kg, P = 0.058). In this South African cohort of newborns with a subnormal distribution of birthweight delayed cord clamping was a safe procedure. Two months after birth the effect of DCC on Hb was not detectable anymore. DCC should be promoted in every singleton delivery in a resource-poor setting irrespective of the birthweight.

Aim: To compare frequency of the anemia in neonates in early versus delayed umbilical cordclamping in term infants. Study design: Randomized controlled trial. Place and duration of study: Department of Obstetrics &amp; Gynecology, Divisional Headquarters Hospital Mirpur AJK from 30th January 2021 to 29th July 2021. Methodology: The study enrolled 96infants which were delivered at term within the gestational range of 37-41 weeks (as assessed on LMP). Those infants who were born to diabetic, sepsis mother or with inborn metabolic errors, jaundice neonatorum or Rh incompatibility and PROM were excluded from the study. Then selected women were placed randomly into two equal groups i.e. Group A (early cord clamping) &amp; Group B(delayed cord clamping) by lottery method. Respective group selection was performed through randomization. In group a neonates, early cord clamping (cord clamping within 15 seconds of birth) was done while in group B neonates, delayed cord clamping (cord clamping after 3 minutes of birth) was done. In both groups, blood sample of all infants was sent after 6 hours of birth for hematocrit level measurement and neonatal anemia was noted. Results: The mean age in years of patients in group A was calculated as 26.52±5.17 while in group B it was calculated as 27.17±3.89. The age of 80.21% patients was within 18 to 30 years and the mean gestational age was determined as 39.23±1.48 weeks. The mean gestational age in group A was 39.25±1.48 weeks and in group B was 39.21±1.49 weeks. Frequency of neonatal anemia in group A (early cord clamp) versus group B (delayed umbilical cord clamping) was 11 (22.92%) and 04 (8.33%) respectively with p-value of 0.049. Practical Implication: we recommend that delayed umbilical cord clamping should be preferred in our routine practice for prevention of neonatal anemia. Conclusion: This study concluded that the neonatal anemia is high after early cord clamping in infants at term as compared to delayed cord clamping Keywords: Cord Clamping, Delayed, Anemia.

Objective To evaluate the clinical outcomes of using the extra-uterine placental transfusion (EPT) approach in very preterm infants (VPIs, gestational age <32 weeks) and compare this to delayed cord clamping (DCC) after birth. Methods In this matched pairs study, we compared the clinical outcomes of the EPT group to those of the DCC group. EPT were performed in fifty-three VPIs, of whom 27 were singletons and 25 were twins. The singleton VPIs were matched for gestational age (±5 days) and delivery mode, and the twin VPIs were matched between each other with the first twin subjected to DCC and the second twin to EPT. Data on the infants were collected and analysed as an overall group. A twin subgroup consisting of DCC and EPT groups was also analysed separately. The primary study outcome was either death or major morbidities. Results In total, 100 infants were included (n = 50 EPT group, n = 50 DCC group). The gestational ages of the DCC and EPT groups were (29.16 ± 1.76) and (29.12 ± 1.84) weeks, respectively. There were no differences in either deaths or major morbidities and other clinical outcomes, including the resuscitation variables, haemoglobin levels and red blood cell transfusion, between the two groups. In twin subgroups (gestational age 29.05 ± 1.89 weeks), EPT was associated with a higher rate of necrotizing enterocolitis (NEC) when compared with DCC (odds ratio = 7 (95% CI, 1.06 to 56.89), p = 0.031). Conclusions In twin subgroups, the incidence of NEC was higher in the EPT group when compared to the DCC group and therefore based on an abundance of caution the use of EPT in very preterm twins is not recommended.

ObjectiveTo study the effect of delayed cord clamping (DCC) on the bilirubin levels and hypoglycemia in neonates with diabetic mothers (NDMs).MethodsThis is a comparison between a prospective cohort and a historical control cohort. Women with gestational diabetes mellitus who performed DCC were enrolled into the prospective cohort (n = 156), and those who performed early cord clamping (ECC) were enrolled into the historical control cohort (n = 161).ResultsNDMs who received DCC had higher transcutaneous bilirubin than those in the ECC group whether maternal glycemic control was good or poor. DCC increased the rate of neonatal hyperbilirubinemia and phototherapy when maternal blood glucose was well controlled but not when it was poorly controlled. No differences were found in initial blood glucose levels on days 1 to 3 of life between the two groups.ConclusionDelayed cord clamping increased bilirubin levels, the risk of neonatal hyperbilirubinemia, and phototherapy in IDMs without improved initial blood glucose levels. Therefore, DCC was not recommended in NDMs.

Background: Evidence published to date has not clearly established the impact of the timing of cord clamping on postpartum blood loss and necessitates further research. The objective was to find out the impact of early and delayed cord clamping on the post partum blood loss and on infant haemoglobin and hematocrit at 90 ±7 days postpartum.Methods: A randomized, controlled trial was performed on 183 consenting women fulfilling eligibility criteria in labour ward of a teaching hospital in India. They were randomly assigned into early cord clamping or delayed cord clamping group; other components of active management of third stage of labour being same for all. The duration of third stage of labour was noted. Quantitative assessment of post partum blood loss was done using BRASSS-V drapes and weighing blood soaked pads. Cord blood haemoglobin and hematocrit at birth and infant haemoglobin and hematocrit at 90 ±7 days were estimated. Statistical analysis done using students unpaired ‘t’ test.Results: No difference was noted in the mean blood loss (203.52 ± 122.74 ml versus 200.74± 104.07 ml in early and delayed cord clamping respectively) and the duration of third stage of labour (Mean: 296.59± 98.97 seconds versus 281.79±104.59 seconds for early and delayed clamping respectively). Infant haemoglobin at 90 ±7 days was 11.07 ± 1.27 gm/dl versus 12.70± 1.41 gm/dl (p=0.0000) and infant hematocrit at 90 ±7 days was 34.13±3.93 % versus 39.33 ±4.88 % in early and delayed clamping respectively (p=0.0000).Conclusion: The timing of cord clamping has no impact on the mean blood loss and duration of third stage of labour. Delayed clamping significantly increases mean venous haemoglobin and hematocrit at 90 ±7 days without increasing NICU admissions.