1. Delayed
Umbilical Cord
Clamping in
Preterm
Neonates
REFERENCES
Backes, C. H., Rivera, B. K., Haque, U., Bridge, J. A., Smith, C. V., Hutchon, D. J. R., &
Mercer, J. S. (2014). Placental transfusion strategies in very preterm neonates: A systematic
review and meta-analysis. Obstetrics and Gynecology, 124(1), 47-56.
Elimian A, Goodman J, Escobedo M, Nightingale L, Knudtson E, Williams M. (2014).
Immediate compared with delayed cord clamping in the preterm neonate: a randomized
controlled trial. Obstetrics and Gynecology, 124(6), 1075-9.
Kaempf, J.W., Tomlinson, M.W., Kaempf, A.J., Wu, Y., Wang, L., Tipping, N., Grunkemeier,
G. (2012). Delayed Umbilical Cord Clamping in Premature Neonates. The American College
of Obstetricians and Gynecologist, 120( 2), 325-330.
Mercer, J.S., Vohr B.R., McGrath, M.M., Padbury, J.F., Wallach, M, Oh, W. (2006). Delayed
cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage
and late-onset sepsis: a randomized, controlled trial. Pediatrics, 117, 1235–42.
Tolosa, J.N., Park, D.H., Eve, D.J., Klasko, S.K., Borlongan, C.V., Sanberg, P.R. (2010).
Mankind’s first natural stem cell transplant. Journal of Cellular and Molecular Medicine,
14(3), 488-495.
CLINICAL QUESTION
What are the risks and benefits to delayed
umbilical cord clamping in preterm
neonates fewer than 37 weeks gestation?
LITERATURE REVIEW
• Meta-analysis (2014): 12 studies analyzed
placental transfusion benefits.
• Systematic Review (2009): 106 studies and
articles on the timing and benefits of delayed
cord clamping.
• Randomized Controlled Trial (2014): n=200,
comparative of risks and benefits of early and
delayed cord clamping in preterm infants.
• Randomized Control Trial (2006): n=72,
immediate versus delayed cord clamping test
for late onset sepsis and intraventricular
hemorrhage.
• Non-Randomized Control Trial (2012): n=172,
before/after investigation comparing early
umbilical cord clamping with delayed
umbilical cord clamping.
METHOD
Databases: Pubmed, Cochrane Library, Mosby’s
Nursing Consult, EBSCOHost
Keywords: “Delayed Cord Clamping,” “ Delayed
Umbilical Cord Clamping,” “DCC,” “Neonatal
Blood Transfusion,” “LBW Infants,” “Early Cord
Clamping,” “Placental Blood Transfusion,”
“Anemia,” “Umbilical cord clamping time,”
”Intraventricular Hemorrhage”
DECISION
In preterm uncomplicated vaginal births clamping of the
umbilical cord should be performed at between thirty
seconds to one minute after birth or when the umbilical cord
stops pulsing; whichever occurs first.
The main contraindications to delayed clamping include
placental abruption; signs of distress shown by the neonate;
and possibly twin to twin transfusion syndrome, especially in
the recipient twin.
IMPLEMENTATION
• Reeducation of birthing team about the benefits of delayed
cord clamping.
• Cord clamping executed between 30 and 60 seconds.
• Include the exact timing into the medical record for further
research.
• Apply immediately after APGAR score.
• Milking and stripping of umbilical cord is not advised.
• Continue to gather evidence to hone timing of delayed
cord clamping and establish better understanding for full
term infants.
EVALUATION
Implementation of delayed cord clamping should see a more
robust establishment of red blood cell volume, a decreased
need for blood transfusions, reductions in necrotizing
enterocolitis, and intraventricular hemorrhage at all grades.
Expected outcomes for preterm neonates include
stabilization of transitional circulation, lessening needs for
inotropic medications and the aforementioned benefits.
Michael Albertine, Frank Bernard,
Ben Kifle, Joseph Williamson,
Emmett Ziegler
DISCUSSION
Delayed cord clamping is a safe and effective intervention in
preterm neonatal births in the majority of situations. The
World Health Organization and American Academy of
Pediatrics currently recommends delayed cord clamping at
1 minute from breach of birth. Current practice, of
immediate clamping, is not evidenced based. Delayed cord
clamping could be implemented immediately but the lack of
clinician education is the main barrier to implementation.
Recommendations allow for clinicians to deviate from the
protocol when the neonate needs resuscitation.
Future research should include application of delayed cord
clamping on very preterm infants and the benefits of
delaying cord clamping during resuscitation efforts.standard
procedure.
FINDINGS
INTRAVENTRICULAR HEMORRHAGE:
• Reduction in total intraventricular hemorrhage
by up to 50%.
• Reduces the incidence of all grades of
hemorrhage.
• In severe IVH no change is observed.
HEMODYNAMICS:
• Increase in neonatal blood volume (hematocrit
and hemoglobin).
• Increase in mean systolic blood pressures.
• Increase in neonatal iron stores - seen up to 6
months.
• Probable increase in stem cells for the neonate
• Reduction of necrotizing enterocolitis.
• Possible reduction in blood transfusions
related to anemia or low blood pressure (needs
further research).
OTHER ISSUES:
• Reduced days on oxygen and ventilation.
• Increased cerebral oxygenation.
• No changes in temperature, peak bilirubin
levels, need for resuscitation, length of stay,
growth rates and morbidities.
• Potential increased need for phototherapy due
to jaundice.