For healthy babies born at full term, current evidence supports deferred umbilical cord clamping rather than immediate clamping, says a new up-dated Scientific Impact Paper published today by the Royal College of Obstetricians and Gynaecologists (RCOG).
The International Federation of Gynecology and Obstetrics (FIGO) and the World Health Organization (WHO) no longer recommend immediate cord clamping. The National Institute for Health and Care Excellence (NICE) recommends that for healthy women at term the cord is not clamped in the first 60 seconds and that it should be clamped before five minutes, although women should be supported if they wish this to be delayed further.
This revised opinion paper looks at placental transfusion, when additional blood is transferred to the baby before the cord is cut, and reviews the existing evidence around the timing of cord clamping. It covers both term and preterm births.
It also provides guidance around the different definitions used in studies and suggests immediate cord clamping is defined as within 30 seconds of the birth and deferred cord clamping means not until at least 2 minutes after birth.
The paper states that immediate cord clamping reduces the flow of blood to the baby and can deprive the baby of iron. Iron deficiency in the first few months is associated with neurodevelopmental delay.
Immediate clamping can also have an impact on blood flow and the transition from fetal to neonatal circulation. This is particularly important for preterm babies as a brief delay in clamping will increase the baby’s blood volume.
Other factors are also considered in the paper such as mode of delivery, as placental transfusion following a caesarean section appears to be less than for a vaginal birth. Moreover cord ‘stripping’ or ‘milking’ is looked at, which is when the cord blood is pushed rapidly into the fetal circulation. However, more research is needed into its benefits and risks states the paper.
Looking at existing evidence for term births, the paper looks at the Cochrane review which concluded that the evidence justifies a more liberal approach to delaying clamping of the cord, as long as access to treatment for jaundice is available. For preterm babies, the evidence suggests deferring clamping of the cord may be beneficial but further research is needed including long-term follow up of the children and the mother.
The paper concludes that in healthy term babies the evidence supports deferred clamping as this appears to improve iron stores in infancy. Moreover, this is in line with the NICE guidance. Once delivered the baby can be placed on the mother’s abdomen or chest with the cord intact and the timing of clamping should be recorded.
Professor Leila Duley, Director, Nottingham Clinical Trials Unit, Faculty of Medicine & Health Sciences and lead author of the paper said:
“Immediate clamping became routine practice without rigorous evaluation. The recent evidence suggests deferred clamping may have benefits for both term and preterm babies however there still needs to be large randomised trials with long term follow up.”
Dr Sadaf Ghaem-Maghami, Chair of the RCOG’s Scientific Advisory Committee, said:
“When to cut the umbilical cord has long been debated and the RCOG recommends that the time at which the cord is clamped should be recorded.
“Timing needs to be based on clinical assessment and the cord should not be clamped earlier than necessary. This paper has looked at the available evidence and deferred clamping may benefit the baby in reducing anaemia, by allowing time for transfusion of placental blood to the newborn.”
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The RCOG Green-top Guideline on Postpartum Haemorrhage, Prevention and Management is available to view here. An Addendum on cord clamping was added in April 2011.
The NICE intrapartum care guidance is available to view here.
About RCOG Scientific Impact Papers
RCOG Scientific Impact Papers (formerly SAC Opinion papers) are produced by the Scientific Advisory Committee. They are up-to-date reviews of emerging or controversial scientific issues of relevance to obstetrics and gynaecology, together with the implications for future practice. These documents have been rebranded to raise awareness of the issues in obstetrics and gynaecology discussed in the documents and to more accurately reflect their content and remit of the Committee.