Has the evidence tipped in favor of delayed cord clamping?

In December 2012, the American College of Obstetricians and Gynecologists
(ACOG) published a Committee Opinion on the timing of umbilical cord clamping after birth, but it found insufficient evidence to recommend early or delayed clamping._¹

In a Cochrane review published earlier this year, McDonald and colleagues reviewed 15 trials and 3,911 mother-infant pairs, exploring the primary outcomes of severe maternal postpartum hemorrhage (≥1,000 mL), maternal death, and severe maternal morbidity and neonatal death associated with early versus delayed clamping. They also analyzed a number of secondary outcomes. None of the primary outcomes reached statistical significance.

In a statement from the World Health Organization (WHO) included in the Cochrane review, it was recommended that “the cord should not be clamped earlier than necessary”; the WHO graded this as a “weak recommendation”
based on “low-quality” evidence.

With such underwhelming evidence, I would guess that the average clinician does not feel very motivated to change his or her practice, if that practice involves early clamping.

One limitation of the Cochrane findings
In the studies included in the Cochrane review, there was marked heterogeneity in the definition of delayed cord clamping, which ranged
from 1 minute after delivery to the complete cessation of cord pulsation (~5 minutes). Some of the studies even used alternate times (2 minutes, 3 minutes, and so on).

Delayed clamping improved neonatal hemoglobin status
Among the secondary outcomes assessed in this review was an improvement in neonatal hemoglobin concentration and overall iron stores associated with delayed clamping—but this benefit came at the expense of a higher incidence of neonatal jaundice requiring phototherapy. As a result, the investigators
concluded that delayed cord clamping should be performed when there is ready
access to phototherapy.

Should we implement delayed clamping?
At this time, I am reluctant to recommend that we shift to delayed clamping. Here are my reasons:

• Data are lacking as to whether increased hemoglobin levels and iron stores in newborns improve outcomes—or provide any benefit. No long-term developmental outcome data were included in the Cochrane review.
• Although I am not a pediatrician, I am unaware of infant iron deficiency being a significant threat to public health in the developed world.
• The greater need for phototherapy in the delayed-clamping group should not be viewed as inconsequential.
• Iron supplementation is probably more readily available than phototherapy, especially in developing countries.
• In the minority of cases in which delayed clamping might be beneficial (eg, prematurity), it is not always feasible, as these infants may already be compromised. Anxious neonatologists generally want the newborn handed over to them for resuscitation as quickly as possible, generally frowning upon a delay of 3 to 5 minutes for the blood to move from the placenta to the infant.

What this evidence means for practice
I recommend that obstetric care providers continue their current practice until more detailed data emerge on the risks and benefits of delayed clamping. If a patient asks about the issue, we should counsel her about the risks and benefits of early versus delayed clamping and comply with her choice when there are no contraindications.
—John T. Repke, MD

Tell us what you think, at rbarbieri@frontlinemedcom.com. Please include your name and city and state.

In December 2012, the American College of Obstetricians and Gynecologists
(ACOG) published a Committee Opinion on the timing of umbilical cord clamping after birth, but it found insufficient evidence to recommend early or delayed clamping._¹

In a Cochrane review published earlier this year, McDonald and colleagues reviewed 15 trials and 3,911 mother-infant pairs, exploring the primary outcomes of severe maternal postpartum hemorrhage (≥1,000 mL), maternal death, and severe maternal morbidity and neonatal death associated with early versus delayed clamping. They also analyzed a number of secondary outcomes. None of the primary outcomes reached statistical significance.

In a statement from the World Health Organization (WHO) included in the Cochrane review, it was recommended that “the cord should not be clamped earlier than necessary”; the WHO graded this as a “weak recommendation”
based on “low-quality” evidence.

With such underwhelming evidence, I would guess that the average clinician does not feel very motivated to change his or her practice, if that practice involves early clamping.

One limitation of the Cochrane findings
In the studies included in the Cochrane review, there was marked heterogeneity in the definition of delayed cord clamping, which ranged
from 1 minute after delivery to the complete cessation of cord pulsation (~5 minutes). Some of the studies even used alternate times (2 minutes, 3 minutes, and so on).

Delayed clamping improved neonatal hemoglobin status
Among the secondary outcomes assessed in this review was an improvement in neonatal hemoglobin concentration and overall iron stores associated with delayed clamping—but this benefit came at the expense of a higher incidence of neonatal jaundice requiring phototherapy. As a result, the investigators
concluded that delayed cord clamping should be performed when there is ready
access to phototherapy.

Should we implement delayed clamping?
At this time, I am reluctant to recommend that we shift to delayed clamping. Here are my reasons:

• Data are lacking as to whether increased hemoglobin levels and iron stores in newborns improve outcomes—or provide any benefit. No long-term developmental outcome data were included in the Cochrane review.
• Although I am not a pediatrician, I am unaware of infant iron deficiency being a significant threat to public health in the developed world.
• The greater need for phototherapy in the delayed-clamping group should not be viewed as inconsequential.
• Iron supplementation is probably more readily available than phototherapy, especially in developing countries.
• In the minority of cases in which delayed clamping might be beneficial (eg, prematurity), it is not always feasible, as these infants may already be compromised. Anxious neonatologists generally want the newborn handed over to them for resuscitation as quickly as possible, generally frowning upon a delay of 3 to 5 minutes for the blood to move from the placenta to the infant.

What this evidence means for practice
I recommend that obstetric care providers continue their current practice until more detailed data emerge on the risks and benefits of delayed clamping. If a patient asks about the issue, we should counsel her about the risks and benefits of early versus delayed clamping and comply with her choice when there are no contraindications.
—John T. Repke, MD

Tell us what you think, at rbarbieri@frontlinemedcom.com. Please include your name and city and state.

In December 2012, the American College of Obstetricians and Gynecologists
(ACOG) published a Committee Opinion on the timing of umbilical cord clamping after birth, but it found insufficient evidence to recommend early or delayed clamping._¹

In a Cochrane review published earlier this year, McDonald and colleagues reviewed 15 trials and 3,911 mother-infant pairs, exploring the primary outcomes of severe maternal postpartum hemorrhage (≥1,000 mL), maternal death, and severe maternal morbidity and neonatal death associated with early versus delayed clamping. They also analyzed a number of secondary outcomes. None of the primary outcomes reached statistical significance.

In a statement from the World Health Organization (WHO) included in the Cochrane review, it was recommended that “the cord should not be clamped earlier than necessary”; the WHO graded this as a “weak recommendation”
based on “low-quality” evidence.

With such underwhelming evidence, I would guess that the average clinician does not feel very motivated to change his or her practice, if that practice involves early clamping.

One limitation of the Cochrane findings
In the studies included in the Cochrane review, there was marked heterogeneity in the definition of delayed cord clamping, which ranged
from 1 minute after delivery to the complete cessation of cord pulsation (~5 minutes). Some of the studies even used alternate times (2 minutes, 3 minutes, and so on).

Delayed clamping improved neonatal hemoglobin status
Among the secondary outcomes assessed in this review was an improvement in neonatal hemoglobin concentration and overall iron stores associated with delayed clamping—but this benefit came at the expense of a higher incidence of neonatal jaundice requiring phototherapy. As a result, the investigators
concluded that delayed cord clamping should be performed when there is ready
access to phototherapy.

Should we implement delayed clamping?
At this time, I am reluctant to recommend that we shift to delayed clamping. Here are my reasons:

• Data are lacking as to whether increased hemoglobin levels and iron stores in newborns improve outcomes—or provide any benefit. No long-term developmental outcome data were included in the Cochrane review.
• Although I am not a pediatrician, I am unaware of infant iron deficiency being a significant threat to public health in the developed world.
• The greater need for phototherapy in the delayed-clamping group should not be viewed as inconsequential.
• Iron supplementation is probably more readily available than phototherapy, especially in developing countries.
• In the minority of cases in which delayed clamping might be beneficial (eg, prematurity), it is not always feasible, as these infants may already be compromised. Anxious neonatologists generally want the newborn handed over to them for resuscitation as quickly as possible, generally frowning upon a delay of 3 to 5 minutes for the blood to move from the placenta to the infant.

What this evidence means for practice
I recommend that obstetric care providers continue their current practice until more detailed data emerge on the risks and benefits of delayed clamping. If a patient asks about the issue, we should counsel her about the risks and benefits of early versus delayed clamping and comply with her choice when there are no contraindications.
—John T. Repke, MD

Tell us what you think, at rbarbieri@frontlinemedcom.com. Please include your name and city and state.