DCC-Sixty Seconds or Beyond

1. Umbilical cord clamping in term
deliveries: the RCOG perspective
Dr Anna David
Reader and Consultant in Obstetrics and
Maternal Fetal Medicine
UCL Institute for Women’s Health

2. Cut cord
between clamps
The transition from
fetal to neonatal life
Placenta
Umbilical
cord
Uterus
Clamping and cutting the cord is
necessary to separate the placenta
from the baby after birth
The time taken to do this is variable

3. The placental transfusion
Uterus
Umbilical cord
Placenta
After birth the uterus continues to
contract and blood continues to flow
from the placenta in the umbilical
vessels to the newborn infant for a
few minutes after birth.
The additional blood volume is the
placental transfusion.
For a term newborn, the placental transfusion gives an additional
80–100ml of blood.
Newborn
Immediate cord clamping
deprives the infant of 20–
30 mg/kg of iron, sufficient
for the needs of a newborn
infant for around 3 months

4. Historical perspective on cord clamping
• Cord clamping or tying became routine in late
1600s
• The reasons given for its use vary
– Avoid blood loss from the cord before physiological
closure of the umbilical vessels
– Prevent soiling of bed linen
– Reduce the chance of infection or contamination of the
baby
• By 1960s, cord-clamping by 1 minute of age was
routine, and was performed before the Apgar
score was assessed.

5. Active vs physiological 3rd stage
• 3rd stage is from birth of the baby to birth of the placenta
• Expectant or physiological management
– Allow cord to stop pulsating naturally
– Expel placenta by maternal effort
• Traditional active management aims to reduce the risk of
pospartum haemorrhage, a complication of childbirth
which accounts for almost one quarter of all maternal
deaths worldwide.
– Drugs to contract the uterus
– Early cord clamping and cutting
– Traction on the cord to deliver

6. Active vs physiological 3rd stage
• 3rd stage is from birth of the baby to birth of the placenta
• Expectant or physiological management
– Allow cord to stop pulsating naturally
– Expel placenta by maternal effort
• Traditional active management aims to reduce the risk of
postpartum haemorrhage, a complication of childbirth
which accounts for almost one quarter of all maternal
deaths worldwide.
– Drugs to contract the uterus
– Early cord clamping and cutting
– Traction on the cord to deliver

7. Factors that influence the placental transfusion
• How hard the uterus squeezes the placenta
– Intravenous ergotamine causes a rapid uterine
contraction
– Placental transfusion is complete by 1 minute with no
difference in the final volume of transfusion
– Intramuscular drugs are now preferred which leads to
uterine contraction after 2.5 minutes (oxytocin) or
ergometrine (7 minutes)
– Neither intramuscular oxytocin or ergometrine are
likely to have an effect on placental transfusion.
• Gravity
– Only has an effect if the baby is held at least 20cm
above or below the woman.

8. Time to clamping

9. Time to clamping
• Based on evidence from systematic review
(Cochrane 2008)
– ‘Early’ cord clamping: within 60 seconds of birth
– ‘Delayed’ cord clamping: >1 minute or when cord
pulsation has ceased
– 11 trials of 2989 mothers and babies
• Recently updated Cochrane review does not
change their conclusions

10. Time to clamping: Maternal outcomes
No effect
• No significant differences in postpartum
haemorrhage, need for manual removal of
placenta, need for uterotonics (drugs to contract
the uterus), need for blood transfusion, delayed
3rd stage

11. Time to clamping: Neonatal outcomes
A mixed picture
• Significant increase in newborn haemoglobin level in late
compared with early cord clamping
– Weighted mean difference 2.17 g/dL (95%CI 0.28 to 4.06), 3
trials of 671 infants
– Haemoglobin effect did not remain past 6 months of age
– Infant iron stores remained increased at 6 months of age
• Significantly more phototherapy for jaundice in the late
compared with early clamping
– RR 0.59 (0.38 to 0.92); five trials of 1762 infants
– Equates to 3% of infants in the early clamping group and 5%
in the late clamping group, a risk difference of 2% (95%CI -
0.04 to 0.00)

12. Time to clamping: Neonatal outcomes
• Insufficient data for reliable conclusions about the
comparative effects on other short-term outcomes
– Symptomatic polycythaemia (high red blood cell
concentration)
– Respiratory problems
– Hypothermia
– Infection
– Need for admission to special care
• No data on long term outcomes
– Infection, neurodevelopment etc

13. The potential for harm needs to be
weighed up by clinicians in context
with the settings in which they work

14. Reduced iron status vs Jaundice
• Iron deficiency in the first few months of life is
associated with neurodevelopmental delay,
which may be irreversible.
– Further research is needed to determine the
impact of time to cord clamping on iron stores and
neurodevelopmental delay
• Untreated chronic neonatal jaundice is
associated with brain damage (kernicterus)
– Access to phototherapy may be challenging in
some countries

15. Immediate cord clamping became routine
practice without rigorous evaluation.
Large randomised trials comparing the effects
of timing of cord clamping are needed, with
assessment of substantive outcomes and
long-term follow-up for both mother and
baby.

16. Current WHO position
• Basic Newborn Resuscitation Guideline 2012
• “In newly-born term babies who do not require
positive-pressure ventilation, the cord should not be
clamped earlier than one minute after birth”
• Strong recommendation based on evidence of high
to moderate quality
• WHO Recommendations for the prevention of
postpartum haemorrhage state that the cord should
not be clamped earlier than is necessary for applying
cord traction (around 3 minutes)

17. • The RCOG recommends that the time at which the
cord is clamped should be recorded.
• The cord should not be clamped earlier than is
necessary, based on clinical assessment of the
situation.
• Delayed cord clamping (more than 30 seconds) may
benefit the neonate in reducing anaemia ……

18. • RCOG will review document taking into consideration
the updated Cochrane review, and data emerging from
long term outcome studies eg follow up to Swedish
study in 2011
• The current recommendation is that the cord should
not be clamped “earlier than necessary” and “delayed
cord clamping of >30 seconds” may benefit the baby