Delayed Umbilical Cord Clamping May Benefit Some High-Risk Newborns

The practice of immediate or early umbilical cord clamping after birth has been the norm since research in the 1950s and 1960s showed that most blood volume for full term babies was achieved “within the first few breaths,” according to a 2012 review from The American College of Obstetricians and Gynecologists’ (ACOG) Committee on Obstetric Practice. Those studies, along with the desire for active management of the third stage of labor, mean most babies in a health care setting now have their cords clamped approximately 10 seconds after birth.

But research over the last 15 years has shown that, especially for preterm babies, waiting 30 seconds or more to clamp the umbilical cord with the infant held below the placenta is associated with higher red blood cell volume, decreased risk of intraventricular hemorrhage and decreased need for blood transfusion. The ACOG review supported delayed cord clamping for pre-term infants, but it called for more research on clamping practices for babies born at less than 28 weeks gestational age and other infant subgroups.

Recent pilot studies led by Carl H. Backes, Jr., MD, at Nationwide Children’s Hospital have helped complete the picture on delayed clamping by demonstrating that it is safe, feasible and beneficial for both babies born 22 to 27 weeks gestational age and babies born with critical congenital heart disease.

“These are high risk groups, and efforts to improve their outcomes remain extremely important,” says Dr. Backes, a cardiologist and neonatologist at Nationwide Children’s. “Our studies add to the increasing evidence that delayed cord clamping may give infants in many categories a better chance.”

The first study, published online in July in the Journal of Perinatology, enrolled women with singleton pregnancies whose fetuses were at least 37 weeks of gestational age and had been identified with critical congenital heart diseases by fetal echocardiogram. A total of 30 infants were randomized at birth – 15 to the early clamping group and 15 to the delayed clamping group. In the delayed group, clamping occurred approximately 120 seconds after birth.

Hematocrits were higher in the delayed group than in the early group during the first 72 hours of life, though similar at later times. The probability of being free of blood transfusion was higher in the delayed group than in the early group as well, 43 percent vs. 7 percent. There were no differences in other measures, including percentages of infants with post-operative bleeding, those given the anemia treatment drug epoetin alfa, or those exposed to platelet transfusions.

The second study, published online in September in the same journal, enrolled women with singleton pregnancies 22.5 to 27 weeks who were admitted to The Ohio State University Wexner Medical Center’s labor and delivery services. A total of 40 infants were randomized at birth – 22 to the immediate clamping group and 18 to the delayed clamping group. In the delayed group, clamping occurred between 30 and 45 seconds after birth.

The delayed clamping group had higher blood pressure readings in the first 24 hours of life and needed fewer red blood cell transfusions in their first 28 days than infants whose umbilical cords were immediately clamped. As in the preterm study, hematocrits were greater in the delayed group for the first 72 hours of life but were not different later.

Dr. Backes and his collaborators speculate that delayed cord clamping and the additional blood volume it provides likely improves pulmonary blood flow and other circulatory measures, stabilizing blood pressure. This may be particularly important for infants with critical congenital heart disease.

Both of these studies measured short-term results, and more research is needed to determine if the early benefits translate to reductions in long-term morbidity, says Dr. Backes, who is also an assistant professor of Pediatrics at The Ohio State University College of Medicine.

“The results are promising, though” Dr. Backes says.

References:

1. Backes CH, Huang H, Cua CL, Garg V, Smith CV, Yin H, Galantowicz M, Bauer JA, Hoffman TM. Early versus delayed umbilical cord clamping in infants with congenital heart disease: a pilot, randomized, controlled trial. Journal of Perinatology. 2015 Oct;35(10):826-831.
2. Backes CH, Huang H, Iams JD, Bauer JA, Giannone PJ. Timing of umbilical cord clamping among infants born at 22 through 27 weeks’ gestation. Journal of Perinatology. 2015 Sep 24 [Epub ahead of print].
3. Committee on Obstetric Practice, American College of Obstetricians and Gynecologists. Committee Opinion No. 543: Timing of umbilical cord clamping after birth. Obstetrics & Gynecology. 2012 Dec;120(6):1522-1526