Delayed Cord Clamping OK for Moms After Cesarean

Troy Brown, RN

November 19, 2019

One day after a planned cesarean delivery, maternal hemoglobin levels were not significantly different among women who delivered term singleton infants and who underwent delayed vs immediate umbilical cord clamping, new data show. In the days after birth, hemoglobin levels were higher for infants in the delayed-clamping group than for the infants in the immediate-clamping group.

The World Health Organization recommends delayed umbilical cord clamping for term infants, but most of the studies upon which this recommendation is based have been performed among women who delivered vaginally. The lack of data from women who underwent cesarean delivery has left some obstetricians concerned about delayed clamping in this setting, according to Stephanie E. Purisch, MD, Columbia University Irving Medical Center, New York City, and colleagues.

"A particular strength of this study is the use of maternal hemoglobin change — an objective measure of blood loss — as the primary outcome measure," they write in an article published today in JAMA.

The study included 113 women who underwent a planned cesarean delivery at one of two hospitals in New York City. The researchers randomly assigned women in a 1:1 ratio to undergo immediate cord clamping within 15 seconds of delivery (immediate cord clamping group; n = 56) or at 60 seconds after birth (delayed cord clamping group; n = 57).

The study's primary outcome, change in maternal hemoglobin from before delivery to postoperative day 1, did not differ significantly between the two groups (mean hemoglobin change in the delayed and the immediate cord clamping groups, −1.90 g/dL and −1.78 g/dL, respectively; mean difference, 0.12 g/dL; P = .49).

In the delayed cord clamping group, the mean preoperative hemoglobin level was 12.0 g/dL, and the mean postoperative day 1 hemoglobin level was 10.1g/dL. In the immediate cord clamping group, the mean preoperative hemoglobin level was 11.6 g/dL, and the mean postoperative day 1 hemoglobin level was 9.8 g/dL.

Secondary maternal outcomes, including total surgical time, estimated blood loss, postpartum hemorrhage, uterotonic administration, hysterectomy, and blood transfusion, were not significantly different between the two groups.

Two women in the immediate cord clamping group required blood transfusions of 2 units of packed red blood cells on postoperative day 1 for symptomatic anemia. One woman in each group required unplanned hysterectomy.

Secondary neonatal outcomes included hemoglobin level, assessed at 24 to 72 hours of life. There were no significant differences in 15 of 19 prespecified secondary outcomes. Mean neonatal hemoglobin level was significantly higher in the delayed compared with the immediate cord clamping group (18.1g/dL vs 16.4 g/dL; mean difference, 1.67 g/dL; P < .001).

Umbilical Cord Milking in Premature Infants

Also published in JAMA today is a randomized clinical trial that compared umbilical cord milking with delayed umbilical cord clamping among infants born at less than 32 weeks' gestation. The two groups did not differ significantly with respect to the rate of death or severe intraventricular hemorrhage, the primary outcome.

However, the study was terminated early because the rate of severe intraventricular hemorrhage was significantly higher among infants in the umbilical cord milking group, report Anup Katheria, MD, Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, California, and colleagues.

The study by Purisch and colleagues showed that delayed umbilical cord clamping is safe for the mother, including those who undergo cesarean delivery, note Heike Rabe, MD, PhD, from Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom, and Ola Andersson, PhD, from Lund University and Skåne University Hospital, Sweden, write in an accompanying editorial.

"However, the safest method for enhancing placental transfusion in preterm infants remains unclear not only in terms of delayed cord clamping vs umbilical cord milking, but also in the duration of delay, the positioning of the infant with regard to the placenta, the number of times the intact cord should be milked, and the use of uterotonics," they write.

Rabe and Andersson conclude that for now, "clinicians should follow the World Health Organization recommendation to delay cord clamping and cutting for 1 to 3 minutes for term infants and for at least 60 seconds in preterm infants to prevent iron deficiency and potentially enable more premature infants to survive."

The editorialists have disclosed no relevant financial relationships. Gyamfi Bannerman reports receiving grants from Society for Maternal-Fetal Medicine/AMAG Pharmaceuticals and personal fees from Sera Prognostics outside the submitted work. The senior author on the preterm milking study reports a variety of financial relationships with multiple companies; the remaining authors have disclosed no relevant financial relationships.

JAMA. Published online November 19, 2019. Abstract

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