Monday, December 7, 2009

Article about Delayed Cord Clamping

Good article about why the cord should not be clamped/cut until it stops pulsating after birth.


"Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial(7)
Randomized 72 VLBW infants (< p =" 0.03)" p ="">
The Influence of the Timing of Cord Clamping on Postnatal Cerebral Oxygenation in Preterm Neonates: A Randomized, Controlled Trial (8)
Randomized 39 preterm infants to immediate clamping vs. 60-90 second delay, and examined fetal brain blood flow and tissue oxygenation. Results showed similar blood flow between groups, but increased tissue oxygenation in the delayed group and 4 and 24 hours after birth.
Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomized controlled trial(9)
Randomized 476 infants to immediate or 2 minute delayed clamping and followed them for 6 months. Delayed clamped babies had higher MCVs (81 vs. 79.5), higher ferritins (50.7 vs. 34.4), and higher total body iron. Effects were greater in infants born to iron deficient mothers. Delayed clamping increased total iron stores by 27-47mg. A follow up study showed that lead exposed infants with delayed clamping also had lower serum lead levels than immediate clamped infants, likely due to iron mediates changes in lead absorption.
A randomized clinical trial comparing immediate versus delayed clamping of the umbilical cord in preterm infants: short-term clinical and laboratory endpoints(10)
Infants delivering at 30 to 36 weeks gestation randomized to immediate vs. 1 minute delay. Delayed group had higher RBC volumes (p = 0.04) and hematocrits (p < p =" 0.03)">
Immediate versus delayed umbilical cord clamping in premature neonates born <>

Randomized 60 infants to clamping at 5-10 seconds vs. 30-45 seconds. Delayed clamping infants had higher BPs and hematocrits. Infants <>
And that’s just some of it. I’ll be happy to send you an Endnote file with a pile more of you’d like it. If the burden of proof is on us to prove that immediate clamping is good, that burden is clearly not met. And furthermore, there is strong evidence that delaying clamping as little as 30 seconds has measurable benefits for the infant, especially in premature babies and babies born to iron deficient mothers.

So basically, we should be doing this. I’m going to try to effect some change in my department, but there are a lot of things that need to happen for us to change as a general culture. It can’t just be the OBs. L and D nurses and pediatricians need to buy in as well.

Some people will argue that premature babies need to be brought to the warmer right away for resucitation. I don’t know the answer to this, but it’s worth study. One might think that it is important to intubate a very premature baby right away, but I have to wonder if that intact cord will be better at delivering oxygen to the baby for 30-60 seconds than the premature lungs. Particularly in cases of fetal respiratory acidosis, there is strong logical argument that a baby might be better resuscitated by unwrapping the cord and letting it flow a bit than trying to oxygenate it through its lungs. Until that placenta is detached, you have a natural ECMO system. Why not use it? Certainly there are exceptions to this logical argument, abruption being the biggest one, and perhaps even severe pre-eclampsia and other poor feto-maternal circulation states.

I wonder at times why delayed cord clamping has not become the standard already; why by and large we have not heeded the literature. It is sad to say that I believe it is because the champions of this practice have not been doctors, but midwives, and sometimes we are influenced by prejudice. Clearly, midwives and doctors tend to have some different ideas about how labor should be managed, but in the end data is data. We championed evidence based medicine, but tend to ignore evidence when it comes from the wrong source, which is unfair. It is fair to critique the research and the methods used to write it, but it shouldn’t matter who the author is. In this case, Mercer and other midwives have done the world a favor by scientifically addressing this issue, and their data deserves serious consideration.

To quote Levy et al (12) “Although a tailored approach is required in the case of cord clamping, the balance of available data suggests that delayed cord clamping should be the method of choice.” We ought to heed this advice better. Like episiotomy, this change in practice may take awhile, but we should get it started. I’m going to work on it myself. How about you?"

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