1 Running Head: Delayed Umbilical Cord Clamping Delayed Umbilical Cord Clamping Regina M. Conceiçaõ State University of New York Downstate Medical Center IMS II Professor Mary Anne Laffin July 26, 2011 2 Running Head: Delayed Umbilical Cord Clamping Delayed Umbilical Cord Clamping The practice of clamping and cutting the umbilical cord at birth is one of the oldest and most prevalent interventions in humans. In the United States cord clamping immediately after birth is a routine obstetric procedure. However, according to Moss (1967), Peltonen (1981), Mercer (2001) and the WHO (1998) in spite of this practice being one of the oldest and most prevalent interventions in humans, the optimal timing of cord clamping has been a controversial issue for decades (as cited in Hutton and Hassan, 2007). The reason controversy exists among the practice is because there are benefits for late and early clamping of the umbilical cord. This paper will discuss the benefits and risks of delayed cord clamping as well as provide useful suggestions on how midwives can address this topic in their practice. Several studies have been conducted regarding delayed and early cord clamping on its benefits. Currently there is no set definition of “delayed” cord clamping and the times to clamp the cord varies significantly among studies (Eichenbaum-‐Pikser &, Zasloff, 2009). Rabe et al.’s (2004) Cochrane metaanlysis defines delayed cord clamping as a delay of 30 seconds or more after birth (as cited in Eichenbaum-‐Pikser &, Zasloff, 2009). A randomized controlled trial (RCT) study by Van Rheenen et al (2006) that compared delayed versus immediate cord clamping in full term neonates recommends waiting 3 minutes before clamping and 60 seconds for infants needing early intervention (as cited in Eichenbaum-‐Pikser &, Zasloff, 2009). Van Rheenen and Brabin (2006) conducted a systemic review and they defined cord clamping as waiting until the umbilical cord stops pulsing which is roughly at about 5 minutes (as cited in Eichenbaum-‐Pikser &, Zasloff, 2009). 3 Running Head: Delayed Umbilical Cord Clamping Studies conducted by McDonald & Middleton (2008) and Cernadas et al (2006) have shown waiting 1 to 3 minutes after birth to clamp the umbilical cord increases the hematocrit (HCT) and hemoglobin (HgB) levels in neonates, which according to Van Rheenen and Brabin (2006) and Cernadas et al (2006) results in less infants with anemia (as cited in Eichenbaum-‐ Pikser &, Zasloff, 2009). A metaanalysis conducted by Hutton & Hassan 2007 revealed several findings 1. the mean level for Hgb levels in infants born 7 hours after being born, HgB level in capillary blood was higher in newborns with delayed cord clamping 2. Hct levels of newborns were significantly higher at 24 to 48 hours after birth when delayed cord clamping was done at a minimum of 2 minutes and 3. ferritin levels at 2 to 3 months were higher for infants who’s umbilical cord was delayed in clamping versus early clamping (Hutton & Hassan 2007), thus resulting in decreased anemia in infancy and increase iron stores which could be found in infants from 2 to 6 months of age (Bond, 2007). Potential adverse effects of delayed cord clamping are polycythemia, hyperbilirubinemia, respiratory distress, maternal hemorrhage, and newborn position (Eichenbaum & Zasloff 2009). Rosekrantz (2003) defines polcythemia as a Hct level >65% that occurs in about 2% to 5% of term infants (as cited in Eichenbaum-‐Pikser &, Zasloff, 2009). Findings in studies have been varied regarding polycythemia in newborns. Hutton and Hassan (2007) study found no significant difference in mean serum bilirubin levels nor an increased risk of neonatal jaundice with the first 24 hours of life associated with DCC. Similarly, McDonald and Middleton (2008) Cochrane metaanalysis found there was no statistical difference of jaundice between newborns that had their umbilical cord clamped early or late. Hyperbilirubinemia also know as newborn jaundice is a condition marked by high levels of 4 Running Head: Delayed Umbilical Cord Clamping bilirubin in the blood (Varney’s, 2004 & Fraser, 2009). According to Ceradas et al (2006),“transient tachypnea, a respiratory condition of the newborn may occur as a result of delayed absorption of lung fluid caused by an increase blood volume related to DCC” (as cited in Eichenbaum-‐Pikser &, Zasloff, p. 324, 2009). Eichebaum-‐Pikser & Zasloff (2009) state maternal hemorrhage may occur if clamping the cord is delayed (Armbruster, 2007). Position of the newborn in regards to the placenta influences the amount of blood transfused. To allow for optimal transfusion of blood within 3 minutes, Van Rheenen et al (2007) and Van Rheenen and Barbin (2006) recommend keeping the newborn between 10cm above and 10 cm below the level of the placenta. Further research regarding newborn position, and as well as the above mentioned conditions must be done in order for clinicians to be able to make recommendations on when to clamp the umbilical cord. Special consideration of DCC exists. One example of a special consideration is DCC is recommended in preterm infants. A study conducted on very preterm infants by Mercer et al (2006) compared the effects of immediate cord clamping (ICC) and delayed cord clamping DCC on very low birth weight infants (VLBW). The study’s objectives was to compare the incidence of bronchopulmonary dysplasia (BDP) in infants less than 32 weeks gestation and to evaluate the effects of DCC on other causes of neonatal death, including late onset sepsis (LOS), intraventricular hemorrhage (IVH), and retinopathy of prematurity (ROP) (Merecer et al, 2006). The results of this study showed delayed cord clamping seemed to protect the incidence of intraventricular hemorrhage (IVH) and late-‐onset sepsis (LOS). Furthermore according to Eichebaum-‐Pikser & Zasloff (2009) DCC has been shown to be beneficial for preterm infants in industrialized countries where 60% to 80% of preterm infants born before 32 weeks of 5 Running Head: Delayed Umbilical Cord Clamping gestation require blood transfusion. DCC is also beneficial to newborns in developing countries because it is a safe and inexpensive way to prevent infant anemia in countries with limited resources (Eichebaum-‐Pikser & Zasloff, 2009). By delaying clamping the cord Rabe & Diaz-‐ Rosselle (2004) state Hgb levels and red blood cell volume is increased resulting in the reduction of an infant needing a blood transfusion (as cited in Eichenbaum-‐Pikser &, Zasloff, 2009). Another special consideration is the request of parents to have Lotus birth. A lotus birth is when the cord of a newborn is left untouched and uncut until it separates by itself from the navel 3 to 10 days postpartum (Crowther, 2006 and Eichenbaum-‐Pikser &, Zasloff, 2009). Because the placenta remains attached to the newborn it makes it less difficult for exposure to infection. Some cultures around the world view the placenta as sacred, with high spiritual regard. The practice is done because it is believed to be nonviolent and allows for an easier transition of the newborn into life. Although the practice occurs around the world they have not been any scientific studies to determine its benefits. A third consideration is Cord Blood Banking. Cord blood banking is the collection of blood from a newborn’s umbilical cord to be preserved for stem cell harvesting in case the child gets a disease that can only be treated with its cord blood. In a situations where parents request cord blood banking, delayed cord clamping may lower the amount of stem cells collected leaving it unusable. In most situations banking companies request practitioners immediately clamp the cord 6 Running Head: Delayed Umbilical Cord Clamping There has been no documentation of significant risks of DCC. In fact, there have been various studies that have shown as explained in this paper that the practice of DCC is beneficial to newborns. Therefore it is incumbent upon midwives to educate our clients about the physiologic impact of the practice of DCC and to involve women and their partners in this decision. (Eichenbaum-‐Pikser &, Zasloff, 2009). It is also important for midwives to respect a family’s decision to have a lotus birth even if we do not promote it. As midwives it is our responsibility to provide evidence-‐based care to our clients. Providing such care can help to ensure better care for the women and babies we serve, and emphasizes a culture of attentiveness to clinical evidence (Eichenbaum-‐Pikser &, Zasloff, 2009). 7 Running Head: Delayed Umbilical Cord Clamping References Armbruster, D, Fullerton, Judith. Cord clamping and active management of the third stage. Journal of Midwifery and Women’s Health 2007;52(5) Bond, S. Late cord clamping improves anemia and iron stores in term infants up to 6 months, but practice remains controversial. Journal of Midwifery and Women’s Health 2007;52(5)521-522. Crowteher, S. Lotus birth:leaving the cord alone. The Practice Midwife 2006;9(6)1214 Eichenbaum-Pikser, G, Zasloff, J. Delayed clamping of the umbilical cord: A review with implication for practice. Journal of Midwifery and Women’s Health 2009; 54(1)1-6. Fraser, D, Copper,M. (2009) Myles’ Textbook for Midwives Edinburgh, New York: Churchill Livingstone. Hutton, E, Hassan,E. Late vs early clamping of the umbilical cord in full-term neonates. JAMA 2007;297(11)1241-1252. Mercer, J. et al Pediatrics 2006; 117(4)1235-1242. Varney, H, Kriebs,J,Gregor,C. (2004) Varney’s Midwifery Sudbury, MA: Jones and Bartlett Publishers.
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