Delayed Umbilical Cord Clamping Research Articles

Delayed umbilical cord clamping in term and near-term newborns

Background and objectives. The authors are shortly reviewing the national and international recommendations for umbilical cord clamping at birth and the most important evidence supporting these recommendations. Also, based on the recommendations discussed, a clinical protocol for delayed umbilical cord clamping (DCC) is proposed.

Knowledge and practices of delivery room midwives on delayed umbilical cord clamping time: a descriptive study from Turkey

This study aimed to evaluate the knowledge and practices of delivery room midwives on delayed umbilical cord clamping (DCC). This descriptive study was conducted with a total of 1,274 delivery room midwives from five regions of Turkey. The data were collected using a Google survey form. Most of the midwives defined DCC as clamping the umbilical cord in term newborns after cessation of pulsations (47.2%), and as clamping the umbilical cord in preterm newborns within 15-30 seconds of birth (31.2%). Their highest DCC time ranged between 0-10 seconds for term and preterm newborns (34.7% and 54.8%, respectively). The rates of applying DCC were 17.6% and 5.3% in term and preterm newborns, respectively. Dealing with the mother (75.6% and 33.4%, respectively), having workload (27.5% and 24.6%, respectively), considering that the newborn would have respiratory distress (16.1% and 33.4%), considering that the newborn would get cold (10.7% and 13.9%, respectively), preventing polycythemia and hyperbilirubinemia (6.7% and 9.7%, respectively), and being afraid of dropping the newborn (5.3% and 19%, 8, respectively) are the most common reasons for midwives not to apply DCC to term and preterm newborns. The majority of the midwives reported that they had no DCC protocol in their institution (80.5%) and did not receive in-service training on DCC (76.5%). This study has concluded that most midwives do not know the correct definition of DCC, do not apply DCC correctly, have quite short DCC times, have no DCC protocol in their institutions and do not receive in-service training on DCC

Physiological-based cord clamping in very preterm infants: the Aeration, Breathing, Clamping 3 (ABC3) trial—study protocol for a multicentre randomised controlled trial

BackgroundInternational guidelines recommend delayed umbilical cord clamping (DCC) up to 1 min in preterm infants, unless the condition of the infant requires immediate resuscitation. However, clamping the cord prior to lung aeration may severely limit circulatory adaptation resulting in a reduction in cardiac output and hypoxia. Delaying cord clamping until lung aeration and ventilation have been established (physiological-based cord clamping, PBCC) allows for an adequately established pulmonary circulation and results in a more stable circulatory transition. The decline in cardiac output following time-based delayed cord clamping (TBCC) may thus be avoided. We hypothesise that PBCC, compared to TBCC, results in a more stable transition in very preterm infants, leading to improved clinical outcomes. The primary objective is to compare the effect of PBCC on intact survival with TBCC.MethodsThe Aeriation, Breathing, Clamping 3 (ABC3) trial is a multicentre randomised controlled clinical trial. In the interventional PBCC group, the umbilical cord is clamped after the infant is stabilised, defined as reaching heart rate > 100 bpm and SpO2 > 85% while using supplemental oxygen < 40%. In the control TBCC group, cord clamping is time based at 30–60 s. The primary outcome is survival without major cerebral and/or intestinal injury. Preterm infants born before 30 weeks of gestation are included after prenatal parental informed consent. The required sample size is 660 infants.DiscussionThe findings of this trial will provide evidence for future clinical guidelines on optimal cord clamping management in very preterm infants at birth.Trial registrationClinicalTrials.gov NCT03808051. First registered on January 17, 2019.

Implementation of Delayed Cord Clamping in public health facilities: a case study from India

BackgroundGlobal and country specific recommendations on Delayed umbilical cord clamping (DCC) are available, though guidance on their implementation in program settings is lacking. In India, DCC (clamping not earlier than 1 min after birth) is a component in the package of services delivered as part of the India Newborn Action Plan (INAP) supported by Nutrition International (NI) in two states. The objective of this case study was to document the learnings from implementation of DCC in these two states and to understand the health system factors that affected its operationalization.MethodsMixed methods were followed. Using the World Health Organization (WHO) Health Systems building blocks as a framework, 20 Key-Informant Interviews were conducted to explore facilitators and barriers to routine implementation of DCC in public health settings. Existing quantitative program data and secondary data from labour-room registers from eight NI- supported districts were analysed to assess the prevalence of DCC implementation in public health systems settings.ResultsA demonstrated commitment from the government to implement DCC at all delivery points in NI supported districts was observed. Funds were sufficient, trainings were optimal, knowledge of the health workforce was adequate and a recording mechanism was in place. According to record reviews, DCC was more likely to happen in facilities that provide Basic Emergency Obstetric services and among normal deliveries. It was less likely to be followed in babies delivered by Caesarean section (OR 0.03; 95%CI 0.02,0.05), birthweight < 2000 g (OR 0.22; 95%CI 0.12,0.47), multiple pregnancies (OR 0.17, 95%CI 0.05,0.63), birth asphyxia requiring resuscitation (0.37; 95%CI 0.26,0.52), and those delivered during day shift (OR 0.59, 95%CI 0.40, 0.83).ConclusionsWide coverage of DCC in public health settings in the two states was observed. Good governance, adequate funding, commitment of health workforce has likely contributed to its success in these contexts. These are critical elements to guide DCC implementation in India and for consideration in other settings.

Association of Umbilical Cord Management Strategies With Outcomes of Preterm Infants

It is unclear which umbilical cord management strategy is the best for preventing mortality and morbidities in preterm infants. To systematically review and conduct a network meta-analysis comparing 4 umbilical cord management strategies for preterm infants: immediate umbilical cord clamping (ICC), delayed umbilical cord clamping (DCC), umbilical cord milking (UCM), and UCM and DCC. PubMed, Embase, CINAHL, and Cochrane CENTRAL databases were searched from inception until September 11, 2020. Randomized clinical trials comparing different umbilical cord management strategies for preterm infants were included. Data were extracted for bayesian random-effects meta-analysis to estimate the relative treatment effects (odds ratios [OR] and 95% credible intervals [CrI]) and surface under the cumulative ranking curve values. The primary outcome was predischarge mortality. The secondary outcomes were intraventricular hemorrhage, severe intraventricular hemorrhage, need for packed red blood cell transfusion, and other neonatal morbidities. Confidence in network meta-analysis software was used to assess the quality of evidence and grade outcomes. Fifty-six studies enrolled 6852 preterm infants. Compared with ICC, DCC was associated with lower odds of mortality (22 trials, 3083 participants; 7.6% vs 5.0%; OR, 0.64; 95% CrI, 0.39-0.99), intraventricular hemorrhage (25 trials, 3316 participants; 17.8% vs 15.4%; OR, 0.73; 95% CrI, 0.54-0.97), and need for packed red blood cell transfusion (18 trials, 2904 participants; 46.9% vs 38.3%; OR, 0.48; 95% CrI, 0.32-0.66). Compared with ICC, UCM was associated with lower odds of intraventricular hemorrhage (10 trials, 645 participants; 22.5% vs 16.2%; OR, 0.58; 95% CrI, 0.38-0.84) and need for packed red blood cell transfusion (9 trials, 688 participants; 47.3% vs 32.3%; OR, 0.36; 95% CrI, 0.23-0.53), with no significant differences for other secondary outcomes. There was no significant difference between UCM and DCC for any outcome. Compared with ICC, DCC was associated with the lower odds of mortality in preterm infants. Compared with ICC, DCC and UCM were associated with reductions in intraventricular hemorrhage and need for packed red cell transfusion. There was no significant difference between UCM and DCC for any outcome. Further studies directly comparing DCC and UCM are needed.

Effect of Delayed Versus Immediate Umbilical Cord Clamping on Maternal Blood Loss in Term Cesarean Delivery: A Randomized Clinical Trial

(JAMA. 2019;322:1869–1876) In 2017, the American College of Obstetricians and Gynecologists recommended that providers delay umbilical cord clamping for at least 30 to 60 seconds after the birth of a preterm or term neonate, assuming that the neonate does not require resuscitation. While the literature strongly supports this recommendation as a neonatal benefit, studies on maternal outcomes are lacking. Furthermore, information regarding the impact of delayed umbilical cord clamping on the mother and neonate during cesarean delivery is also lacking. This study aimed to compare the impact of maternal blood loss when the umbilical cord was clamped immediately as compared with delayed during cesarean delivery.

Transfusion or Timing: The Role of Blood Volume in Delayed Cord Clamping During the Cardiovascular Transition at Birth.

Placental transfusion has been thought to be the main benefit of delayed umbilical cord clamping (DCC) in preterm neonates. However, the importance of cardiovascular stability provided by allowing lung aeration prior to cord clamping has recently been highlighted. We aimed to determine the influence of blood volume changes on cardiovascular stability at birth. Preterm lambs (0.85 gestation) were instrumented for measurement of pulmonary, systemic and cerebral blood pressures and flows, systemic oxygen saturation and cerebral oxygenation. Left ventricular output (LVO) was assessed by Doppler Echocardiography. Lambs underwent immediate cord clamping followed by (1) 25 ml/kg infusion of whole blood over (90 s; or 2) withdrawal of 10 ml/kg blood over 90 s. Ventilation was initiated 30 s after volume change (2 min after cord clamping) and was maintained for 30 min. Blood infusion significantly increased pulmonary blood flow (PBF) which maintained systemic cardiac output during the infusion, and increased carotid arterial pressure, flow and heart rate, which remained elevated until after ventilation onset. Upon completion of transfusion PBF rapidly returned to control levels and LVO decreased. Conversely, blood withdrawal decreased PBF and LVO. The cardiovascular changes that accompanied ventilation onset were similar between groups. Providing a blood volume transfusion immediately after umbilical cord clamping maintains PBF and cardiac output during the transfusion, which does not persist beyond the period of the transfusion. Our study implies that an apneic newborn cannot maintain cardiac output through an increase blood volume alone. Importantly, delaying umbilical cord clamping until after breathing/aeration of the lung may be a way to maintain cardiac output throughout delivery at birth.

The Effect of the Timing of Umbilical Cord Clamping on Hemoglobin Levels, Neonatal Outcomes and Developmental Status in Infants at 4 Months Old.

Delayed umbilical cord clamping (DCC) increases blood transfer to newborns. Hence we investigated the effect of the timing of DCC on hemoglobin levels, neonatal outcomes and developmental status in infants at four months old. This clinical trial examined infants born to 400 pregnant women immediately upon birth and at the age of four months in Isfahan, central Iran in 2016. A table of random numbers was used to randomly allocate the newborns to intervention group with a 90-120-sec delay in umbilical cord clamping and the control group with a clamping delay of below 60 sec, and blood samples were taken from their umbilical cords. The Ages and Stages Questionnaire was used to evaluate the infants' developmental status. Umbilical cord hemoglobin was significantly higher in the intervention group compared to in the controls (P=0.024). No significant differences were observed between the two groups in terms of neonatal complications except neonatal jaundice was significantly more common in the intervention group (P=0.025), although the need for phototherapy was not different between the groups. Overall, no significant differences were observed between the two groups in terms of developmental status at four months old; however, the infants had better problem-solving skills in the DCC group (P=0.015). Despite elevating hemoglobin, DCC has no effects on infant development except in terms of problem-solving skills. Further studies are recommended on the effects of DCC on infant development.

Implementation and Outcomes of Universal Delayed Umbilical Cord Clamping at Term.

To evaluate the implementation of an institutional protocol for universal delayed umbilical cord clamping (DCC) at term on maternal, neonatal, and umbilical cord blood gas outcomes. This is a retrospective cohort study of singleton term gestations from April through July 2017. On June 1, 2017, a protocol was implemented for DCC in all deliveries. Outcomes were compared between patients delivered prior to and those delivered after implementation. The primary outcome was postpartum hemorrhage (PPH). Secondary outcomes were additional adverse maternal, neonatal, and umbilical cord blood gas outcomes. Multivariable logistic regression was used to adjust for potential confounders. Of 682 patients, 341 were delivered preprotocol and 341 were delivered postprotocol. After implementation, there was 91.8% adherence to the protocol. Overall, there was no significant difference in PPH between patients delivered preprotocol and those delivered postprotocol (8.2 vs. 13.2%; adjusted relative risk [aRR]: 1.26, 95% confidence interval [CI]: 0.98-1.51). There was a significant decrease in the ability to obtain paired arterial and venous umbilical cord blood gases from preprotocol to postprotocol (83 vs. 63.6%; aRR: 0.62 [95% CI: 0.50-0.76]). There were no significant differences in abnormal umbilical cord blood gases or neonatal outcomes. We did not find an increased risk of adverse outcomes associated with the widespread use of DCC.

Effect of Delayed Cord Clamping on Moderately Preterm Infants

Background: Delayed umbilical cord clamping (DCC) appears to be beneficial for preterm and term infants. In very preterm infants DCC improves hemodynamic stability after birth and decreases major neonatal morbidities, such as intraventricular hemorrhage (IVH) and necrotizing enterocolitis (NEC). In term infants DCC increases hemoglobin levels at birth and improves iron stores in the first several months of life. All of these have favorable effect on infant developmental outcomes. But, none of the published studies specifically focused on moderately preterm infants born between gestational ages 32 to 35 …

The Effect of Delayed Cord Clamping on Moderate and Early Late-Preterm Infants.

This study aims to evaluate the clinical consequences of protocol-driven delayed umbilical cord clamping (DCC) implementation in moderate and early late-preterm (MELP) infants born between 320/7 and 346/7 weeks gestation. We conducted a prospective cohort study with a historic control cohort comparison. The prospective study period was 1 year when DCC was performed for 60 seconds duration (DCC cohort, n = 106). The study period for historic control cohort with no DCC was also 1 year before DCC implementation (historic cohort, n = 137). The mean hematocrit at birth was significantly higher in the DCC cohort compared with the historic cohort (49.1 ± 14.9 vs. 45.7 ± 15.7; p = 0.01). Fewer infants in the DCC cohort were admitted to neonatal intensive care unit (NICU) on respiratory support compared with the historic cohort (17.9 vs. 29.9%; p = 0.04). The incidence of respiratory distress syndrome was significantly lower in the DCC cohort compared with the historic cohort (2.8 vs. 14.6%; p = 0.002). There were no differences in the incidence of phototherapy or NICU length of stay (LOS) between groups. In MELP infants, DCC was associated with increased hematocrit and better respiratory transition at birth. DCC was not associated with increased phototherapy or NICU LOS.

Delayed Umbilical Cord Clamping at

Objectives This study aims to evaluate the implementation of a delayed umbilical cord clamping (DCC) protocol for neonates &lt;32 weeks. Secondarily, to evaluate the impact of DCC on maternal outcomes and on the ability to obtain umbilical cord blood gases. Study Design Retrospective cohort study from November 2014 to March 2016 of patients delivered by 316/7 weeks. In 2014, an institutional protocol for DCC at &lt;32 weeks was implemented. We assessed adherence to the protocol and compared adverse maternal outcomes (utilizing a hemorrhage composite). We evaluated the impact of DCC on the ability to obtain adequate umbilical cord blood gas specimens. Results Of the 185 patients included in the study, 90 underwent DCC, and 72% of potentially eligible patients appropriately received DCC. There was no significant difference in the maternal hemorrhage composite outcome between DCC and immediate cord clamping (23.3 vs. 36.8%, adjusted odds ratio = 0.64, 95% confidence interval = 0.33, 1.26). There was also no significant difference in the ability to obtain a single or paired umbilical cord blood gas result. Conclusion Implementation of a DCC protocol for preterm neonates is feasible and was successful. We did not find an increase in maternal risk or a decrease in the ability to obtain umbilical cord blood gases following DCC.

A Quality Improvement Initiative to Reduce the Need for Mechanical Ventilation in Extremely Low Gestational Age Neonates.

Objective Limiting early intubation and mechanical ventilation in extremely low gestational age neonates (ELGAN) may decrease neonatal morbidity and mortality. The aim of our study was to demonstrate the feasibility, efficacy, and tolerability of a delivery room respiratory management protocol, including delayed umbilical cord clamping (DUCC) in combination with optimized nCPAP with high PEEP levels and less invasive surfactant administration (LISA). Study Design This cohort quality improvement study analyzed the respiratory and neonatal outcomes of all consecutive infants born between 24+0 and 26+6 weeks' gestation before (period 1, n = 40) and after (period 2, n = 52) implementing the new protocol. Results Compared with the period 1 infants, the period 2 infants had a lower rate of intubation in the delivery room (31 vs. 90%, p = 0.001) and were less likely to need mechanical ventilation on day 3 (28 vs. 62%, p = 0.002) and during the hospital stay (75 vs. 92.5%, p < 0.05). The two groups did not differ in terms of mortality or neonatal morbidity. Conclusion A delivery room respiratory management protocol based on DUCC, optimized nCPAP with high PEEP levels, and LISA procedure is both feasible and safe, and improved ELGAN respiratory outcomes.

Safety and efficacy of delayed umbilical cord clamping in multiple and singleton premature infants - A quality improvement study.

To evaluate the safety and efficacy of a quality improvement (QI) program of delayed umbilical cord clamping (DCC) in multiple and singleton preterm infants born at our center. After DCC protocol implementation, compliance and success rate were assessed. Clinical outcomes of selected 150 preterm infants <34 weeks gestation born in 2014 after protocol implementation (Epoch II) were compared to those of preterm infants born in 2013 before protocol implementation (Epoch I). Overall protocol compliance rate was 92% (246/267). DCC was successfully performed in 77% (205/267) after protocol implementation. There were higher multiple births in Epoch II compared to Epoch I (27.3 vs. 15.3% , p < 0.01). At birth, infants in Epoch II had significantly decreased need for intubation in delivery room (23.3 vs. 39.3% , p < 0.01), had higher hematocrit (46.4±7.3 vs. 44.0±7.1% , p < 0.01) and less metabolic acidosis (base excess -4.1±2.7 vs. -5.3±4.2 mmol/L, p < 0.01) compared to those born in Epoch I. During hospital stay, fewer infants in Epoch II received rescue surfactant therapy (45.3 vs. 56.7% , p = 0.05), medical treatment for PDA (6.7 vs. 16.6% , p = 0.04%) and red blood cell transfusions (20.7 VS. 32.0% , p < 0.01) compared to Epoch I. Protocol-guided practice of DCC for 30 seconds can be safely performed in multiple and singleton preterm infants. In addition to higher initial hematocrit, infants in our QI project had lower need for delivery room resuscitation and less metabolic acidosis at birth. We also observed decreased need for rescue surfactant therapy, medical treatment for PDA and red blood cell transfusions after DCC protocol implementation.

Effect of delayed cord clamping on very preterm infants

Despite significant proposed benefits, delayed umbilical cord clamping (DCC) is not practiced widely in preterm infants largely because of the question of feasibility of the procedure and uncertainty regarding the magnitude of the reported benefits, especially intraventricular hemorrhage (IVH) vs the adverse consequences of delaying the neonatal resuscitation. The objective of this study was to determine whether implementation of the protocol-driven DCC process in our institution would reduce the incidence of IVH in very preterm infants without adverse consequences. We implemented a quality improvement process for DCC the started in August 2013 in infants born at ≤32 weeks' gestational age. Eligible infants were left attached to the placenta for 45 seconds after birth. Neonatal process and outcome data were collected until discharge. We compared infants who received DCC who were born between August 2013 and August 2014 with a historic cohort of infants who were born between August 2012 and August 2013, who were eligible to receive DCC, but whose cord was clamped immediately after birth, because they were born before the protocol implementation. DCC was performed on all the 60 eligible infants; 88 infants were identified as historic control subjects. Gestational age, birthweight, and other demographic variables were similar between both groups. There were no differences in Apgar scores or admission temperature, but significantly fewer infants in the DCC cohort were intubated in delivery room, had respiratory distress syndrome, or received red blood cell transfusions in the first week of life compared with the historic cohort. A significant reduction was noted in the incidence of IVH in the DCC cohort compared with the historic control group (18.3% vs 35.2%). After adjustment for gestational age, an association was found between the incidence of IVH and DCC with IVH was significantly lower in the DCC cohort compared with the historic cohort; an odds ratio of 0.36 (95% confidence interval, 0.15-0.84; P < .05). There were no significant differences in deaths and other major morbidities. DCC, as performed in our institution, was associated with significant reduction in IVH and early red blood cell transfusions. DCC in very preterm infants appears to be safe, feasible, and effective with no adverse consequences.

Clamp late and maintain perfusion (CLAMP) policy: delayed cord clamping in preterm infants

Objective: Randomized controlled trials have demonstrated that delayed umbilical cord clamping (DCC) in preterm infants results in improved neonatal outcomes, including increased hematocrit, and decreased rates of intraventricular hemorrhage (IVH) and packed red blood cell transfusions. We hypothesized that implementation of a DCC policy in preterm infants would result in similarly improved outcomes, despite initial clinician resistance.Study design: A DCC policy (30–60 s) for singleton infants <35 weeks gestation was implemented in September 2011. We conducted a pre-test/post-test analysis of neonatal outcomes among singletons delivered between 24 0/7 weeks and 34 6/7 weeks gestation from 2009 to 2013 (2 years pre-implementation and 2 years post-implementation). The primary outcomes were rates of policy compliance and four neonatal outcomes.Results: Despite multiple routes of policy dissemination, DCC was attempted in only 49% of the deliveries. In spite of this, infants delivered post-policy implementation (n = 196) had a significant decrease in IVH, significant increase in initial hematocrits, and improved temperatures compared with infants delivered pre-implementation (n = 204).Conclusion: After implementation of a DCC policy, preterm singleton infants had improved temperatures, increased hematocrits and a decreased prevalence of IVH without significant differences in adverse outcomes, suggesting that the benefits of DCC outweighed the risks.

Steps for implementing delayed cord clamping in a hospital setting.

BackgroundDelayed umbilical cord clamping (DCC) permits placental-to-newborn transfusion and results in an increased neonatal blood volume at birth. Despite endorsement by numerous medical governing bodies, DCC in preterm newborns has been slow to be adopted into practice. The purpose of this article is to provide a framework to guide medical providers interested in implementing DCC in a hospital setting. A descriptive implementation guideline is presented based on the author’s personal experiences and the steps taken at the University of Washington (UW) to implement DCC in premature newborns <37 weeks’ gestational age. Quality improvement data was obtained to assess compliance with DCC performance over the initial six months following initiation of the treatment protocol in July 2014. An anonymous electronic survey was administered to obstetrical providers in January 2015 to assess DCC policy awareness and adherence.ResultsImportant steps to consider regarding implementation of DCC in a hospital settings include applying a multidisciplinary educational approach aimed at motivating potential stakeholders potentially impacted by DCC, addressing safety concerns regarding DCC, and developing a standardized DCC treatment protocol. In the first month following DCC protocol implementation at UW, 79.2% (19/24) of premature newborns admitted to the neonatal intensive care unit received DCC, but compliance decreased over time, with DCC documented in only 40.1% (61/150) of newborns during the 6-month period following implementation. The majority of obstetrician survey respondents (90.9%, 20/22) were aware of the UW DCC policy for preterm deliveries, had performed DCC in the past 6 months (95.5%, 21/22), felt that they had sufficient understanding of the risks and benefits of DCC (90.9%, 20/22) and cited concerns for maternal hemorrhage and the need to resuscitate the baby as the main reasons to perform immediate cord clamping instead of DCC.ConclusionHealthcare providers interested in implementing DCC may benefit from a procedural practice plan that includes an assessment of organizational readiness to adopt a DCC protocol, methods to measure and encourage staff compliance, and ways to track outcome data of infants who underwent DCC. Strategies to improve protocol awareness after DCC has been implemented are recommended since compliance may decrease over time.

Obstetricians’ attitudes and beliefs regarding umbilical cord clamping

Objective: Although delayed umbilical cord clamping has been demonstrated to reduce the incidence of intraventricular hemorrhage and neonatal sepsis, and decrease the need for neonatal transfusions (without affecting cord pH, Apgar scores or the need for phototherapy), the extent to which this practice is being employed is unknown. We conducted a survey of US obstetricians to assess their attitudes and beliefs about cord clamping.Study design: Questionnaires were randomly mailed to members of the American College of Obstetricians and Gynecologists (ACOG), and the Collaborative Ambulatory Research Network (CARN). The data were analyzed using Chi-square and Student t tests.Results: The response rates for the CARN and other ACOG members were 47% and 21%, respectively. Most (88%) responders reported their hospital had no umbilical cord clamping policy. The most frequent response for optimal timing of umbilical cord clamping, regardless of gestational age, was “don’t know”. Potential for neonatal red blood cell transfusion was the only concern cited as a reason for being somewhat or very inclined to delay umbilical cord clamping (51%). Delayed neonatal resuscitation (76%) was listed as a reason to clamp the cord immediately, despite the paucity of literature to support immediate cord clamping in this cohort.Conclusion: Despite substantial evidence supporting the practice of delayed cord clamping, few institutions have policies regarding this practice. Moreover, obstetricians’ beliefs about the appropriate timing for umbilical cord clamping are not consistent with the evidence that demonstrates its beneficial impact on neonatal outcomes.

A randomized controlled trial on delayed cord clamping and iron status at 3–5 months in term neonates held at the level of maternal pelvis

Background: Delayed umbilical cord clamping (DCC) for two to three minutes after birth, results in substantial transfusion of blood from the placenta to the newborn, thus likely to improve iron status within the first months of life. However, optimal infant position during DCC in relation to mother's pelvis has not yet been determined and this maneuver has been suggested to have substantial risk of neonatal jaundice and cardiopulmonary compromise. Objective: To study the effect of DCC with the infant held at the level of mother's pelvis, compared to early cord clamping on: a) iron status at 3-5 months of age (primary outcome), b) hemoglobin and iron status in immediate postnatal period, and c) potential hazards on neonatal outcome. Methods: This randomized controlled trial was conducted on mother-infant pairs born at term by normal vaginal delivery following uncomplicated low risk pregnancies. Neonates were randomized to early cord clamping, done immediately after birth (≤15 seconds) and DCC (3 minutes after birth), starting from the time of shoulder delivery, with the baby held at the level of mother's pelvis. Both groups were evaluated for hematological parameters mainly, transferrin saturation and serum ferritin at 24 hours and then at 3-5 months postnatally. Results: A total of 180 mother-infants pairs were included; with 90 subjects in each group. At 3-5 months old, infants with DCC had significantly higher serum ferritin (430 vs. 228 ug/L, p < 0.001). Although hemoglobin (Hb) concentration did not differ between groups, DCC group had fewer cases with diagnosed with low serum ferritin (p < 0.001). At 24 hours postnatally, infants with DCC had significantly higher Hb (19.6 vs. 16.8 g/dl, p < 0.001) and hematocrit values (55.8 vs. 51.4%, p < 0.001) compared to early cord clamping group. None of the cases, in either group had respiratory distress or polycythemia in the immediate postnatal period with no significant difference in mean serum bilirubin level on comparing both groups. Conclusion: with the baby held at the level of mother's pelvis, DCC resulted in increased ferritin concentrations and reduced the prevalence of iron deficiency at 3-5 months of age, without demonstrable adverse neonatal effects.

Placental Transfusion Strategies in Preterm Infants &lt; 1000 G BW: Meta-Analysis of Short and Long Term Outcomes

Background: Delayed umbilical cord clamping (DCC) or umbilical cord milking (UCM) in ELBW neonates reduces the number of blood transfusions. DCC is now a common practice in term infants, but the outcomes of preterm infants below 1000g subjected to DCC or UCM are unclear. Objective: A meta-analysis of short and long term outcomes of infants < 30weeks GA and < 1000g BW randomised to either DCC or UCM as compared to immediate cord clamping (ICC). Methods: Twi independent investigators searched the literature for trials that randomised preterm infants < 1000g BW to either experimental(DCC or UCM) or control(ICC) groups. Primary outcome was 24 month Neurodevelopmental Impairment(NDI) using standardised outcomes; secondary outcomes included transfusions. Additional information was requested of authors. Data was summarised by RevMan5 as weighted mean difference(WMD) and 95%CI. Results: Searches yielded 15 studies, 6 were included, describing 108 infants. Data on NDI was limited and could not be pooled. One study (Mercer) recorded Bayley at 7 months for 27 infants(WMD MDI -4.40; CI -18.02, +9.22; p=NS). Another study (Hosono) found no significant differences in disability rates(UCM 19% vs ICC 27%; p=NS) at 24months using a Japanese scale. Short term benefits of DCC/UCM included better mean BP on admission(WMD -4.9;CI -5.58,-4.22) and hemoglobin(WMD 3.71;CI 3.94, 3.47). Other benefits included reduced number of blood transfusions and days on ventilator. Figure Conclusions: Only one study reports 24 month NDI, and no pooling is possible. Short term benefits of DCC include rise in hemoglobin, decreased number of transfusions and shorter days on ventilator.