Delayed umbilical cord clamping

1. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
1

2. ‫شيرمادر‬ ‫با‬ ‫تغذيه‬ ‫ترويج‬ ‫علمی‬ ‫انجمن‬ ‫مديره‬ ‫هيئت‬ ‫عضو‬
‫شيرمادر‬ ‫کشوری‬ ‫کميته‬ ‫عضو‬

3. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
mPerceptions about the umbilical cord clamping
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4. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 The optimal timing of umbilical cord
clamping has been debated in the
scientific literature for over a century.
 In the early 19th century, the English
physician, Erasmus Darwin mentioned
“another thing very injurious to the
child is the tying and cutting of the
navel string too soon, which should
always be left till the child has not only
repeatedly breathed but till all
pulsation in the cord ceases.
Perceptions about the umbilical cord clampingChanging views on when to cut the umbilical cord
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5. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 Before the 1950s, the umbilical cord usually was cut after
it stopped pulsating, anywhere from one to five minutes
after birth.
 After studies showed that more than 90 percent of a
baby’s blood volume was achieved within the first few
breaths after birth,
 And no studies could determine the optimal time to cut
the cord.
The time between birth and clamping the
cord grew shorter and shorter.
Changing views on when to cut the umbilical cord
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6. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 At each birth, obstetrical providers decide when to clamp
and cut the umbilical cord.
 Immediate cord clamping (ICC) has become the routine
practice in the United States without scientific evaluation of
its potential impact on an infant’s health and development.
 Fear of hyperbilirubinemia and polycythemia are concerns
that have hindered the adoption of delayed cord clamping
(DCC) as routine care.
J Perinatol. 2017 March ; 37(3): 260–264. doi:10.1038/jp.2016.222.
Changing views on when to cut the umbilical cord
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7. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 Immediate cord clamping (ICC)
◦ immediately few seconds even before breathing
 Early cord clamping (ECC)
◦ in the first 60 seconds, generally within the first 15–30 seconds
 Intermediate cord clamping (IMCC)
◦ between 60–180 seconds
 Delayed umbilical cord clamping (DCC)
◦ 180 seconds and more
 Physiological-Based Cord Clamping (PBCC)
◦ cord will be clamped after the infant is respiratory stable, rather than
arbitrarily choosing a time to clamp the cord.
Perceptions about the umbilical cord clamping
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8. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
mWorld Health Organization 2014
Multivariate analyses, however, demonstrated a clinically and statistically significant
interaction of maternal anaemia, time of umbilical cord clamping and infant anaemia.
The adjusted odds of developing anaemia among infants born to anaemic mothers was
40% lower at 4 months of age and 60% lower at 8 months of age for each minute
that clamping was delayed

9. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
mBeyond survival:
integrated delivery care practices for long-term maternal and infant nutrition, health and development
 Delayed umbilical cord clamping,
 Early mother to newborn skin-to-skin contact, and
 Early initiation of exclusive breastfeeding,
are three simple practices that, in addition to
providing immediate benefit, can have long-term
impact on the nutrition and health of both mother
and child.
WHO and Pan American Health Organization, 2014

10. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 DCC defined as : the clamping of the cord within 1 to 3 minutes of
birth, or when the umbilical cord pulsations have stopped ..
◦ WHO. Guideline: Delayed umbilical cord clamping 2014.
◦ Effect of timing of umbilical cord clamping of term infants on maternal and neonatal
outcomes (Review). Cochrane Database Syst Rev. 2008.
 The cord should not be clamped earlier than one minute after birth
,Optimal time to clamp the umbilical cord for all infants regardless of
gestational age or fetal weight is when the circulation in the cord has
ceased, and the cord is flat and pulseless, approximately 3 minutes or
more after birth (WHO 2014)
Perceptions about the umbilical cord clamping
10
World Health Organization 2014

11. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
mOptimal timing of umbilical cord clamping
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12. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
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UMBILICAL FLOW IS UNRELATED TO CESSATION OF PULSATIONS.

14. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 Reduction in the number of transfusions
 Decreased incidence of intraventricular hemorrhage (IVH) of
all grades
 Reduced requirement for inotrope support
 Improved important neonatal outcomes such as necrotizing
enterocolitis (NEC) and late-onset sepsis
 Better hemodynamic stability in the first few days of life
 Less surfactant
 Associated with improved neurodevelopment outcomes….
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Delayed Cord Clamping for Preterm Neonates

15. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 WHO 2014: DCC defined as the clamping of the cord within 1 to 3 minutes of birth,
Optimal time to clamp the umbilical cord for all infants regardless of gestational age or
fetal weight is when the circulation in the cord has ceased, and the cord is flat and
pulseless, approximately 3 minutes or more after birth . or when the umbilical cord
pulsations have stopped ..
 Ann-Marie Widstrom 2019:Delayed cord clamping >180 seconds after delivery is
recommended(Skin-to-skin contact the first hour after birth, underlying implications and
clinical practice).
 Royal College of Midwives (RCM) 2018:recommended the practice of delayed cord
clamping and estimated that this time “between 1 and 3 minutes after birth”.
 NICE 2019 (National Institute for Clinical Excellence): New evidence suggests that volume
of placental transfusion was similar in babies that were given straight to the mother
compared to being held at vagina level for 2-minutes.
Perceptions about the umbilical cord clamping
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16. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 AAP 2016: Umbilical cord clamping should be delayed in term and preterm infants due to several
health benefits, according to AAP-endorsed guidance from the American College of Obstetricians
and Gynecologists (ACOG) "recommends a delay in umbilical cord clamping in vigorous term and
preterm infants for at least 30-60 seconds after birth."
 AAP NRP 2020:In preterm birth, there are also potential advantages from delaying cord clamping.
 ACOG, 2014 and 2017: A delay in umbilical cord clamping in vigorous term and preterm infants
for at least 30–60 seconds after birth:.
 Umbilical cord clamping practices of U.S. obstetricians: 67% of respondents reported DCC by 1
minute or more after vaginal births at term. After preterm and near-term vaginal births, 73% and
79% said they waited at least 30 seconds before clamping.(Journal of Neonatal-Perinatal Medicine, vol. 11,
no. 1, pp. 51-60, 2018)
 ACNM 2014: For term newborns, delaying the clamping of the cord for 5 minutes if the newborn
is placed skin-to-skin or 2 minutes with the newborn at or below the level of the introits ensures
the greatest benefit.
Perceptions about the umbilical cord clamping
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17. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 Canada (SOGC) and Canadian Association of Midwives (CAM) recommend that cord
clamping should be delayed by ≥60 seconds in babies who do not require
resuscitation, irrespective of the mode of delivery.(Minimum of 60 seconds
irrespective of mode of delivery) (Journal of Obstetrics and Gynaecology Canada VOLUME 40, ISSUE
2, P155, FEBRUARY 01, 2018)
 Timing of cord clamping (TOCC) in New Zealand maternity hospital , Cord clamping
timing ranged from a minimum of 14 seconds to a maximum of 34 minutes. The
median umbilical cord clamping time for all births in the study was 3.5 minutes,
(Otago Polytechnic, Dunedin, New Zealand9 December 2019)
 Current Practice of Cord Clamping in The Netherlands:DCC ≥60 seconds was applied
after uncomplicated vaginal term deliveries in 90% and ECC in 6%, and no timing was
specified in 4%. Midwives used DCC more often than obstetricians (97 vs. 75%).
Other country
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18. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 Sweden, Ola Andersson,”My former partner was a midwife said At that time, the normal
practice at the majority of Sweden’s delivery units to cut the umbilical at an early stage, that
is 10–30 seconds after the baby is born.”
◦ In 2008 UC in sweden maternity unit was 2-3 min term and 30-120 s preterm
◦ In 2013, Ola Andersson was awarded a doctoral degree from Uppsala University, based on
a thesis entitled “Effects of Delayed versus Early Cord Clamping on Healthy Term Infants”.
◦ The prospectively recruited infants were born at Karolinska University Hospital, Huddinge,
Sweden, between April 2012 and May 2015, The UC was clamped after 60±10 s.
◦ In 2019 (99 NICU conference) Ola Andersson said current cc is 6 minuts.
 Guidelines :
◦ Sweden 2008: Term 2-3 min ,Preterm 30-120 s
◦ WHO 2014 : >I min
◦ UK(NIC) 2014 : Term 1-5 min
◦ ERC 2015 :> 1 min
◦ USA(ACOG) 2017 :30-60S
◦ ITALY 2018: Term1-3 MIN ,<29 W 60 S ,>29 W 90 S
◦ IRAN 2016:≥ 1min, prefer until 3 min
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Other country

19. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 RBCs
◦ 15 mL/kg RBCs
◦ Iron: 30 to 75 mg
(enough for 3 to 6 mo's need)
 Plasma/cells for volume expansion
 Stem Cells , immunoglobulins
◦ Several million to 1 billion SCs
◦ (and cytokines to direct them)
What is in Cord Blood?
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20. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 “ …a delay in cord clamping may
increase stem cell supply to the
baby…innate stem cell therapy…acute
benefits in case of NB disease….long
term benefits against age-related
diseases”
Stem Cells: Baby’s First Transplant
Tolosa JN, Park DH, Eve DJ, Klasko SK, Borlongan CV, Sanberg PR. Mankind’s
first natural stem cell transplant. J Cell Mol Med.
2010;14:488-495. Sanberg P, Park, D-H & Borlongan. (2009). Stem Cell
Transplants at Childbirth. Stem Cell Rev and Rep
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Umbilical cord blood collection must not adversely
affect the health of the mother or newborn. Cord
blood collection should not interfere with delayed
cord clamping. (III-E)
SOGC clinical practice guideline. EPTEMBER JOGC SEPTEMBRE 2015

21. Dr.Ravari, New born Skyroom 24 Nov 2020
 A term infant’s blood volume is approximately
70 ml/kg following ICC compared with 90ml/kg
with DCC (3 min).
 Marked increase in placental transfusion during
the initial breaths of the newborn, which is
thought to be due to the negative intra-thoracic
pressure generated by lung inflation.
 This is accomplished by the large volume of
blood moving from the fetal ‘lung' (placenta) to
newborn lung. Thus, placental transfusion
rapidly creates an increase in the circulatory
bed in the lung.
21
Placental transfusion
J Perinatol. 2017 Feb; 37(2): 105–111 AAP .NeoReviews May 2015, 16 (5) e263-e269;
DOI: https://doi.org/10.1542/neo.16-5-e263

22. Dr.Ravari, New born Skyroom 24 Nov 2020
 By term 1/3 of the blood flows through the
placenta and 2/3 flows through the fetus.
 ICC results in 25-30% (54-160 mL)of feto-
placental blood volume remaining in the
placenta,
 DCC reduces residual placental blood to 20%
of the feto-placental blood volume by 60 s
and to 13% by ~ 3–5 min.
 Placental transfusion(DCC) resulting in
approximately a 20 to 30% increase in blood
volume and a 50% increase in RBC volume.
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What happens when there is ICC
J Perinatol. 2017 March ; 37(3): 260–264(

23. Dr.Ravari, New born Skyroom 24 Nov 2020
 Timing of cord clamping,
 Uterine contractions,
 Reduced neonate-to-placental
flow due to umbilical arterial
spasm,
 Spontaneous respirations and
 Gravity influence the magnitude
of transfusion.
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Factors influencing placental transfusion with
delayed cord clamping (DCC).
J Perinatol. 2017 March ; 37(3): 260–264. doi:10.1038/jp.2016.222..

24. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 Mean weight change(DCC 2min) was 56 g (SD 47, 95% CI 50-63) for
197 babies in the introitus group compared with 53 g (45, 46-59) for
194 babies in the abdomen group, supporting non-inferiority of the
two approaches (difference 3 g, 95% CI -5.8 to 12.8; p=0.45).
 Therefore, and because of the potential of enhanced bonding between
mother and baby and increased success of breastfeeding and the
compliance with the procedure, holding the infant by the mother
immediately after birth should be strongly recommended.
Effect of gravity on volume of placental transfusion
The Lancet · April 2014 DOI: 10.1016/S0140-6736(14)60197-5
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25. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
mEffect of Gravity on volume of placental transfusion
The Lancet · April 2014 DOI: 10.1016/S0140-6736(14)60197-5
AAP .NeoReviews May 2015, 16 (5) e263-e269; DOI: https://doi.org/10.1542/neo.16-5-e263
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26. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
Blood sampling from the umbilical cord :A sling of the umbilical cord is clamped with one hand. You then take an arterial and venous sample
before releasing the manual stasis. Final umbilical cord removal can then take place when pulsation in the umbilical cord has ceased or after
at least 1 - 3 minutes
https://tidsskriftet.no/2013/11/originalartikkel/avnavling-ved-fodsel-praksis-ved-norske-fodeinstitusjoner
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Blood sampling from the umbilical cord

27. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
A shock-free birth for every baby
Physiological-Based Delayed Cord Clamping (PBDCC)
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28. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 Timing of cord clamping, performing PBCC
rather than arbitrarily choosing a time to
clamp the cord, Stabilization of the infant is
performed while the cord is intact and the
cord will be clamped after the infant is
respiratory stable, defined as
◦ The establishment of regular spontaneous
breathing,
◦ A heart rate >100 bpm and
◦ Oxygen saturation above 90% while using
supplemental oxygen < 40%.
The Concord, a mobile resuscitation table
Pediatr., 12 April 2019 | https://doi.org/10.3389/fped.2019.00134
28
Timing of cord clamping

29.  Human and experimental animal data show that
delaying the clamping of the umbilical cord until after
the onset of respirations promotes cardiovascular
stability in the minutes immediately after birth (Semin Fetal
Neonatal Med. 2013;18(6):385-392).
 Physiological-based cord clamping (PBCC) led to a
more stable cardiovascular adaptation and better
oxygenation in preterm infants .
 Recent studies suggest that delayed cord clamping
(DCC) is advantageous for achieving hemodynamic
stability and improving oxygenation compared to the
immediate cord clamping (ICC) during fetal-to-
neonatal transition.(Maternal Health, Neonatology, and Perinatology 2019 5:5)
29
Physiological-Based Cord Clamping (PBCC)

30. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬ 30
“ Bringing the
resuscitation to the baby,
rather than the baby to
the resuscitation “

31. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
Demonstration of how to set up the LifeStart trolley for neonatal care beside the mother immediately after birth
at caesarean section (note: the neonatal team should be scrubbed to maintain the sterility).

32. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
Demonstration of how to set up the Life Start trolley for neonatal care beside the mother immediately after birth at vaginal births

33. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
Illustration of the Routine Delayed Cord Clamping approach using the standard resuscitation
table(cord was clamped at 30-60 seconds after birth)
Resuscitation. 2020 Feb 1;147:26-33.
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34. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
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35. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
Illustration of the Physiological-based cord clamping approach using the Concord. Stabilization of the infant
is performed while the cord is intact and the cord will be clamped after the infant is respiratory stable.
Resuscitation. 2020 Feb 1;147:26-33.
35

36. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
36PBCC CS 25 W

37. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
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TERM INFANT

38. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 A new delivery-room protocol involving mobile resuscitation
equipment successfully eliminated early cord clamping in
assisted vaginal deliveries of term and near-term infants.
Neonatal transitional support with intact umbilical
cord in assisted vaginal deliveries (Norway)
BMC Pregnancy Childbirth. 2020 Aug 27. doi: 10.1186/s12884-020-03188-0
38

39. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
Norwegian Resuscitation Council (NRR)
39

40. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
mNeonatal transitional support with intact umbilical cord in assisted
vaginal deliveries
BMC Pregnancy Childbirth. 2020 Aug 27. doi: 10.1186/s12884-020-03188-0
40

41. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
Neonatal transitional support with intact umbilical cord in assisted vaginal deliveries
BMC Pregnancy Childbirth. 2020 Aug 27. doi: 10.1186/s12884-020-03188-0
41

42. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 Cord milking is a safe alternative to DCC when one must cut the cord
prematurely. J Perinat Neonatal Nurs. 2012;26(3):202-217.
 ACNM recommends that delayed cord clamping be adopted as the
standard of care in all birth settings for term and preterm newborns.
For situations requiring resuscitation, umbilical cord milking may be
of benefit when delayed cord clamping is not feasible, particularly for
the preterm newborn. (American College of Nurse-Midwives (ACNM) Board of Directors
May 2014)
 Cord milking is being studied as an alternative to delayed cord
clamping but A large multicenter RCT found higher rates of intra-
ventricular hemorrhage with cord milking in preterm babies born at
less than 28 weeks’ gestational age. (Pediatrics. 2020; doi: 10.1542/peds, Part
5: Neonatal Resuscitation 2020 AAP)
UCM(umbilical cord milking )
42

43. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 Placental transfusion through cord
milking with an intact cord (I-UCM)
attached to the placenta. Placental
blood can potentially increase
blood flow to the brain and lungs.
 Pulmonary vasodilation in response
to spontaneous respiration or
crying can create a ‘physiologic
sink’ to accommodate placental
blood.
 Placental blood is a rich source of
fetal red blood cells and stem cells.
Cord milking with an intact cord (I-UCM)
J Perinatol. 2017 Feb; 37(2): 105–111
43

44. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 Early cord clamping was also advocated in
response to concerns that a placental transfusion
of blood to the newborn, which occurs when the
cord is not immediately clamped, would result in
neonatal respiratory distress, polycythemia, and
jaundice from circulatory overload.
 More recently, however, researchers in large, well-
designed, randomized, controlled trials found that
these complications do not occur in term or
preterm newborns when clamping and cutting the
umbilical cord are delayed.
Placental transfusion concerns
-Neonatology. 2008;93:138-144 ,
-Cochrane Database Syst Rev. 2012;8:CD003248.
44

45. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 Polycythemia, Hyperbilirubinemia, survival
◦ Term infants had early hematological advantage of DCC without increases in hyperbilirubinemia
or symptomatic polycythemia. (J Perinatol. 2017 March ; 37(3))
◦ The belief that DCC causes hyperbilirubinemia or symptomatic polycythemia is unsupported by
the available research. (Journal of Perinatal & Neonatal Nursing: July/September 2012 - Volume 26)
◦ Seven randomized controlled trials (2324 infants) examined the risk of receiving phototherapy
for hyperbilirubinaemia following delayed umbilical cord clamping in term neonates. In the
majority of the studies, the criteria used for phototherapy were not strictly defined. Delayed-
clamped infants were significantly more likely to require phototherapy for jaundice, with a risk
difference of <2% between early- and delayed-clamped infants (Guideline: delayed umbilical cord
clamping for improved maternal and infant health and nutrition outcomes, WHO 2014)
◦ with no difference between delayed and early umbilical cord clamping. Compared with term
infants receiving early cord clamping, those receiving delayed cord clamping had increased
polycythemia in meta-analyses of 13 and 8 RCTs, respectively.(Neonatal Resuscitation 2020 AAP)
Placental transfusion concerns
45

46. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 Polycythemia, Hyperbilirubinemia, survival -cont
◦ The belief that DCC causes hyperbilirubinemia or symptomatic polycythemia is unsupported
by the available research.( J Perinat Neonatal Nurs. 2012;26(3):202-217).
◦ Compared with term and late preterm infants receiving early cord clamping, those receiving
delayed cord clamping showed no significant difference in mortality, admission to the
neonatal intensive care unit, or hyperbilirubinemia leading to phototherapy in meta-
analyses of 4,10 and 15 RCTs, respectively (Part 5: Neonatal Resuscitation 2020 AAP)
◦ Among preterm infants not requiring resuscitation, delayed cord clamping may be
associated with higher survival than early cord clamping is. .(Pediatrics. 2020; doi: 10.1542/peds,
Part 5: Neonatal Resuscitation 2020 AAP)
 Maternal Hemorrhage
◦ Ten RCTs found no difference in postpartum hemorrhage rates with delayed cord clamping
versus early cord clamping (Pediatrics. 2020; doi: 10.1542/peds, Part 5: Neonatal Resuscitation 2020 AAP)
◦ There is no observed increased risk of PPH, or the need for manual removal of placenta,
following DCC (https://www.clinicalguidelines.scot.NHS.uk/.../cord-clamping-guidelines, Last reviewed: 20 March
2019
◦ )
Placental transfusion concerns
46

47. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 A requirement for immediate resuscitation or baby has a heartbeat
below 60 beats/minute that is not getting faster.
 Abruption or early separation, Bleeding placenta Previa
 Uterine inversion
 Cord issues i.e. no pulsation, cord snapping or incision, limited cord
length.
 Multiple gestations:Monochorionic twins (where risk of placental
vessel anastomoses may result in draining of blood from twin 2 to
twin 1 during DCC procedure)
 Maternal concern e.g. PPH, shock, seizure etc.
47
DCC is contraindicated in:
https://www.clinicalguidelines.scot.NHS.uk/.../cord-clamping-guidelines, Last reviewed: 20 March 2019
National Institute for Clinical Excellence (NICE)

48. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
 DCC is recommended even among women living with HIV or the women
with unknown HIV status. HIV status should be ascertained at birth, if not
already known and HIV women and infants should receive the appropriate
ARV drug.(WHO 2014).
◦ The evidence shows that the benefits a delayed cord clamping for 1-3 min outweigh
the risks of transmission of HIV.
 Should we continue delayed-cord clamping practices in COVID19?
◦ Delayed cord clamping practices should continue per usual center practice.
◦ Mothers with COVID19 should use a mask while holding their baby during delayed
cord clamping.
DCC in HIV & COVID19
Guideline: delayed umbilical cord clamping for improved maternal and infant health and nutrition outcomes, WHO 2014
48
WHO , 2 September 2020 | Q&A in COVID19
AAP no longer recommends separating newborns from mothers with COVID-19 Last Updated 07/22/2020

49. ‫ماه‬ ‫دی‬ ‫خانواده‬ ‫و‬ ‫زنان‬‫سالمت‬ ‫ملی‬ ‫کنگره‬1399‫راوری‬‫دکتر‬
m
49