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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.
