Apresentação do Clube de Revista de Saúde Baseada em Evidências

1. Encontro 02
Keitty Regina Cordeiro de Andrade
05/11/2013

2. Effect of timing of umbilical cord clamping of
term infants on maternal and neonatal
outcomes
Susan J McDonald, Philippa Middleton,
Therese Dowswell, Peter S Morris.
Cochrane Database of Systematic
Reviews, Issue 7, 2013 (CD004074).
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3. Background
• Policies for timing of cord clamping vary, with
early cord clamping generally carried out in
the first 60 seconds after birth, whereas later
cord clamping usually involves clamping the
umbilical cord more than one minute after the
birth or when cord pulsation has ceased.
• The benefits and potential harms of each
policy are debated.
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4. Objectives
• To determine the effects of early cord clamping
compared with late cord clamping after birth on
maternal and neonatal outcomes.
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5. Methods
Search methods for identification of studies:
1. monthly searches of the Cochrane Central Register
of
Controlled Trials (CENTRAL);
2. weekly searches of MEDLINE;
3. weekly searches of EMBASE;
4. handsearches of 30 journals and the proceedings
of major conferences.
We did not apply any language restrictions.
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6. Methods
• Participants: Women who have given birth to
a term infant.
• Intervention: Early cord clamping (application
of a clamp to the umbilical cord within 60
seconds of the birth of the infant).
• Comparison: Later (delayed) cord clamping,
defined as application of a clamp to the
umbilical cord greater than one minute after
birth or when cord pulsation has ceased.
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7. Methods
• Types of outcome measures: Primary outcomes
1. Severe PPH (measured blood loss 1000 mL or
more, or, as defined by the trial authors);
2. Maternal death or severe morbidity composite;
3. Neonatal mortality.
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8. • Secondary outcomes:
• Maternal
Matern death) a.PPH (500 ml)
Length of third stage of labor
The average blood loss
Blood transfusion
Use of therapeutic uterotonic
Postnatal anemia
• Neonatal
Birthweight
Apgar score less than seven at five minutes
Admission to neonatal intensive care unit or special care
respiratory distress
hipóxiaIcterícia requiring phototherapy
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9. Methods
• Statistical analysis was done using the module
Metaview Application Review Manager;
• For dichotomous variables, we used the
method of difference in absolute risk with a
confidence interval of 95% (random effects
model);
• For continuous variables, we calculated the
weighted mean difference (random effects
model) with a confidence interval of 95%.
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10. Methods
• The existence of statistical heterogeneity was
evaluated in this study included the chi-square
with N degrees of freedom, where N equals the
number of studies that contributed data minus
one.
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11. Results: Description of eligible studies
• 15 trials were included, with a total of 3911 mother and baby
pairs.
• Participants generally were healthy pregnant women
expected to give birth vaginally, but one study focused on
women who were anaemic and another study was conducted
in a malaria-endemic area. Three studies included data for
caesarean section birth.
• Studies were from Argentina (1 trial), Australia (1), Canada (2),
India (2), Iran (1), Libya (1), Mexico (1), Saudi Arabia (1),
Sweden (1), UK (2), USA (1) and Zambia (1).
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12. Results: maternal outcomes
• No studies reported on the primary outcomes of maternal
death or on severe maternal morbidity.
• There was no significant difference between the early versus
late cord clamping groups for
- severe PPH (blood loss of ≥1000 ml) (RR: 1.04, 95% CI:
0.65 to 1.65; 5 trials, 2066 women);
- PPH of ≥ 500 ml (RR: 1.17, 95% CI: 0.94 to 1.44; 5 trials,
2260 women);
- or mean blood loss (MD: 5.11 ml, 95% CI: -23.18 to
33.39, 2 trials, 1345 women).
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13. Results: neonatal outcomes
• There was no significant difference for neonatal deaths;
low Apgar score (<7) at 5 minutes or admission to a special care
baby nursery; or neonatal intensive care unit.
• Infants in the early cord clamping group were more likely to be
iron deficient at 3 to 6 months (RR: 2.65, 95% CI: 1.04 to 6.73, 5
trials, 1152 infants) but less likely to require phototherapy for
jaundice (RR: 0.62, 95% CI: 0.41 to 0.96, 7 trials, 2324 infants).
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14. 14

15. Conclusions
• A more liberal approach to delaying clamping of the
umbilical cord in healthy term infants appears to be
warranted, particularly in light of growing evidence
that delayed cord clamping increases early
haemoglobin concentrations and iron stores in
infants.
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16. Pontos críticos
• Você diria que as duas estratégias têm os mesmos efeitos?
• Como esse estudo influencia na tomada da decisão em relação ao
tempo do campleamento?
• Qual a aplicabilidade em nosso país?
• Será que outras informações ajudariam na tomada de uma decisão
sobre o momento de pinçamento do cordão umbilical para os bebês
nascidos a termo ?
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17. Referências
• McDonald SJ, Middleton P, Dowswell T, Morris PS. Effect of timing of
umbilical cord clamping of term infants on maternal and neonatal
outcomes. Cochrane Database of Systematic Reviews 2013, Issue 7. Art.
No.: CD004074. DOI: 10.1002/14651858.CD004074.pub3.
• Cochrane Journal Club: http://www.cochranejournalclub.com/
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