Delayed Cord Clamping in newborns has proven beneficial, both in preterm and term infants. Previous studies have suggested that delaying cord clamping is recommended for premature infants because these studies' results are significantly better than cord clamping immediately after birth.


Delayed Cord Clamping: Benefits, Side Effects, and Technique


Currently, cord clamping is performed shortly after birth, usually under 10-15 seconds after birth. This clamping is known as Immediate Cord Clamping (ICC).

According to WHO recommendations, Delayed Cord Clamping (DCC) is the umbilical cord's clamping at least 1 minute after birth. According to the American College of Obstetricians and Gynecologists Committee on Obstetric Practice, the recommended delay of cord clamping is at least 30-60 seconds after birth in term and preterm infants who do not require positive pressure ventilation.

This article will discuss the advantages and risks of delayed cord clamping under the circumstances in which delayed cord clamping is performed.



Benefits of Delayed Cord Clamping

a. Benefits of Delayed Cord Clamping in Term Infants

Research has found that as much as 80-100 mL of blood volume can be transferred from the placenta to the newborn within the first 1-3 minutes of life. This increase in blood volume in term infants can increase hemoglobin/hematocrit up to 4-12 months of age.

Additional blood volume adds ± 40-50 mg/kg of iron levels. When combined with blood iron levels in term infants (75mg / kg), this additional iron level is very useful in preventing iron-deficiency anemia in the first year of life.

Ferritin levels in blood were higher in DCC infants than in ICC up to the first 6 months of life with a mean difference of + 11.8 µg / L (95% CI 4.07-19.53).

Iron deficiency anemia often occurs in children under 5 years of age; this can be prevented by providing iron supplementation. Still, the implications are difficult to realize in low-income countries with limited supplies. So delaying the umbilical cord's clamping is one way to prevent the occurrence of iron deficiency anemia.

Term infants with delayed cord clamping also have a higher survival rate against malaria in endemic areas. Also, because of the competitive effect between iron and lead, by delayed umbilical cord clamping, term infants living in highly polluted areas have lower circulating blood lead levels.

Research on the long-term benefits of DCC is still limited. Still, several existing cohort studies found that at 4 years of age, neonates with ICC had lower social and fine motor skills scores than those in the neonatal group with DCC.


b. Benefits of Delayed Cord Clamping in Preterm infants

The umbilical cord's clamping immediately causes no blood flow to the right ventricle of the baby's heart, resulting in a decrease in the right cardiac output by up to 50%.

In preterm infants with delayed cord clamping, this significant increase in blood volume prevents the superior vena cava flow from stopping so that the baby can maintain right ventricular cardiac output and stroke volume for up to 48 hours after birth. It also affects cerebral blood circulation resulting in better oxygenation at 4 hours of life (69.9% vs. 65.5%) and lasts up to 24 hours of life (71.3% vs. 68.1%).

Delayed Cord Clamping in Premature Infants requiring Immediate Resuscitation
The debate about delayed cord clamping occurs in situations of fetal distress and/or neonatal asphyxia requiring immediate neonatal resuscitation, in which delayed cord clamping is deemed to delay the time to save the baby.

On the other hand, it is precisely how delayed cord clamping provides the most significant benefits. Fetal distress due to intrauterine cord compression is caused by oxygen-containing blood not entering from the placenta to the fetus. The volume of oxygen-rich blood decreases in fetal blood circulation. Increasing circulating oxygenated blood by placental transfusion with delayed cord clamping has a very positive effect on this fetal distress and should be considered the first step in neonatal resuscitation.

According to the WHO's Guidelines on Basic Newborn Resuscitation, if there are capabilities and availability of equipment, positive pressure ventilation (VTP), resuscitation can be done without cutting the umbilical cord first. However, if there is no prior experience, then neonates requiring VTP should be clamped immediately to perform ventilation resuscitation as soon as possible.

With the increase in blood volume, the need for blood transfusions to overcome low systemic blood pressure (RR 0.39; 95% CI 0.18-0.85) and anemia will decrease (RR 0.49; 95% CI 0.31-0. , 81). This is recommended to be done in developing countries because of the limited availability of blood, which is not always available all the time.

If the fetal distress is immediately clamped after birth, its life depends entirely on neonatal resuscitation ventilation's effectiveness to convert deoxygenated blood to oxygen-rich blood.

However, if the right ventricle's blood volume has decreased by ~ 50% and ventilation in resuscitation is not working properly, lung pressure will remain high. Blood from the right ventricle cannot enter the pulmonary circulation and into the left ventricle.

The reduction in left ventricular cardiac output will be managed by rapid bolus administration of neonatal resuscitation steps. This has a side effect of the occurrence of intraventricular bleeding of the brain (Intraventricular Haemorrhage / IVH), especially in infants who are still very premature because of the maximally dilated cerebral vascular condition and the cerebral autoregulation system, which is still immature. So doing DCC can significantly prevent the incidence of intraventricular bleeding (p <0.002) compared to ICC (RR 0.59; 95% CI 0.41-0.85).



Side Effects of Delayed Cord Clamping

The risk of delayed umbilical cord clamping side effects negatively impacts children's neurocognition, the occurrence of polycythemia, hyperbilirubinemia, and the need for phototherapy, acute respiratory distress syndrome (ARDS), and maternal bleeding. However, recent research has found that not all of the risks of these side effects are proven. The following is a discussion of each of the risks of side effects.

a. Polycythemia

Polycythemia is a condition in which there are too many erythrocytes in the circulation, proven objectively by examining hematocrit> 65%. It can lead to circulatory, respiratory problems, hyperbilirubinemia, and hyperviscosity. 

The theory suggests that delayed cord clamping can lead to polycythemia due to increased blood volume from placental transfusions. However, no studies have shown that delayed cord clamping significantly and consistently increases the risk of developing polycythemia. A meta-analysis revealed no significant change or increased risk of polycythemia when delayed cord clamping was performed (RR 0.39; 95% CI 0.12-1.27; n = 463).


b. Hyperbilirubinemia 

A meta-analysis found that delayed cord clamping did not lead to an increase in bilirubin levels in the first 24 hours of life (RR 1.35; 95% CI 1.00-1.81).  However, in the infant meta-analysis study 1762, icteric's clinical incidence requiring phototherapy treatment was higher in the group of infants with DCC (RR 0.62; 95% CI 0.41-0.96).

The risk of these side effects makes delayed cord clamping not recommended in areas with limited health facilities or in the middle to lower class communities who do not have health insurance.


c. Acute Respiratory Distress Syndrome (ARDS)

Research into the association of delayed cord clamping with ARDS is inconclusive. The meta-analysis revealed that the DCC and ICC groups had the same likelihood of ARDS (RR 0.70; CI 0.22-2.19; n = 835).

Transient tachypnea of ​​the neonate may occur due to delayed absorption of lung fluids due to increased blood volume in delayed cord clamping. Another study found an increase in the respiratory rate in infants with DCC but no need for respiratory therapy (oxygen therapy for up to 24 hours of life).


d. Maternal Bleeding

ICC is the most frequently used method, followed by active 3rd stage management to prevent post-partum hemorrhage. However, the application of delayed cord clamping does not increase the risk of post-partum hemorrhage.

A study of 2,200 women found no association between delayed umbilical cord clamping and post-partum hemorrhage, increased blood loss volume during labor, or differences in hemoglobin levels leading to transfusion. However, in maternal bleeding, shock (hemodynamic instability), and abnormal placental placement (placenta previa and abruption), delayed cord clamping is impossible.


Delayed Cord Clamping Techniques

  1. Place the infant on the mother's stomach or chest to initiate skin touch stimulation, or be held by the operator / operating assistant if the delivery is done by Caesarean section.
  2. Perform stimulation to make Infantum cry or breathe by tapping the feet' soles or on the baby's back, then covering the infant with a dry cloth to maintain body temperature.
  3. If secretions or meconium obstruct the airway, clear it with a suction device.
  4. Then do an APGAR score assessment while waiting for the remaining delayed umbilical cord clamping time (30-60 seconds).
This delayed umbilical cord clamping process should not be accompanied by active 3rd stage management, including uterotonic medicine before delayed cord clamping.


Contraindications

Contraindications for delayed cord clamping include the following:
  • Maternal problems: bleeding, shock (hemodynamically unstable), abnormal placenta location (placenta previa, placenta abruption)
  • Fetal/neonatal problems: intact placenta-fetal circulation (placenta abruption, placenta previa, IUGR with abnormal Doppler evaluation, and cord avulsion)
  • If there are any of the above problems, immediate umbilical cord clamping is the main option that must be done.

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